OBJECTIVE:The primary objective of this study is to assess the impact of hysteroscopic metroplasty on symptom relief, including dysmenorrhea, dyspareunia, and menstrual blood flow in women with partial uterine septa (U2a class). Additionally, the study aims to investigate potential correlations between clinical and ultrasonographic characteristics and changes in these symptoms. METHODS:This was a prospective cohort study conducted at a single center, enrolling women who underwent hysteroscopic metroplasty between March 2022 and September 2023. Participants presented with dysmenorrhea, dyspareunia, and abnormal menstrual blood flow and had expressed a desire for pregnancy. Preoperative symptom severity was measured using a visual analog scale, ranging from 0 to 100. Preoperative three-dimensional transvaginal ultrasonography was performed to assess septal characteristics. A 12-month follow-up was conducted to evaluate changes in symptoms postoperatively. Exclusion criteria included alternative causes of pelvic pain, incomplete septum correction necessitating further surgery, and pregnancy or hormonal therapy within 12 months prior to or following the surgery. RESULTS:A total of 52 symptomatic patients with U2a uterine septa underwent hysteroscopic metroplasty, and data from 44 patients were analyzed according to the inclusion and exclusion criteria. Postoperative assessments revealed a significant reduction in dysmenorrhea (mean ± standard deviation: 50.2 ± 20.5 vs. 33.1 ± 20.4, P < 0.001) and dyspareunia (mean ± standard deviation: 41.4 ± 9.5 vs. 28.6 ± 24.5, P < 0.028). However, no significant changes were observed in menstrual blood flow. CONCLUSION:Hysteroscopic metroplasty in patients with partial uterine septa results in significant symptom relief, particularly for dysmenorrhea and dyspareunia. These findings underscore the potential benefits of metroplasty beyond reproductive outcomes. Further large-scale studies are necessary to confirm these results.

Deep infiltrating endometriosis and oncologic radical pelvic surgeries pose a significant risk of nerve damage. A thorough understanding of pelvic anatomy is essential for surgical precision and to avoid neurological complications or dysfunctions. Laparoscopic cadaveric dissections, with their magnification and bloodless dissection advantages, provide a safe and effective training method for mastering pelvic neuroanatomy and refining surgical skills

OBJECTIVE:To compare surgical and oncologic outcomes between conventional resectoscopic surgery and mechanical hysteroscopic tissue removal (mHTR) systems in high-risk patients not suitable for standard surgery undergoing conservative treatment for multifocal endometrial atypical hyperplasia/endometrial intraepithelial neoplasia (EAH/EIN) or early-stage low-grade endometrioid endometrial cancer (EEC). METHODS:We conducted a single-center, retrospective cohort study at the Department of Gynecology and Physiopathology of Human Reproduction, S. Orsola-Malpighi Hospital, University of Bologna, Italy. A total of 31 high-surgical-risk patients with EAH/EIN or early-stage low-grade EEC were included: 18 underwent conventional resectoscopic endo-myometrial resection, while 13 were treated with mHTR systems. All patients received a levonorgestrel-releasing intrauterine device (LNG-IUD) postoperatively. After treatment, patients underwent an 18-month follow up with endometrial biopsies every 6 months. RESULTS:The mHTR group had significantly shorter operative times (mean 12.3 ± 7.7 min) compared with the resectoscopic surgery group (mean 40.6 ± 11.8 min, P < 0.001). Additionally, the incidence of intrauterine adhesions was lower in the mHTR group (P < 0.001). There were no significant differences between the two groups in terms of disease presence at 6, 12, or 18 months. CONCLUSIONS:Hysteroscopic endo-myometrial resection, with resectoscopic technique or with mHTR systems, combined with LNG-IUD may represent a safe alternative for patients at high surgical risk with EAH/EIN or early-stage low-grade EEC. Moreover, mHTR demonstrated advantages such as shorter operative times and fewer adhesions. A large multicenter prospective study is needed to confirm our study findings.

