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Mettler L.,University of Kiel | Tinelli A.,Vito Fazzi Hospital | Hurst B.S.,Assisted Reproduction Center | Teigland C.M.,Carolinas Medical Center | And 5 more authors.
Expert Review of Endocrinology and Metabolism | Year: 2011

The myoma pseudocapsule is a surgical-anatomical entity surrounding the fibroid that separates the myoma from normal uterine tissue. The myoma pseudocapsule has a delicate vascular network rich with neurotransmitters analogous to the neurovascular bundle surrounding the prostate. The pseudocapsule neurovascular bundle is extremely important during myomectomy to promote uterine myometrial healing and, consequently, for uterine reproductive function. New advancements in surgery, including the use of laparoscopic myomectomy by an intracapsular technique and magnification of the myoma pseudocapsule to enhance visualization are comparable to the dissection during a radical prostatectomy. Fibroid detachment occurring inside the pseudocapsule causes less bleeding, spares the neurovascular bundle and promotes better uterine healing. The maintenance of myometrial integrity after laparoscopic myomectomy maintains uterine function and therefore improves reproductive outcomes, including labor. © 2011 Expert Reviews Ltd.

Tinelli A.,Imaging | Giorda G.,Centro Of Riferimento Oncologico | Manca C.,Vito Fazzi Hospital | Pellegrino M.,Vito Fazzi Hospital | And 4 more authors.
Journal of Surgical Oncology | Year: 2012

Background and Objectives The prevention of lymphoceles was tested using collagen patch coated with the human coagulation factors (TachoSil) on 58 consecutive patients with endometrial cancer who had undergone hysterectomy and pelvic lymphadenectomy (PL). Methods Patients were randomized in two groups: standard technique plus TachoSil (30 patients, group 1) and standard technique only (28, group 2). All surgical parameters were collected and patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were: the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery and the drainage volume and duration. Results Same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 7 patients in group 1 and 16 in group 2, but only 3 were symptomatic in group 1 and 9 symptomatic in group 2, with statistical difference. Percutaneous drainage proved necessary in five cases: only one was in group 1 and four in group 2. Conclusions Intraoperative application of TachoSil reduced rate of postoperative lymphocysts after PL, and it seems to provide a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL. Copyright © 2011 Wiley Periodicals, Inc.

Tinelli A.,Vito Fazzi Hospital | Malvasi A.,Santa Maria Hospital | Cavallotti C.,University of Rome La Sapienza | Dell'Edera D.,Unit of Cytogenetic and Molecular Genetics | And 3 more authors.
Expert Opinion on Therapeutic Targets | Year: 2011

Background: We examined the presence of collagen IV and laminin in the pseudocapsule of uterine myomata to clarify different ultra-structural characteristics and their possible role in the management of this condition. Methods: Twenty non-pregnant patients underwent laparoscopic intracapsular myomectomies. Samples of the removed fibroids pseudocapsules were analyzed by immunochemical staining for collagen IV, immunohistochemical location of the vascular membrane-bound laminin and quantitative analysis of their images. Results: In the blood vessels of the pseudocapsules, a reduction in laminin and increase in collagen IV with increasing diameter of fibroids was noted. These proteins are related to loss of the basal membrane and to ageing of the tissue. The increase of collagen IV is linked to the increase of amorphous substance, including glycosaminoglycans and glycoproteins. Conclusion: Based on immunohistochemical findings, the authors propose to remove fibroids in women seeking pregnancy whilst respecting the pseudocapsule by neurofibre sparing in the incision site. This is essential for optimal muscular healing and myometrial function in future pregnancies, and also when fibroids remain under 6 cm diameter, especially in young women wishing pregnancies. Fibroid removal should be performed before the myoma reaches a size causing compression of the surrounding tissues, which results in the loss of regenerative potential. © 2011 Informa UK, Ltd.

