Rectovaginal Septum Research Articles

Cross-Tissue Regulatory Network Analyses Reveal Novel Susceptibility Genes and Potential Mechanisms for Endometriosis

Endometriosis (EMT) is a common gynecological disease with a strong genetic component, while its precise etiology remains elusive. This study aims to integrate transcriptome-wide association study (TWAS), Mendelian randomization (MR), and bioinformatics analyses to reveal novel putatively causal genes and potential mechanisms. We obtained summary-level data of the Genotype-Tissue Expression Project (GTEx), v8 expression quantitative loci (eQTL) data, and the genome-wide association study (GWAS) data of EMT and its subtypes from the R11 release results of the FinnGen consortium for analysis. GWAS data of modifiable risk factors were collected from IEU Open GWAS. Cross-tissue TWAS analyses were performed using the unified test for molecular signature (UTMOST), while functional summary-based imputation (FUSION) was employed for single-tissue TWAS analyses. Furthermore, we also conducted multi-marker analysis of genomic annotation (MAGMA) analyses to validate the significant associations. Subsequent Mendelian randomization (MR) and colocalization analysis elucidated the causal associations between the identified genes across various tissues and EMT. To further delve into mechanisms, two-sample network MR analyses were conducted. At last, bioinformatics analyses were employed to enhance our understanding of the functional implications and expression patterns of these identified genes. For EMT, 22 significant gene signals were identified by UTMOST, 615 by FUSION, and 354 by MAGMA. Ultimately, six genes, including CISD2, EFRB, GREB1, IMMT, SULT1E1, and UBE2D3, were identified as candidate susceptibility genes for EMT. Through similar procedures, we identified GREB1, IL1A, and SULT1E1 for EMT of the ovary, and we identified GREB1 for EMT of the pelvic peritoneum, EMT of rectovaginal septum and vagina, and deep EMT. In MR analyses, the expression of IMMT in 21 tissues, EFR3B in the adrenal gland, CISD2 in 17 tissues, and UBE2D3 in 7 tissues demonstrated causal relationships with EMT risk. In addition, CISD2, IMMT, and UBE2D3, across different tissues, exhibited strong colocalization with EMT (PPH4 > 0.7). Two-sample network MR analyses revealed that CISD2, EFR3B, and UBE2D3 could potentially regulate the levels of blood lipids and hip circumference so as to influence the risk of EMT. Furthermore, bioinformatics analyses confirmed our findings and delved into the biological functions of the identified genes. Our study unveiled seven novel candidate genes whose predicted expression was associated with the risk of EMT, providing new insights into the underlying genetic framework of EMT. These findings will facilitate a deeper comprehension of the tissue-specific transcriptional regulatory mechanisms associated with EMT, paving the way for optimizing the management and treatment of EMT.

Adenomyosis: A potential cause of surgical failure in treating dyspareunia in rectovaginal septum endometriosis.

Dyspareunia can severely impact the quality of life of patients with endometriosis. This symptom is often linked to a specific form of deep infiltrating endometriosis, such as rectovaginal septum endometriosis. Despite the radicality of surgery, persistence and recurrence of symptoms post-surgery are not uncommon. The aim of the present study was to determine whether adenomyosis contributes to the failure of surgical interventions for dyspareunia in these patients. A retrospective single-cohort study was conducted at the at tertiary care gynecologic center of the University Federico II of Naples, using medical records from January 2020 to July 2023. The study included patients who underwent surgery for dyspareunia associated with rectovaginal endometriosis and had a definitive histologic diagnosis. Pain and sexual quality of life were assessed using the visual analog scale (VAS) and the sexual quality of life-female (SQoL-F) questionnaire, both before and 6 months after surgery. Patients with isolated rectovaginal endometriosis were compared to those with concurrent adenomyosis. A total of 94 patients were included: thirty-five in group A (endometriosis with adenomyosis) and 59 in group B (isolated rectovaginal endometriosis). Histology confirmed deep infiltrating endometriosis (DIE) in all patients. Clinical characteristics such as age, BMI, abnormal uterine bleeding, and infertility, showed no significant differences between the groups. Multiparity was more common in group A (20%) compared to group B (5.1%) (P < 0.001). Pain VAS scores decreased significantly in both groups: from 7.11 to 5.40 in group A and from 7.34 to 3.31 in group B (both P < 0.001). Sexual quality of life (SQoL) scores improved significantly: from 42 to 57 in group A and from 41 to 66 in group B (both P < 0.001). Patients in group B showed a more significant improvement. Adjusted linear regression showed no significant association between parity and the severity of dyspareunia or sexual quality of life. Adenomyosis appears to reduce the effectiveness of surgical treatment for dyspareunia in patients with rectovaginal septum endometriosis. Comprehensive preoperative screening for adenomyosis is recommended to improve surgical outcomes and provide appropriate counseling. Future research should further explore the impact of adenomyosis on dyspareunia and the potential benefits of adjunctive medical therapies.