OBJECTIVE:Bowel endometriosis affects 8% to 12% of women with infiltrating endometriosis, mostly involving the rectum and sigmoid [1]. Surgery is preferred when medical therapy fails or is contraindicated. Although segmental resection has shown good outcomes, it carries significant risks of perioperative complications [1-3], partially due to the mini-laparotomy required for specimen retrieval and bowel anastomosis (postoperative pain, wound-related issues, blood loss, hernias). Total intracorporeal laparoscopic anastomosis may reduce them [4,5]. While promising, experience with this technique is limited, and there is no consensus on its use. This video showcases our technique for total intracorporeal end-to-end anastomosis using a purse-string suture after bowel resection for endometriosis. DESIGN:Case report and video-description of the surgical technique. SETTING:Tertiary level academic hospital. INTERVENTION:A 32-year-old woman with severe, symptomatic endometriosis unresponsive to hormone therapy was referred to our hospital. Preoperative evaluation identified a 5cm nodule involving the anterior rectal wall, recto-sigmoid junction, and right uterosacral ligament, located 10cm from the anal verge. After obtaining informed consent, surgery was scheduled. The recto-sigmoid colon was mobilized using a nerve-sparing approach [1-3,5], followed by resection of the affected segment. The specimen was exteriorized from the right ancillary trocar site, and a total intracorporeal end-to-end colorectal anastomosis was performed without the need for a suprapubic mini-laparotomy, using a circular stapler and a monofilament purse-string suture to secure the anvil. Bowel integrity and residual vascular assessment with near-infrared indocyanine green were performed, and the patient experienced an uneventful recovery, with significant clinical improvement at follow-up. CONCLUSION:In our experience total intracorporeal anastomosis technique improves minimally invasive surgery for deep endometriosis, avoiding the drawbacks of mini-laparotomy and requires less sigmoid mobilization. The most threatening complication after full-thickness bowel resection is anastomotic leakage, often due to poorly supplied residual horns. Our technique using a purse-string suture during intracorporeal anastomosis, preventing formation of residual horns, can provide greater anvil stability for a secure anastomosis seal.

STUDY OBJECTIVE:To evaluate surgical outcomes of hysteroscopic metroplasty for complete uterine septa with or without associated cervical anomalies and/or vaginal septa, and to compare reproductive outcomes to determine if the presence of these anomalies affects surgical success and fertility outcomes. DESIGN:multicentre retrospective observational study. SETTING:2 university affiliated hospitals in Italy. PARTICIPANTS:The study cohort comprised patients with history of primary infertility, recurrent pregnancy loss or severe preterm birth with complete uterine septum with or without cervical and/or vaginal septa anomalies diagnosed on 3D transvaginal ultrasound and hysteroscopy for which they had hysteroscopic metroplasty between January 2020 and May 2023 in either of the 2 participating centres. INTERVENTIONS:hysteroscopic metroplasty performed in the operating room under general or loco-regional anesthesia, using either miniaturized instruments (5Fr electrodes or 15Fr bipolar resectoscope) or 27Fr bipolar resectoscopes followed by application of auto-cross-linked hyaluronic acid gel for the prevention of post-operative adhesions. MEASUREMENTS AND MAIN RESULTS:A total of 101 patients were included in our study. We collected perioperative outcomes including operative time, operative complications, ease of the procedure and need for a repeat resection for residual septum. We also explored reproductive outcomes including clinical pregnancy, live birth and miscarriage rates. All surgical procedures were successfully performed without any significant complications. Operative time was shorter and procedures were reported to be easier in patients without cervical anomalies (U2bC0V0). A second surgical resection was required in most cases regardless of the presence of cervical abnormalities. Reproductive outcomes were available for 66 (65.3 %) patients and there were no significant differences in reproductive outcomes between patients with and without cervical/vaginal anomalies. CONCLUSION:Hysteroscopic metroplasty for complete uterine septum, with or without cervical/vaginal abnormalities is effective and safe. The presence of cervical anomalies doesn't seem to affect the need for a second resection or reproductive outcomes.