Hurst B.S.,Assisted Reproduction Center | Mettler L.,University of Kiel | Tsin D.A.,Mount Sinai Hospital of Queens | Pellegrino M.,Vito Fazzi Hospital | And 3 more authors.
Human Reproduction | Year: 2012

STUDY QUESTION Can uterine scar healing after laparoscopic intracapsular myomectomy (LIM) be adequately monitored by traditional two-dimensional (2D) ultrasound (US) and Doppler velocimetry? SUMMARY ANSWER The myometrial area of the scar after LIM can be followed by 2D US and Doppler velocimetry. WHAT IS KNOWN ALREADY Apart from post-surgical adhesions, the main concern linked to laparoscopic myomectomy is the quality of healing of the myometrial incision: it has been suggested that US could be useful for assessing uterine scars after myomectomy. However, no diagnostic method has yet been widely accepted to assess the healing process. STUDY DESIGN , SIZE, DURATION A cohort prospective study (level of evidence II-2), run in University-affiliated hospitals: 149 women with symptomatic uterine fibroids (UFs) underwent LIM, between January 2007 and October 2011. During follow up 13 patients withdrew from the study. PARTICIPANTS/MATERIALS, SETTING, METHODS After LIM, all patients were followed by traditional 2D US scanning and Doppler velocimetry on Days: 0, 1, 7, 30 and 45. Authors evaluated: number, size and location of UFs, scar diameter and Doppler velocimetry and resistance index (RI) of the uterine arteries, at their ascending branch. MAIN RESULTS AND THE ROLE OF CHANCE The uterine examination showed a significant (P < 0.05) progressive reduction of uterine scar area from 78 of the previous UF location on the first day, to 19 on 30th day, and <4 on the 45th day. There was no correlation with the size of the fibroid or the relative reduction in the size of the scar, on both Days 1 and 45. There was a significant (P < 0.05) increase in the RI of the ipsilateral uterine arteries from 0.65 on the first post-operative day to 0.83 after 7 days followed by a decrease to 0.71 on the 30th and 0.61 on the 45th post-operative day. LIMITATIONS, REASONS FOR CAUTION This is a cohort investigation on a limited number of patients and it does not surgically compare LIM and 'classic' myomectomy in the scar US follow up. WIDER IMPLICATIONS OF THE FINDINGS LIM avoided intraoperative bleeding and excessive tissue damage, as post-operative US follow up showed, with just two intra-myometrial hematomas (1.5). The 2D US and Doppler velocimetry, a non-invasive safe method to check the myometrium after LIM, can detect post-operative hematoma and disechogenic, heterogeneous or ill-defined scar area, all unfavorable signs for myometrial scarring. Moreover, Doppler transvaginal monitoring, evaluating the pulsatility index (PI) and RI of the uterine arteries at their ascending branch, could identify patients with altered PI and RI parameters, possible markers of impaired wound healing. © The Author 2012.

Malvasi A.,Santa Maria Hospital | Cavallotti C.,University of Rome La Sapienza | Morroni M.,Marche Polytechnic University | Lorenzi T.,Marche Polytechnic University | And 3 more authors.
European Journal of Obstetrics Gynecology and Reproductive Biology | Year: 2012

Objective: The fibroid pseudocapsule is a structure which surrounds the uterine fibroid, separates it from the uterine tissue and contains a vascular network rich in neurotransmitters like a neurovascular bundle. The authors examined the composition of the fibroid pseudocapsule using electron microscopy. Study design: Twenty non-pregnant patients were submitted to laparoscopic myomectomy by the intracapsular method and samples of the removed pseudocapsules were analyzed using transmission electron microscopy. Results: At the ultrastructural level the pseudocapsule cells have the features of smooth muscle cells similar to the myometrium. So, the pseudocapsules are part of the myometrium which compresses the leiomyoma. Conclusion: This ultrastructural feature suggests that when removing fibroids their pseudocapsules should be preserved. This study confirms preliminary evidence that pseudocapsules contain neuropeptides together with their related fibers, as a neurovascular bundle. The surgeon's behavior should be directed to carefully control and spare this muscular surrounding tissue during fibroid excision, in order to preserve the myometrium as much as possible. © 2012 Elsevier Ireland Ltd.

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