Robotic techniques in endometriosis: six steps for excision of rectovaginal nodules – the butterfly method

To present a standardized and reproducible approach for the surgical excision of deep endometriosis in the rectovaginal septum, represented by #ENZIAN A. Surgical video article. A tertiary referral center. The case of a patient with an isolated endometriotic nodule in the rectovaginal septum was used to illustrate the surgical technique, also referred to as the butterfly method. An Intuitive Xi DaVinci system was used at the tertiary referral center, IFEMEndo in Bordeaux, France. Patient consent was obtained. Step-by-step approach for the excision of endometriosis in the rectovaginal septum. This educational film presents a systematic approach dividing the surgical procedure into following six steps: We used the metaphor of the butterfly because it comprehensively and pictorially reflects the resection line of the endometriotic nodule in the rectovaginal septum. Surgical management of rectovaginal endometriosis can be challenging and requires as much as possible the preservation of autonomic nerves. A systematic approach enables the endoscopists to perform a safe and complete removal of the lesion.

Deficient Rectovaginal Septum and Uterine Prolapse through the Anal Margin

Deficient Rectovaginal Septum and Uterine Prolapse through the Anal Margin

Assessment of Pain in Endometriosis: A Radiologic Perspective on Disease Severity.

Background Endometriosis is a prevalent gynecological disorder characterized by extra-uterine endometrial-like tissue, causing substantial morbidity, including chronic pelvic pain and infertility. Little is known about the correlation between imaging findings and pain severity in endometriosis. Methods We conducted a prospective observational study, enrolling 150 women diagnosed with endometriosis. Clinical, imaging (MRI and transvaginal ultrasound (TVUS)), and histopathological criteria were used for diagnosis. Pain severity was assessed using the Visual Analog Scale (VAS). Statistical analysis included multivariate regression to identify predictors of pain severity. Results Imaging revealed common sites of endometriosis involvement, predominantly ovaries (73.3%) and rectovaginal septum (40%). Deep infiltrating endometriosis (DIE) was present in 30% of patients, predominantly affecting uterosacral ligaments (66.7% of DIE cases). Patients with ovarian endometriomas and DIE exhibited significantly higher VAS scores (7.6 ± 1.5 and 8.0 ± 1.2, respectively) compared to those without (6.5 ± 1.9 and 6.9 ± 1.8, respectively). Surgical intervention led to a significant reduction in VAS scores (from 7.4 ± 1.6 to 3.2 ± 1.7, p < 0.001), correlating with reductions in lesion size and extent observed in follow-up imaging. Conclusion Advanced imaging techniques, particularly MRI and TVUS, play a critical role in assessing pain severity in endometriosis. Ovarian endometriomas and DIE are independent predictors of increased pain severity, guiding personalized treatment strategies. Surgical excision of lesions, particularly in cases of DIE, offers substantial pain relief and improves quality of life, emphasizing the integration of imaging in clinical decision-making for optimal endometriosis management.