Background: Although hysteroscopy with endometrial biopsy is the gold standard in the diagnosis of endometrial pathology, the gynecologist experience is crucial for a correct diagnosis. Deep learning (DL), as an artificial intelligence method, might help to overcome this limitation. Unfortunately, only preliminary findings are available, with the absence of studies evaluating the performance of DL models in identifying intrauterine lesions and the possible aid related to the inclusion of clinical factors in the model. Aim: To develop a DL model as an automated tool for detecting and classifying endometrial pathologies from hysteroscopic images. Methods: A monocentric observational retrospective cohort study was performed by reviewing clinical records, electronic databases, and stored videos of hysteroscopies from consecutive patients with pathologically confirmed intrauterine lesions at our Center from January 2021 to May 2021. Retrieved hysteroscopic images were used to build a DL model for the classification and identification of intracavitary uterine lesions with or without the aid of clinical factors. Study outcomes were DL model diagnostic metrics in the classification and identification of intracavitary uterine lesions with and without the aid of clinical factors. Results: We reviewed 1500 images from 266 patients: 186 patients had benign focal lesions, 25 benign diffuse lesions, and 55 preneoplastic/neoplastic lesions. For both the classification and identification tasks, the best performance was achieved with the aid of clinical factors, with an overall precision of 80.11%, recall of 80.11%, specificity of 90.06%, F1 score of 80.11%, and accuracy of 86.74 for the classification task, and overall detection of 85.82%, precision of 93.12%, recall of 91.63%, and an F1 score of 92.37% for the identification task. Conclusion: Our DL model achieved a low diagnostic performance in the detection and classification of intracavitary uterine lesions from hysteroscopic images. Although the best diagnostic performance was obtained with the aid of clinical data, such an improvement was slight.

STUDY OBJECTIVE:Anatomic anomalies of the female reproductive genital tract affect approximately 5.5% of women [1]. The hemiuterus or class U4 by the European Society of Human Reproduction and Embryology / European Society for Gynaecological Endoscopy 2013 classification is a rare congenital malformation defined as a unilateral uterine development, with a contralateral part that could be either incompletely formed or absent. This class is divided into 2 subclasses depending on the presence or not of a functional rudimentary cavity (U4a/U4b) [2]. This work aimed to share our experience performing an hysteroscopic and laparoscopic combined technique to surgically manage this uterine malformation exploiting the hysteroscopic transillumination. DESIGN:A step-by-step explanation of surgical technique with narrated video footage. SETTING:Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. INTERVENTIONS:A 32-year-old woman with a symptomatic (severe dysmenorrhea and chronic pelvic pain) suspected U4a uterine malformation diagnosed at our center was scheduled for laparoscopic removal of the right uterine horn and ipsilateral salpingectomy exploiting the contemporary hysteroscopic transillumination guidance. We selected this approach to avoid possible complications owing to the anatomic anomalies that are very common in these cases [3,4]. After coagulation and section of the right round ligament at the uterine angle and opening of the right broad ligament, access to the retroperitoneum was obtained to directly visualize the entire course of ureter and the uterine artery. The right uterine artery was coagulated and sectioned at the uterus. Then, the hysteroscope was introduced to the uterine fundus and the light source brightness was increased up to 100% to allow an adequate transmural visualization of the uterine defect from the laparoscope. Once the defect edge was well highlighted, the right uterine horn was isolated and removed using a monopolar hook, taking care to preserve an adequate amount of myometrium. A double layer running suture with barbed absorbable thread (V-Loc) for reconstructive purposes was performed. The specimen was retrieved inside an endobag to allow a safe extraction. Right salpingectomy was then performed. CONCLUSION:Considering the great anatomic variability of this condition, this type of surgery is not always simple. Indeed, the borders between the uterus and the rudimentary uterine horn are often not perfectly recognizable; this can lead to accidental removal of healthy myometrium and increase the risk of perioperative bleeding [5]. In our experience, the combined hysteroscopic and laparoscopic combined technique allows the surgeon to better delimit the borders of the hemiuterus, providing a more conservative and safer surgery. Hysteroscopic transillumination offers the possibility to modulate the radicality in the resection of the rudimentary horn and in the final treatment of dysmorphism.

