Papers by Caterina Exacoustos
Journal of Minimally Invasive Gynecology
Journal of Minimally Invasive Gynecology
Gynecological Endocrinology
Journal of minimally invasive gynecology, Jan 5, 2018
To describe a laparoscopic technique for the resection of deep endometriosis, treating the three ... more To describe a laparoscopic technique for the resection of deep endometriosis, treating the three compartments. Educational video SETTING: Tertiary referral center in Strasbourg, France PATIENTS: This is the case of a 37-year-old primiparous woman. Her main symptoms included dysmenorrhea and dyspareunia associated with pollakiuria and macroscopic menstrual hematuria (with emission of endometriotic tissue on analysis). She also complained of dyschezia. The MRI revealed an endometriotic nodule in the vesicouterine space with an involvement of the anterior wall of the uterus and a suspicion of bladder adenomyosis. There are lateral spicules attracting the ovaries towards the midline and an infiltration of the round ligaments and nodules related to the rectovaginal space's endometriosis. A possible invasion is noted underneath the rectal mucosa. The patient wants to preserve her fertility. Adenomyomectomy, partial cystectomy, and bowel resection. Fertility preservation is mandatory d...
Ultrasound in obstetrics & gynecology : the official journal of the International Society of Ultrasound in Obstetrics and Gynecology, Jan 22, 2018
To develop a uniform classification and standardized reporting system of ultrasound findings of a... more To develop a uniform classification and standardized reporting system of ultrasound findings of adenomyosis using the Morphological Uterus Sonographic Assessment (MUSA) criteria. The opinion presented in this manuscript was built based on a thorough discussion among all authors, including a Delphi procedure. Selected images and videos of typical cases of the different morphological variations of adenomyosis were used in the debates. A classification and reporting system of different types of adenomyosis based on ultrasound was agreed upon including (1) identification of adenomyosis based on MUSA criteria, (2) disease location (anterior, posterior, left lateral, right lateral, fundal), (3) classification of the lesions as focal or diffuse, (4) presence or absence of intralesional cysts, (5) myometrial layer involvement (junctional zone, myometrium, serosal involvement), (6) disease extent (< 25%, 25-50%, > 50% of uterine volume affected by adenomyosis) and (7) lesion size. We p...
The Journal of clinical endocrinology and metabolism, Mar 1, 2017
Hirsutism is frequently expressed in women affected by polycystic ovary syndrome (PCOS). The effi... more Hirsutism is frequently expressed in women affected by polycystic ovary syndrome (PCOS). The efficacy of oral contraceptive pill (OC) plus anti-androgens in the treatment of its severe expression is controversial due to the lack of randomized double-blind long-term studies. The primary outcome was the reduction of hirsutism in PCOS women objectively measured by videodermoscopy (VD) on the androgen-sensitive skin areas assessed by the modified Ferriman&Gallwey (mF&G) total score, after 12 months of therapy with OC+Bicalutamide (BC) versus OC plus placebo (P). The secondary outcomes were to evaluate tolerability of bicalutamide and body composition as well as the occurrence of adverse events. This was an experimental, phase III, prospective, multicenter, randomized, double-blind, placebo-controlled trial. Patients were evaluated at the baseline visit, at the sixth and twelfth month during treatment and six months after its end. 70 women with classic PCOS (severe hirsutism, oligo-anovu...
Ultrasound in Obstetrics & Gynecology
Ultrasound in Obstetrics & Gynecology, 2017
Objective To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic in... more Objective To evaluate, in patients who underwent Fallopian-tube sterilization by hysteroscopic insertion of an Essure ® device, the feasibility and accuracy of three-dimensional (3D) transvaginal sonography (TVS) to check the position of the device and 3D hysterosalpingo-foam sonography (3D-HyFoSy) using contrast-enhanced gel foam to assess consequent tubal occlusion. Methods This was a prospective multicenter study conducted from June 2012 to July 2014 in four Italian centers, which included 50 women who underwent hysteroscopic Essure microinsert placement in a total of 95 Fallopian tubes. Placement of the microinserts was performed in an outpatient setting following standard procedure recommendations. All patients underwent transvaginal 3D-HyFoSy and hysterosalpingography (HSG) approximately 12-14 weeks after the procedure. The position of the devices was first checked on 3D-TVS and classified according to specific criteria (Positions A, B, C and D). Then, 3D-HyFoSy with ExEm ® gel foam as the ultrasound contrast agent was performed to confirm tubal occlusion by the absence of contrast agent within the tubes and/or around the ovaries. To evaluate the feasibility of 3D-HyFoSy, consecutive volume acquisitions were performed while injecting the gel foam. After sonographic evaluation, women underwent HSG to assess the success of sterilization, as standard methodology. Side effects and pain evoked during and after 3D-HyFoSy and HSG were evaluated using a numeric pain rating scale.