Peripheral blood leukocyte Telomere length and endometriosis: A Mendelian randomization study

BackgroundThe link between peripheral blood leukocyte telomere length (LTL) and endometriosis has remained uncertain. In order to investigate this association, a two-sample Mendelian randomization(MR) analysis was performed. MethodsWe extracted Single-nucleotide polymorphisms (SNPs) associated with LTL from a published genome-wide association study (GWAS) comprising 472,174 individuals. Data on endometriosis, including its seven subtypes, were sourced from the iue open gwas project. Four methods were employed for MR: Inverse-variance weighted analysis (IVW), Mendelian randomization-Egger regression (MR Egger), weighted-median analysis, and Weighted Mode. ResultsGenetically determined LTL was identified as a factor that can promote the occurrence of endometriosis. With every 1-SD increase in LTL, the risk of endometriosis increased by 26 % (OR = 1.260, 95 % CI = 1.073 to 1.479; P = 0.005). Genetically determined LTL also contributed to endometriosis subtypes: intestine (OR = 3.584, 95 % CI = 1.597 to 8.041; P = 0.002), ovary (OR = 1.308, 95 % CI = 1.033 to 1.655; P = 0.026), rectovaginal septum and vagina (OR = 1.360, 95 % CI = 1.000 to 1.851; P = 0.049). There was no observed causal relationship between LTL and the other four subtypes. ConclusionThis study, utilizing genetic data, offers evidence that longer LTL may cause increased risks of endometriosis, specifically endometriosis of the intestine, ovary, rectovaginal septum and vagina. These findings not only suggest that LTL may serve as a predictive factor for assessing the prevalence of three endometriosis subtypes but also provide new insights into the study of endometriosis pathogenesis.

Comparative study on the establishment efficacy of four types of animal models of rectovaginal fistula in rabbits

Various surgical methods have so far been developed for treating rectovaginal fistula (RVF), each with its own advantages and disadvantages. The lack of standardized animal models of RVF is a major reason for the failure to establish a unified and effective surgical method for the treatment of RVF. This study aimed to explore the feasibility of an RVF animal model by magnetic compression and compare it with the traditional modeling method. Thirty-two female Japanese white rabbits were randomly divided into four groups: A, B, C, and D, based on how the rectovaginal septum was treated. The operation time, intraoperative blood loss, and model success rate of each group were determined. The experimental animals were euthanized 2 weeks after the operation. Their rectovaginal septum specimens were obtained. RVF was observed by the naked eye. The fistula size was measured. Histological changes of fistula were observed by hematoxylin and eosin and Masson staining. All rabbits completed the RVF model and survived 2 weeks after the operation. Groups A and B had no bleeding, while groups C and D had < 0.5 mL of bleeding. The magnet detached in 4–6 days in group A, while it remained in place for 2 weeks after surgery in group B. Only one group D rabbit had a plastic hose for 2 weeks after surgery. The RVFs of groups A and C healed by themselves. In group B, the fistula was well formed. In group D, fistula healing was observed in three animals and the diameter of the fistulas was only 2.82–4.64 mm in the other four animals. Groups B and D had a scar on the inner surface of fistulas. Our study shows that the magnetic compression technique based on the T-shaped magnet is a highly useful method to establishing a continuous and stable RVF model in rabbits.

Effective timing of hyaluronate gel injection in image-guided adaptive brachytherapy for uterine cervical cancer: a proposal of the 'adjusted dose score'.