OBJECTIVE:Involvement of the lower urinary tract is found in 0.2 to 2.5% of all deep infiltrating endometriosis (DIE) [1,2]. The bladder is the most affected organ with a prevalence of up to 80% of cases [3]. Patients with bladder endometriosis are often symptomatic (dysuria, hyperactive bladder, recurrent urinary tract infections, and hematuria). Surgery is the gold standard treatment for this condition when medical therapy fails [1,2]. Several studies have shown the feasibility, effectiveness, and safety of the laparoscopic approach [4] but data about robotic-assisted approach are missing in literature. Currently, novel platforms are entering the market and the Hugo™RAS (Medtronic, Minneapolis, USA) is a new system (HRS) consisting of an open console with 3D-HD screen and a multimodular bedside units. Even if some series are already available for radical cystectomies for oncologic purposes [5], a full description of DIE surgery performed with HRS is still lacking. Aim of this video-article is to show our technique and surgical setup to carry out a complex case of anterior compartment DIE. DESIGN:A step-by-step explanation of surgical technique with narrated video footage. SETTING:Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero-Universitaria di Bologna" Bologna, Italy. INTERVENTION:A 36-year-old nulliparous woman affected by DE was referred to our center due to severe dyspareunia, dysuria with hematuria and postvoiding pain not responsive to oral progestins. The preoperative work up consisted of a gynecological examination, pelvic ultrasound and MRI that showed the presence of an endometriotic nodule of the bladder base. All possible therapeutic strategies and related complications have been discussed with the patient before the signature of the informed consent. To carry out the procedure a "straight" port placement in a "compact" docking configuration [6] was installed. After developing the paravesical spaces bilaterally, the bladder nodule was approached in a latero-medial direction then a partial cystectomy with macroscopical free margins was performed. A double layer horizontal running suture with barbed thread was used to repair the bladder wall. CONCLUSION:To the best of our knowledge, this is the first case of bladder endometriotic nodule excision performed with HRS. We explained our technique and robotic set-up to successfully manage a compelx case of DIE of the bladder. VIDEO ABSTRACT.

Background: Recent advances in cancer diagnosis and treatment have significantly improved survival rates among women of reproductive age facing cancer. However, the potential iatrogenic loss of fertility caused by chemotherapeutic agents underscores the need to understand and predict chemotherapy-induced ovarian damage. This study addresses this gap by systematically reviewing the literature to investigate genetic markers associated with chemotherapy-induced ovarian failure (CIOF). Objective: The primary objective is to identify genetic markers linked to CIOF, contributing to a comprehensive understanding of the factors influencing fertility preservation in female cancer survivors. Methods: A systematic review was conducted using PubMed, EMBASE, Web of Science, Scopus, and OVID electronic databases from inception through December 2023. Studies were included if they featured genomic assessments of genes or polymorphisms related to CIOF in women with histologically confirmed tumors. Exclusion criteria comprised in vitro and animal studies, reviews, and pilot studies. The resulting four human-based studies were scrutinized for insights into genetic influences on CIOF. Results: Of the 5179 articles initially identified, four studies met the inclusion criteria, focusing on alkylating agents, particularly cyclophosphamide, and anthracyclines. Su et al. explored CYP3A41B variants, revealing modified associations with CIOF based on age. Charo et al. investigated GSTA1 and CYP2C19 polymorphisms, emphasizing the need to consider age and tamoxifen therapy in assessing associations. Oktay et al. delved into the impact of BRCA mutations on anti-Müllerian hormone (AMH) levels post-chemotherapy, supported by in vitro assays. Van der Perk et al. focused on childhood cancer survivors and revealed significant associations of CYP3A43 and CYP2B6*2 SNPs with AMH levels. Conclusions: This systematic review analyzes evidence regarding genetic markers influencing CIOF, emphasizing the complex interplay of age, specific genetic variants, and chemotherapy regimens. The findings underscore the need for a personalized approach in assessing CIOF risk, integrating genetic markers with traditional ovarian reserve testing. The implications of this study extend to potential advancements in fertility preservation strategies, offering clinicians a comprehensive baseline assessment for tailored interventions based on each patient's unique genetic profile. Further research is essential to validate these findings and establish a robust framework for integrating genetic markers into clinical practice.