Journal of Minimally Invasive Gynecology, 2017
To investigate the feasibility of hysterosalpingo-foam sonography (HyFoSy) with automated 3D soft... more To investigate the feasibility of hysterosalpingo-foam sonography (HyFoSy) with automated 3D software in the evaluation of tubal patency and visualization of the tubal course by obtaining a 3D volume acquisition of tubes. Prospective observational study DESIGN: Classification: Canadian Task Force III. University Hospital PATIENTS: 132 infertile females between October 2013 and February 2015 INTERVENTIONS: All patients underwent HyFoSy with the new automated 3D software Coded Contrast Imaging (CCI) followed by 2D real-time HyFoSy. To evaluate the feasibility of 3D visualization of tubal course, consecutive volume acquisitions during gel foam contrast agent injection was performed. Conventional two-dimensional (2D) real-time HyCoSy by detection gel foam moving through the tubes and around the ovaries was finally performed and considered as final results of tubal status. All the patients underwent 3D-CCI HyFoSy followed by 2D real-time HyFoSy. After both procedures we observed 108 patients (81,8%) with bilateral tubal patency, 22 patients (16.6%) with unilateral tubal patency and 2 patients (1,5%) with bilateral tubal occlusion. Concordance rate for tubal status between first and second 3D volume acquisition and the final 2D real time evaluation was 84.8% and 97.0% respectively. TVS HyFoSy with 3D volume reconstruction of the uterus and tubes is an accurate and safe technique that allows a complete visualization of tubal shape and patency with high patients compliance.
Fertility and Sterility, 2016
To study outcomes and complications during pregnancy and at delivery in women with a posterior de... more To study outcomes and complications during pregnancy and at delivery in women with a posterior deep infiltrating endometriosis (DIE) nodule persisting after surgery and diagnosed at transvaginal sonography (TVS) in comparison with a control group of women without endometriosis. Design: Multicenter observational and cohort study. Setting: University hospital. Patient(s): Women (n ¼ 200) with a posterior DIE nodule equal or more than 2 cm centimeters in size who desired a pregnancy and a control group of women (n ¼ 300) with no previous recorded diagnosis of endometriosis who delivered in our clinic during the same time period. Intervention(s): Patient data collected from medical charts and by phone interviews. Main Outcome Measure(s): Evaluation of complications during pregnancy and delivery. Result(s): Of the 101 women with a posterior DIE nodule, 52 become pregnant among whom 25 used assisted reproductive technology. Of these 52 pregnancies, 11 ended in an early abortion, and 41 delivered a baby; 13 (31.7%) had a premature delivery, 7 (17.8%) a placenta praevia, and 28 (68.2%) had a cesarean delivery. When compared with the control group, the women with endometriosis had a higher risk of pregnancy complicated by preterm birth, placenta previa, placental abruption, and hypertension. Cesarean delivery and complications during surgery (hysterectomy, hemoperitoneum, and bladder injuries) were statistically significantly more frequent in women with endometriosis than in controls. Conclusion(s): Women with an incomplete removal of posterior DIE have a high complications rate during pregnancy and delivery.
