Objective: to evaluate risk factors, causes, management and surgical therapy of postcoital vaginal perforation and evisceration in women with no prior pelvic surgery. Data sources: We used MEDLINE (PubMed), Scopus, Embase and Web of Science for our research. Our review includes all reports from 1980 to November 2020. The research strategy adopted included different combinations of the following terms: (intercourse) AND (coitus) AND (vaginal perforation). Methods of study selection: we report a case of vaginal evisceration after consensual intercourse in a young and healthy woman. In addition, we performed a systematic review of vaginal perforations with or without evisceration in women without prior surgery or any other predisposing disease. All studies identified were listed by citation, title, authors and abstract. Duplicates were identified by an independent manual screening, performed by one researcher and then removed. For the eligibility process, two authors independently screened the title and abstracts of all non-duplicated papers and excluded those not pertinent to the topic. Tabulation, integration and results: We have followed the PRISMA guidelines. Five manuscripts were detected through the references of the works that had been identified with the research on MEDLINE (PubMed), Scopus, Embase and Web of Science. We found 16 cases between 1980 and 2020. The young age and the virginal status represent the principal risk factors and all the lacerations occurred in the posterior vaginal fornix. The most common surgical technique was the laparotomic approach and, in the remaining cases, the laparoscopic and vaginal route was performed. Conclusions: Post-coital vaginal perforation and evisceration in women with no prior pelvic surgery is a rare condition in the clinical practice and, when it is associated with evisceration it is a surgical emergency. Usually, these injuries are not life-threatening conditions but, a delay in diagnosis, can lead to severe complications. In consideration of the high heterogeneity of the data in the literature, it is essential to define a diagnostic–therapeutic management for the patients with vaginal perforation. With our review, we try to identify the associated risk factors, the best and fastest diagnosis, and the best surgical approach. We believe that a combined vaginal and laparoscopic approach can be the best surgical treatment, useful to diagnose injuries of the abdominal organs and to improve postoperative outcome.
The etonogestrel (ENG) implant is among the most effective reversible contraceptives. It can be a good option for patients with different chronic diseases due to no clinically significant effects on lipid metabolism or liver function. Some limitations in the use of this type of device are represented by social and psychiatric disorders, where the easy accessibility of the device becomes a negative feature. In these patients several cases of self-removal or damage to the device have been reported. We report the successful insertion of the Nexplanon® device into the scapular region in a young woman with a chronic psychiatric disorder. To verify the presence in the literature of other possible implantation sites, we performed a systematic review of the literature on Pubmed, Google scholar and Scopus from 2000 to 2021 using different combinations of the following terms: (Nexplanon), (contraceptive implant), (insertion). Two manuscripts with three cases were detected. Nexplanon® was implanted in the upper back. In all cases, there were no complications during the insertions and the follow up demonstrated no side effects with contraceptive efficacy. Our report and review is a further confirmation that the scapular region can become a valid insertion site, maintaining good efficacy and safety of the subcutaneous device.
Background Vaginal vault prolapse is the most frequent long-term complication in patients undergoing hysterectomy and sacralcolpopexy is considered the gold standard. We report our surgical strategy maintaining single-arm mesh when the sacral promontory is not accessible to fix the mesh for an unknown sacral osteophytosis during a laparoscopic sacralcolpopexy. This is significant because, to our knowledge, the bone variant as a procedure limiting factor has never been described before. This opens new horizons for the sacralcolpopexy surgery, because it becomes necessary to know of a valid surgical alternative with mesh maintenance if this complication occurs again or to perform an assessment of the accessibility of the sacral promontory immediately after its dissection. Case presentation We present a case of a 75-year-old woman with recurrence of vaginal vault prolapse. A laparoscopic sacralcolpopexy was recommended. During surgery, we found that the procedure was not feasible due to the presence of an unknown osteophytosis of the sacrum which prevented the fixing of the mesh to the sacral promontory. We decided to proceed with a single-arm lateral suspension by using a modified approach of the original technique, maintaining the mesh originally shaped for the sacral colpopexy. At follow-up, the vaginal vault is well suspended. Conclusion This exit strategy may represent a valid surgical alternative when laparoscopic sacral colpopexy is not possible for anatomical variants, allowing to keep the laparoscopic approach using mesh. To our knowledge, cases in which the anatomical bone variant prevented access to the sacral promontory have never been described in the literature, as bone evaluation has never been considered a limiting element of this procedure.
Objectives: To explore the value of contrast-enhanced ultrasound (CEUS) in the differential diagnosis of leiomyoma subtypes and sarcomas. Methods: To collect the cases of uterine leiomyoma or suspected sarcoma of uterine mass found by preoperative ultrasound examination, and to observe perfusion of the pelvic organs by bolus injecting contrast agent (Sonovue, Bracco France) through the middle elbow vein with a dose of 2.4 ml. According to the location of the focus, the imaging data of CEUS were collected by abdominal or vaginal ultrasound and stored. The perfusion features in lesions were analysed by two experienced sonologists. The sensitivity, specificity, PPV and NPV of CEUS features for leiomyoma subtypes (common, hypervascular or cellular, degenerative) and sarcomas according to the pathological results were compared. Results: From January 2019 to March 2020, 30 cases with 36 uterine lesions (maximum diameters 67mm ± 23mm) with pathological results were included in this study. There were 13 common myomas, 17 myomas with cellularity or hypervascularity, 6 common myomas with local or entire hyaline degeneration and 2 uterine. The features of CEUS for the three leiomyoma subtypes and sarcoma were: from peripheral-ring to tree-branching enhancement for common myoma, feather-like higher enhancement with clear boundary for cellular or hypervascular myoma, local or entire hypo-perfusion for degenerative myoma, and uneven high enhancement without regular border associated with large areas of non-enhancement for sarcoma. The sensitivities were 100%, 94.1%, 83.3% and 100% (P<0.05). The specificities were 95.6%, 94.7%, 93.3% and 100% (P>0.05). The PPV were 92.9%, 94.1%, 71.4% and 100% (P<0.05). The NPV were 100%, 94.7%, 96.6% and 100%, respectively (P>0.05). Conclusions: For the characteristic enhancement features, CEUS can accurately distinguish uterine leiomyoma from uterine sarcoma, and help to identify the subtypes of myoma by evaluating the blood supply and distribution in the lesion. VP66.11 Clinical and ultrasound characteristics of ovarian carcinosarcomas
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