Hyaluronate gel injection (HGI) in the rectovaginal septum and vesicovaginal septum is effective in the setting of high-dose-rate image-guided adaptive brachytherapy (IGABT) for cervical cancer. We aimed to retrospectively investigate optimal conditions for HGI to achieve optimal dose distribution with a minimum number of HGI. We classified 50 IGABT plans of 13 patients with cervical cancer who received IGABT both with and without HGI in the rectovaginal septum and vesicovaginal septum into the following two groups: plan with (number of plans = 32) and plan without (number of plans = 18) HGI. The irradiation dose parameters of high-risk clinical target volume (CTVHR) and organs at risk per fraction were compared between these groups. We also developed the adjusted dose score (ADS), reflecting the overall irradiation dose status for four organs at risk and CTVHR in one IGABT plan and investigated its utility in determining the application of HGI. HGI reduced the maximum dose to the most exposed 2.0cm3 (D2.0 cm3) of the bladder while increasing the minimum dose covering 90% of CTVHR and the percentage of CTVHR receiving 100% of the prescription dose in one IGABT plan without causing any associated complications. An ADS of ≥2.60 was the optimum cut-off value to decide whether to perform HGI. In conclusion, HGI is a useful procedure for improving target dose distribution while reducing D2.0 cm3 in the bladder in a single IGABT plan. The ADS can serve as a useful indicator for the implementation of HGI.

Diagnostic performance of transvaginal sonography vs. magnetic resonance imaging for rectovaginal septum deep infiltrating endometriosis: a head-to-head comparative meta-analysis

We aimed to compare the diagnostic performance of transvaginal sonography (TVS) versus magnetic resonance imaging (MRI) in identifying deep infiltrating endometriosis (DIE) in the rectovaginal septum (RVS) of affected patients. An extensive search was conducted in the PubMed, Embase databases to identify available publications up to November 2023. Studies evaluating the diagnostic perfor-mance of TVS and MRI for DIE in patients with rectovaginal septum involvement were all included. Sensitivity and specificity analyses employed the DerSi-monian and Laird method, complemented by the Freeman-Tukey double arc-sine trans-formation. Additionally, the study quality was rigorously evaluated using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) method. The meta-analysis encompassed 8 articles with a total of 721 patients. It revealed that the overall sensitivity of TVS was 0.51 (95% CI: 0.31-0.72), contrasted with 0.74 (95% CI: 0.66-0.82) for MRI. This finding suggests a higher sensitivity of MRI compared to TVS (P=0.04). Conversely, the overall specificity was 0.97 (95%CI: 0.94-1.00) for TVS and 0.93 (95% CI: 0.84-0.99) for MRI, indicating a comparable level of specificity between the two modalities (P=0.22). Our meta-analysis reveals that MRI exhibits higher sensitivity and comparable specificity to TVS in patients with DIE of the RVS. However, the limited number of articles included may affect the evidence of these results. Therefore, further d number of articles included may affect the evidence of these results. Therefore, further research with larger sample sizes and prospective designs is essential to validate these findings.

Long-term results of rectocele surgical treatment by rectovaginal septum repair with a W-shaped mesh implant

40 patients with grade 2 and 3 rectocele were included in the study. The long-term results of surgical treatment within a timeframe of 12–42 months after surgery were evaluated in 34 (85 %) patients. The average duration of the disease history amounted to 5 (0.7–19) years. The mean age of the patients was 53.1±10.3 (Me=54.5) years. Before the surgery, as well as 6 and 12 months after the surgery, all patients underwent radiological defecography and were interviewed by means of specialized questionnaires to determine the disorders of the evacuation function of the colon and comprehensively assess the symptomatology of pelvic organ prolapse. Late postoperative complications were revealed in 2 out of 35 (5.7 %) patients 6 months after the surgical intervention. Twelve months after surgery and over, 31 out of 34 (91 %) patients had good or satisfactory outcomes characterized by a significant decrease in the manifestations of obstructed defecation syndrome, confirmed by the results of defecography, which showed an improvement in all criteria of the rectal evacuation function evaluation. These data objectively confirm the effectiveness of this method of treatment. The comparative analysis of the results of the patient survey by means of specialized questionnaires demonstrated a statistically significant difference between the level of scores before the intervention and 12 months after rectovaginal septum repair with W-shaped mesh implant. In conclusion, the method of rectovaginal septum repair with W-shaped mesh implant demonstrated its high efficiency, including the evaluation in the long-term follow-up period.