Seminars in Reproductive Medicine, 2017
The main challenges of imaging for endometriosis are the detection of nonovarian disease and the ... more The main challenges of imaging for endometriosis are the detection of nonovarian disease and the evaluation of the extension of the disease into pelvic structures. Transvaginal ultrasonography (TVS) has been proposed as the first-line imaging technique because it allows extensive exploration of the pelvis. The &quot;typical&quot; endometrioma is a unilocular cyst with homogeneous low-level echogenicity (ground glass echogenicity) of the cyst fluid. The use of color Doppler helps avoid classifying malignancies as endometriomas, defining the presence of vascular flow in papillations. The real-time dynamic TVS examination of adhesions and pouch of Douglas (POD) obliteration, using the sliding sign technique, seems to be useful in the identification of women at increased risk for bowel endometriosis. Transvaginal ultrasound allows an accurate assessment of the vagina, particularly the areas of the posterior and lateral vaginal fornixes, the retrocervical area with torus uterinum and uterosacral ligaments, and the rectovaginal septum. The slightly filled bladder permits an evaluation of the bladder walls and the presence of endometriotic nodules which appear as hypoechoic linear or spherical lesions bulging toward the lumen, involving the serosa, muscularis, or (sub)mucosa of the bladder. Deep nodules of the rectum appear as hypoechoic lesions, linear or nodular retroperitoneal thickening with irregular borders, penetrating into the intestinal wall distorting its normal structure with the presence of few vessels observed with power Doppler evaluation. Adenomyosis can be observed with the two-dimensional (2D) TVS showing the typical myometrial features and 3D evaluation of the junctional zone. Although the sensitivity and specificity of TVS in the prediction of deeply infiltrating endometriosis and adenomyosis is high, their assessment by TVS is difficult and needs a great expertise.
J Minim Invasive Gynecol, 2007
Intervention: The adhesions were divided or transected by electrode needle or loop under directly... more Intervention: The adhesions were divided or transected by electrode needle or loop under directly vision. Measurements and Main Results: Among 61 subjects with second look hysteroscopy 27.9% had reformation of the adhesions. Among 39 women who conceived, 64.1% achieved a live birth. After hysteroscopic adhesiolysis, the chances of conception in women who remained amenorrhea (18.2%) was significantly lower than those who continued to have menses. At second look hysteroscopy, the conception rate in women who had reformation of intrauterine adhesions was significant lower than that of women who have normal cavity. Most of the pregnancies (87.2%) occurred within two years after surgery. Conclusion: The outcome of hysteroscopic adhesiolysis for Asherman's syndrome is significantly affected by recurrence of intrauterine adhesions.
J Minim Invasive Gynecol, 2007
Minerva ginecologica, Jan 25, 2016
Myomas represent a large part of benign gynecological pathology, widely spread in fertile female ... more Myomas represent a large part of benign gynecological pathology, widely spread in fertile female population. First step to diagnose fibroids is ultrasound (US) that can be 2-dimensional (2D), 3-dimensional (3D), Color Doppler (CD) and sonohysterography (SHG). This review develops according to MUSA's sonographic features (Morphological Uterus Sonographic Assessment). One of the main topic of interest for ultrasonographer today is endo/myometrial Junctional Zone (JZ) because it may be useful to discern a diagnosis of myoma and adenomyosis. Another important aspect of ultrasound is the analysis of vasculariza- tion in front of an uterine lesion. Indeed, vascular pattern can be used to make differential diagnosis between myoma - adenomyosis and layomiosarcomas. To date, there aren't guidelines for ultrasound evaluation of myomas but should be relevant for Scientific Community gets an harmonize nomenclature for future research.
Journal of Minimally Invasive Gynecology, 2016
STUDY To assess whether the use of a novel graduated intrauterine palpator can improve the accur... more STUDY To assess whether the use of a novel graduated intrauterine palpator can improve the accuracy of hysteroscopic metroplasty, introducing objective intraoperative criteria. A prospective randomized study (Canadian Task Force I, evidence obtained from a properly design, randomized, controlled trial). University Federico II hysteroscopic clinic. Ninety women with a uterine septum diagnosed during office hysteroscopy and 3-dimesional transvaginal ultrasound (3D-TVS) were randomized into 2 groups: group T (metroplasty with intrauterine palpator) (n = 45) and group C (metroplasty without intrauterine palpator) (n = 45). Outpatient hysteroscopic metroplasty under conscious sedation using a 5-mm hysteroscope and miniaturized 5F instruments including a bipolar electrode for the removal of three quarters of the septum, blunt scissors to refine the base of the septum, and an intrauterine palpator to measure the portion of the removed septum (only group T). 3D-TVS and second-look hysteroscopy were used to identify the number of optimal (residual septum &amp;amp;amp;amp;amp;amp;lt;5 mm), suboptimal (residual septum 5-10 mm), and incomplete resections (residual septum &amp;amp;amp;amp;amp;amp;gt;10 mm). In group T, metroplasty was stopped when the intrauterine palpator showed that the resected septum corresponded to presurgical ultrasonographic measurements in order to obtain a fundal notch of 1.0 cm. In group C, metroplasty was interrupted once the tubal ostia were clearly visible on the same line and/or hemorrhage from small myometrial vessels of the fundus was observed. No differences were observed in baseline characteristics between the 2 groups. The proportion of patients with complete septum resection was significantly higher in group T (71.5% vs 41%, χ(2): p = .006; relative risk: 1.684; 95% confidence interval, 1.116-2.506). Suboptimal resection was achieved in 13 cases (28.5%) in group T and 14 cases (20%) in group C, whereas incomplete resection was observed in only 12 patients in group C (27%). Presurgical evaluation with 3D-TVS together with the use of a graduate intrauterine palpator improves the accuracy of hysteroscopic metroplasty, allowing complete removal of a uterine septum in 1 surgical step.