STUDY OBJECTIVE:Although surgery is the gold standard treatment for pain refractory to medical management or partial occlusion owing to rectosigmoid endometriosis, surgical resection can be associated with major perioperative complications. From general surgery experience, intraoperative proctosigmoidoscopy has shown encouraging results as a feasible, safe, and effective technique in reducing the risk of complications related to intestinal anastomosis after segmental resection. Unfortunately, there are no studies evaluating its role after discoid resection for rectosigmoid endometriosis. DESIGN:A pilot, multicentric, observational, prospective, cohort study. SETTING:Two academic hospitals, from March 1 to December 31, 2022. PATIENTS:We enrolled all consecutive fertile-age patients affected by symptomatic endometriosis scheduled for laparoscopic discoid bowel resection. Inclusion criteria were (1) age between 18 and 50 years, (2) diagnosis of rectosigmoid endometriosis performed by transvaginal ultrasound and/or magnetic resonance imaging, and (3) women scheduled for laparoscopic discoid bowel resection of endometriosis at low risk of segmental resection. INTERVENTIONS:During data analysis, enrolled patients were divided into 2 study groups for comparisons based on whether or not the intraoperative proctosigmoidoscopy was performed upon surgeons' discretion after discoid resection for treating endometriosis, in addition to standard integrity tests. Primary outcome was the rate of intraoperative proctosigmoidoscopy success. Secondary study outcomes were the differences between the intraoperative proctosigmoidoscopy group and the nonintraoperative proctosigmoidoscopy group in (1) mean of total operative time and (2) rate of perioperative complications. MEASUREMENTS AND MAIN RESULTS:A total of 28 patients were enrolled and equally distributed in the 2 groups. The rate of intraoperative proctosigmoidoscopy success was 86%. No significant difference was reported between the 2 groups in terms of total operative time (p = .1) and intraoperative and postoperative complications (p = .5 and p = 1, respectively), with no surgical complication related to intraoperative proctosigmoidoscopy. CONCLUSION:Intraoperative proctosigmoidoscopy seems as a feasible and non-time-consuming intraoperative procedure in women undergone discoid resection for rectosigmoid endometriosis. Larger studies with longer follow-up period are necessary to confirm our findings and assess clinical benefits over standard procedure.

Background The septate uterus is the most common uterine abnormality, comprising 35% of all identified uterine malformations. According to the ESHRE/ESGE 2013 classification, the class U2bC2V1 is a rare congenital malformation characterized by a complete septate uterus with double cervix and nonobstructive longitudinal vaginal septum. Study objective to share the decision-making process, the preoperative ultrasonographic assessment and our step-by-step hysteroscopic surgery technique to manage this complex malformation: including how to access the septate uterine cavity, the resection of the septum and its post-operative management. The goal of the surgical treatment is to restore the regular morphology of the vaginal canal and the uterine cavity with the right amount of myometrium. Methods we present video footage of a hysteroscopic approach at a tertiary care academic medical center for managing a 21-year-old patient with a symptomatic uterine septum with double cervix and non-obstructive longitudinal vaginal septum. Results Both the Intraoperative and postoperative periods were uneventful: a complete resolution of the vaginal septum and creation of a single uterine cavity were obtained. Conclusion Due to the significant anatomic variability of this condition, this type of surgery can be challenging. The goal of this video is also educational, aiming to illustrate a reproducible technique that can be utilized by younger or less experienced surgeons. In our experience, this hysteroscopic technique appears to be a valid option for patients with symptomatic Mullerian malformation or those with a history of recurrent miscarriages or unexplained infertility.