A 5-year evaluation of quality of life, pelvic discomfort, and sexual function following posterior pericervical repair.

The aim of this study was to evaluate the quality of life, pelvic discomfort, and sexual function of patients who underwent posterior pericervical repair or level I to III surgical procedures for pelvic organ prolapse (POP) after 5 years of follow-up. This retrospective cohort study enrolled 107 women with POP who were referred to the Imam Khomeini Hospital Complex, an academic center affiliated with the Tehran University of Medical Sciences, Tehran, Iran, from 2014 to 2021. The patients underwent transvaginal surgery using native tissue, in which the rectovaginal fascia was attached to the pericervical ring. The Pelvic Floor Distress Inventory-20 (PFDI-20) and Lower Urinary Tract Symptoms Module (ICIQ-FLUTSsex) questionnaires were completed by each patient before and 5 years after surgery. Of the 107 patients, only 78 completed the 5-year follow-up. The mean PFDI-20 scores before, 12 months, and 5 years after surgery were 141.87 ± 34.48, 100.87 ± 26.48, and 37.49 ± 56.39, respectively, indicating a significant improvement in the patients' symptoms after surgery (P < 0.001). The total mean score of ICIQ-FLUTSsex was 3.67 ± 3.63 (range, 0-10). In total, 22 (28.2%) women had an ICIQ-FLUTSsex score of 0, indicating no problems. The attachment of the rectovaginal fascia to the pericervical rings can be an effective surgical technique for correcting posterior vaginal wall prolapses, without significant morbidity. The PFDI-20 score improved significantly from before surgery to 12 months and 5 years after surgery.

Rectovaginal Fistulas Not Involving the Rectovaginal Septum Should Be Treated Like Anal Fistulas: A New Concept and Proposal for a Reclassification of Rectovaginal Fistulas.

Many rectovaginal fistulas(RVF), especially low RVF, do not involve/penetrate the RV-septum, but due to lack of proper nomenclature, such fistulas are also managed like RVF (undertaking repair of RV-septum) and inadvertently lead to the formation of a high RVF (involving RV-septum) in many cases. Therefore, REctovaginal Fistulas, Not Involving the Rectovaginal Septum, should be Treated like Anal fistulas(RENISTA) to prevent any risk of injury to the RV septum. This concept(RENISTA) was tested in this study. RVFs not involving RV-septum were managed like anal fistulas, and the RV-septum was not cut/incised. MRI, objective incontinence scoring, and anal manometry were done preoperatively and postoperatively. High RVF (involving RV-septum) were excluded. Twenty-seven patients with low RVF (not involving RV-septum) were operated like anal fistula[age:35.2±9.2 years, median follow-up-15 months (3-36 months)]. 19/27 were low fistula[<1/3 external anal sphincter(EAS) involved] and fistulotomy was performed, whereas 8/27 were high fistula (>1/3 EAS involved) and underwent a sphincter-sparing procedure. Three patients were excluded. The fistula healed well in 22/24 (91.7%) patients and did not heal in 2/24 (8.3%). The healing was confirmed on MRI, and there was no significant change in mean incontinence scores and anal pressures on tonometry. RV-septum injury did not occur in any patient. RVF not involving RV-septum were managed like anal fistulas with a high cure rate and no significant change in continence. RV-septum injury or formation of RVF with septum involvement did not occur in any patient. The RENISTA concept was validated in the present study. A new classification was developed to prevent any inadvertent injury to the RV-septum.