Uterine Adenomyosis, 2015
Gynecological Surgery, 2015
What is the recommended diagnostic work-up of female genital anomalies according to the European ... more What is the recommended diagnostic work-up of female genital anomalies according to the European Society of Human Reproduction and Embryology (ESHRE)/European Society for Gynaecological Endoscopy (ESGE) system? The ESHRE/ESGE consensus for the diagnosis of female genital anomalies is presented. Accurate diagnosis of congenital anomalies still remains a clinical challenge due to the drawbacks of the previous classification systems and the non-systematic use of diagnostic methods with varying accuracy, with some of them quite inaccurate. Currently, a wide range of non-invasive diagnostic procedures are available, enriching the opportunity to accurately detect the anatomical status of the female genital tract, as well as a new objective and comprehensive classification system with well-described classes and sub-classes. The ESHRE/ESGE Congenital Uterine Anomalies (CONUTA) Working Group established an initiative with the goal of developing a consensus for the diagnosis of female genital...
Journal of Minimally Invasive Gynecology, 2015
A retrospective evaluation of our series to evaluate feasibility and safety of laparoscopic segme... more A retrospective evaluation of our series to evaluate feasibility and safety of laparoscopic segmental bowel resection for deep infiltrating endometriosis. II-3 SETTING: Malzoni Clinic - Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy PATIENTS: Retrospective cohort of 248 cases (between 1st of January 2011 and 31th December 2014) INTERVENTION: Laparoscopic segmental bowel resection for deep infiltrating endometriosis. Bowel endometriosis was histologically confirmed in 248/248 patients (100%). Mean length of the resected specimen was 11.83 ± 4.56 cm (mean± SD). Margins were free of disease in all cases and muscular layer was infiltrated up to the submucosal layer in all 248/248 cases (100%), while the mucosal layer showed signs of infiltration only in 4 cases out of 248 (1.6%). In 36 patients (36/248, 14.5%) coexistence of 2 nodules was found, while 3 nodules were found only in 8 cases (8/248, 3.2%). None of the resected bowel segments had nodules less than 3 cm in length and the majority of lesions had a longitudinal diameter between 3 and 7 cm. In the majority of cases resected segments involved the mid-low rectum (distance of the lower margin of resected segment from the anal verge between 4 and 12 cm) while in 6% of cases, ultra low resections (equal or below 4 cm) was performed. No intraoperative complications occurred and conversion to laparotomy was not required We recorded perioperative and early and late post-operative major complications in 20 cases (20/248, 8.06%) . A significant reduction of pain associated disease was observed up to 1 year follow up, irrespectively of postoperative hormonal treatment. Pelvic relapse was found in up to 50% of cases, especially in patients without hormonal suppression, but only in the form of endometriomas or adherences, with no recurrent deep lesions observed. .This large single center series demonstrates that laparoscopic bowel resection for deep infiltrating endometriosis is a feasible technique, with low complication rates. Deep fibrotic endometriosis nodules treated by laparoscopic segmental resection is very effective in symptomatic patients in terms of reduced pain and restored bowel function. It can be considered a safe, complex surgery, requiring specific skills in laparoscopic urologic and colorectal procedures and should be performed only in specialized high volume centers by high volume surgeons.
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Papers by Caterina Exacoustos