Objective: To compare contained and free manual vaginal morcellation of large uteruses after total laparoscopic hysterectomy (TLH) in women at low risk of uterine malignancy in terms of feasibility and safety.Methods: A single-center, observational, retrospective, cohort study was carried out including all patients undergoing TLH requiring manual vaginal morcellation for specimen extraction of large uteruses from January 2015 to August 2021 at the Division of Gynecology and Human Reproduction Physiopathology, IRCCS Azienda Ospedaliero-Universitaria of Bologna, Bologna, Italy. Patients were divided into two groups according to the type of manual vaginal morcellation (contained or free), and compared in terms of demographic, clinical, and perioperative data.Results: In all, 271 patients were included: 186 (68.6%) in the contained morcellation group and 85 (31.4%) in the free morcellation group. The mean operative time was significantly lower in the contained morcellation group compared with the free morcellation group (median [interquartile range] 130 [45] vs. 155 [60] min; P < 0.001). No significant difference was found in complications related to the morcellation step, overall, intraoperative and postoperative complications, estimated blood loss, length of hospital stays, uterine weight, and rate of occult malignancy between the two groups.Conclusion: Contained vaginal manual morcellation of the uterus after total laparoscopic hysterectomy using a specimen retrieval bag appears to be a safe procedure with significantly lower operative time than free vaginal manual morcellation.

OBJECTIVE:To report an uncommon case of primary OP treated laparoscopically. Ectopic pregnancy (EP) is the leading cause of maternal mortality during the first trimester and the incidence increases with assisted reproductive techniques, occurring in approximately 1.5%-2.1% of patients undergoing in vitro fertilization.1 Omental pregnancy (OP) is an extremely rare form of EP accounting for less than 1% of all EPs. OP can be classified as primary or secondary on the basis of Studdiford's criteria2. The preoperative diagnosis of OP is complex and usually occur in acute circumstances during a throughout intraoperative evaluation of the abdomen.3-5 A delayed diagnosis poses a serious threat to the survival of the patient; therefore, it is important to remark that EP can exist in unusual locations and prompt surgical intervention may be necessary. DESIGN:A step-by-step narrated video of a rare clinical case and description of the surgical procedure. SETTING:Tertiary Level Academic Hospital "IRCCS Azienda Ospedaliero - Universitaria di Bologna" Bologna, Italy. PATIENT:A 36-year-old woman was referred to our emergency room because of acute abdominal pain and nausea for 2 hours with no signs of hemodynamic instability. The patient also complained that poor vaginal bleeding appeared during the last 24 hours. The patient has undergone a cycle of in vitro fertilization with an elective single frozen embryo transfer of a blastocyst on day 5, 2 months before. She had no relevant clinical or surgical history. Diffuse abdominal tenderness and a painful uterus at mobilization were appreciated at clinical examination. A massive hemoperitoneum was diagnosed using transvaginal-transabdominal ultrasound, and no uterine or adnexal lesions were identified. The β-human chronic gonadotropin level was 43.861 mIU/mL, and the hemoglobin value was 10.5 g/dL. INTERVENTIONS:On suspicion of a ruptured EP, after detailed counseling and the acquisition of informed consent, a laparoscopic exploration was planned. First, the hemoperitoneum was evacuated to allow visualization of the abdominal cavity. At pelvic inspection, no EP was found. Throughout the exploration of the abdominal cavity, a 4-cm bluish cystic mass of friable consistency was detected infiltrating the omentum and the mesentery. According to Studdiford's criteria, the diagnosis of a primary OP was established. A careful and complete excision of the ectopic implant was performed with an ultrasonic system and required a considerable hemostatic effort using bipolar energy, endoscopic clips, and mechanical compression. The postoperative course was uneventful. The β-human chronic gonadotropin levels gradually decreased to negative values within 29 days after surgery. MAIN OUTCOME MEASURE(S):Omental ectopic pregnancy can be successfully managed with a laparoscopic approach even in an emergency setting. CONCLUSION:Omental pregnancy can easily be overlooked, even by skilled surgeons, during laparoscopic exploration. It is mandatory that all peritoneal surfaces and the omentum be carefully inspected during surgery in patients without other signs of pelvic EP.We confirm that the patient included in this video gave consent for publication of the video and posting of the video online, including on social media, the journal website, scientific literature websites, and other applicable sites.