Botyroid Rhabdomyosarcoma of the Vagina in A Two-month-old Girl

Botyroid rhabdomyosarcoma is the most common malignant mesencymal tumor of the vagina in children and infants. It is a malignant tumor that arises from immature skeletal muscle cells (i.e., rhabdomyoblasts) lining the walls of hollow organs, including the vagina, bladder, and biliary tract. This cancer most commonly affects children under the age of 4, although it can sometimes present in older individuals. Botyroid sarcoma is usually found in the vagina during infancy and early childhood, in the cervix during reproductive years, and in the corpus uteri during postmenapausal years. Treatment is combination of surgery with adjuvants chemotherapy and radiotherapy. We report a case of two-month-old girl presented with a history of vaginal bleeding and a mass protruding from vagina. Diffusion Magnetic Resonance Imaging (MRI) showed an approximately 6 cm mass in rectovaginal septum. Excisional biopsy from the vagina confirmed the diagnosis of botyroid rhabdomyosarcoma. After biopsy the patient received multiple cycles of chemotherapy. The patient is disease-free on remission at this time.

Preoperative predictive parameters for accurate detection of stage IV endometriosis

BackgroundSurgery is the main line of treatment of endometriosis. Patients with stage IV endometriosis have more extensive adhesions, which make the surgery difficult. There are no accurate non-invasive predictive preoperative parameters of stage IV endometriosis and no consensus has been reached.Therefore, the aim of the present study was to evaluate and detect preoperative non-invasive parameters for the detection of stage IV endometriosis.Patients and methodsIn the present study, we included 150 females admitted for surgical removal of endometriosis. We scored and classified endometriosis into four stages according to the revised ASRM classification. We compared between baseline characteristics of patients with different stages of endometriosis, and then we selected the best combination of diagnostic and predictive parameters of stage IV endometriosis.ResultsPredictors of stage IV endometriosis and indicators for safety surgery were as follows: VAS ≥ 4 (p < 0.001), fixed uterus (p = 0.005), fixed ovarian cysts (p < 0.001), tender uterosacral ligament nodule (p < 0.001), tender rectovaginal septum nodule (p = 0.003), bilateral endometriosis (p < 0.001), and sum of sizes of endometriotic nodules (p < 0.001).ConclusionFixed uterus, fixed ovarian cysts, tender uterosacral ligament nodule, tender rectovaginal septum nodule, bilateral endometriosis, and indications for surgery were significantly considered adequate predictive markers for stage IV endometriosis.

Ultrasonographic characterization of parametrial endometriosis: a prospective study

ObjectiveTo study the ultrasonographic diagnostic accuracy and characteristics of parametrial endometriosis comprehensively. DesignThis prospective study enrolled patients with suspected deep endometriosis scheduled for laparoscopic surgical treatment. Preoperative ultrasonographic examinations were performed following the International Deep Endometriosis Analysis criteria. The study aimed to evaluate the presence of parametrial endometriosis and its ultrasonographic characteristics, using surgical diagnosis as the reference standard. Additionally, indirect signs of deep endometriosis and concomitant deep endometriosis nodules associated with parametrial involvement were identified, assessing their predictive significance in anterior, lateral, and posterior parametrial areas. SubjectsPatients with suspected deep endometriosis scheduled for surgical treatment. Intervention/ExposureStandardized preoperative ultrasonographic examination. Main Outcome MeasuresThe diagnostic accuracy of transvaginal ultrasound in identifying parametrial endometriosis, including sensitivity and specificity. Ultrasonographic characteristics of parametrial nodules, prevalence in distinct parametrial areas, and associations with indirect deep endometriosis signs and concomitant nodules. ResultsSurgical confirmation of parametrial nodules was observed in 105 out of 545 patients (18.5% left, 17.0% right). Transvaginal ultrasound demonstrated a sensitivity of 77.1% (95% CI 68.0–84.8%) and specificity of 99.1% (95% CI 67.7–99.8%). Parametrial nodules typically exhibited characteristics such as a mild hypoechoic appearance (83.6%), starry morphology (74.7%), irregular margins (70.2%), and low vascularization. The posterior parametrium was the most common location (52.2%), followed by the lateral (41.0%) and anterior parametrium (6.8%). Concomitant deep nodules in the rectum (63.5%) and infiltrating the rectovaginal septum (56.5%) were significantly more prevalent in patients with parametrial involvement (both p<0.001). Indirect signs of deep endometriosis, such as ovaries fixed to the uterine wall (71.8%) and the absence of a posterior sliding sign (51.8%), were also more common in women with parametrial DE nodules (both p<0.001). Hydronephrosis, though relatively uncommon in patients with parametrial involvement (8.2%), was largely detected in lateral parametrial nodules (70.0%). ConclusionThis study represents a systematic ultrasonographic characterization of parametrial endometriosis, comprehensively assessing the diagnostic accuracy of transvaginal ultrasound in identifying parametrial involvement within a sizable cohort of patients with preoperative suspicion of deep endometriosis.