Adenomyosis has been associated with better survival outcomes in women with endometrial cancer. However, although the endometrial cancer patients' risk stratification has been revolutionized by molecular findings, the impact of the molecular signature on the favorable prognosis of endometrial cancer patients with coexistent adenomyosis is unknown. The aim of our study was to compare the prevalence of molecular groups at poor and intermediate prognosis between endometrial cancer patients with and without coexistent adenomyosis. A multicentric, observational, retrospective, cohort study was performed to assess the differences in the prevalence of p53-abnormal expression (p53-abn) and mismatch repair protein-deficient expression (MMR-d) signatures between endometrial cancer patients with and without coexistent adenomyosis. A total of 147 endometrial cancer patients were included in the study: 38 in the adenomyosis group and 109 in the no adenomyosis group. A total of 37 patients showed the MMR-d signature (12 in the adenomyosis group and 25 in the no adenomyosis group), while 12 showed the p53-abn signature (3 in the adenomyosis group and 9 in the no adenomyosis group). No significant difference was found in the prevalence of p53-abn (p = 1.000) and MMR-d (p = 0.2880) signatures between endometrial cancer patients with and without coexistent adenomyosis. In conclusion, the molecular signature does not appear to explain the better prognosis associated with coexistent adenomyosis in endometrial cancer patients. Further investigation of these findings is necessary through future larger studies.

Background: Undiagnosed ectopic pregnancies are among the main gynecological emergencies, and hemorrhage from an ectopic pregnancy is still the leading cause of maternal mortality in the first trimester. During the first lockdown period in Italy (March–April 2020) and in March 2021 restrictive measures were issued by the Italian government, but their impact on the incidence of ruptured tubal pregnancies remains unknown. Methods: The purpose of this study was to evaluate the impact of restrictive measures for the COVID-19 outbreak on the incidence of ruptured tubal pregnancies at our referral center for endoscopic gynecologic surgery. In particular, the primary outcome was the comparison of the incidence of ruptured tubal pregnancies between the lockdown phases and the other months of the pandemic. For this retrospective cohort study we considered all women examined for tubal ectopic pregnancy at our emergency unit from 1 January 2019 to 30 April 2021. We divided patients into three groups according to the period they were referred to our center: 10 March 2019–10 March 2020 (Pre-Covid period); 11 March–4 May 2020 and 6 March–30 April 2021 (Lockdown periods); 5 May 2020–5 March 2021 (COVID-19 pandemic period without restrictive policies). We compared data acquired during the lockdown phases with data collected both before the COVID-19 pandemic and during the restriction-free COVID-19 period. Results: 31 of 85 women were diagnosed with a ruptured tubal pregnancy. The proportion of ruptured ectopic pregnancies was higher during the lockdown period than the other two periods combined (62.5% vs 30.4%, p = 0.016). Mean gestational age and beta-HCG levels showed the same tendency (7.31 ± 1.25 weeks vs 5.99 ± 1.28 weeks, p < 0.0001; 7392.56 ± 4337.50 mUI/mL vs 4188.36 ± 3235.95 mUI/mL, p = 0.001). There were no differences between the proportion of ruptured pregnancies during the whole COVID-19 pandemic and the months preceding it (45.7% vs 25.6%, p = 0.07). Conclusions: Our study demonstrated that restrictive lockdown policies for the containment of the COVID-19 outbreak are associated with an increased rate of ruptured extrauterine tubal pregnancies.