Unraveling the relationship between gut microbiota and site-specific endometriosis: a Mendelian randomization analysis.

Although numerous studies have illustrated the connection between gut microbiota and endometriosis, a conspicuous gap exists in research focusing on the pathogenesis of endometriosis at various sites and its linkage with infertility. In this study, we used a two-sample Mendelian randomization analysis to investigate the effect of gut microbiota on the development of endometriosis in different regions, including the uterus, ovary, fallopian tube, pelvic peritoneum, vagina, and rectovaginal septum, as well as the intestine. Additionally, we explored the correlation between gut microbiota and endometriosis-induced infertility. Genetic associations with gut microbes were obtained from genome-wide association study (GWAS) datasets provided by the MiBioGen consortium, whereas endometriosis-related GWAS data were sourced from the FinnGen dataset. In our analysis, single-nucleotide polymorphisms were used as instrumental variables, with the primary estimation of the causal effect performed via the inverse variance weighting method. Our sensitivity analyses incorporated heterogeneity tests, pleiotropy tests, and the leave-one-out method. We identified associations at the genus level between four bacterial communities and endometriosis. Subsequently, several associations between the gut microbiota and various subtypes of endometriosis at different anatomical sites were recognized. Specifically, three genera were linked with ovarian endometriosis, six genera were associated with tubal endometriosis, four genera showed links with pelvic peritoneum endometriosis, five genera were connected with vaginal and rectovaginal septum endometriosis, and seven genera demonstrated linkages with intestinal endometriosis. Additionally, one genus was associated with adenomyosis, and three genera exhibited associations with endometriosis-induced infertility. Our study elucidates associations between gut microbiota and site-specific endometriosis, thereby augmenting our understanding of the pathophysiology of endometriosis. Moreover, our findings pave the way for potential therapeutic strategies targeting gut microbiota for individuals grappling with endometriosis-related infertility.

The Antigen-Processing Pathway via Major Histocompatibility Complex I as a New Perspective in the Diagnosis and Treatment of Endometriosis.

Endometriosis is a debilitating gynecological disease defined as the presence of endometrium-like epithelium and/or stroma outside the uterine cavity. The most commonly affected sites are the pelvic peritoneum, ovaries, uterosacral ligaments, and the rectovaginal septum. The aberrant tissue responds to hormonal stimulation, undergoing cyclical growth and shedding similar to appropriately located endometrial tissue in the uterus. Common symptoms of endometriosis are painful periods and ovulation, severe pelvic cramping, heavy bleeding, pain during sex, urination and bowel pain, bleeding, and pain between periods. Numerous theories have been proposed to explain the pathogenesis of endometriosis. Sampson's theory of retrograde menstruation is considered to be the most accepted. This theory assumes that endometriosis occurs due to the retrograde flow of endometrial cells through the fallopian tubes during menstruation. However, it has been shown that this process takes place in 90% of women, while endometriosis is diagnosed in only 10% of them. This means that there must be a mechanism that blocks the immune system from removing endometrial cells and interferes with its function, leading to implantation of the ectopic endometrium and the formation of lesions. In this review, we consider the contribution of components of the Major Histocompatibility Complex (MHC)-I-mediated antigen-processing pathway, such as the ERAP, TAP, LMP, LNPEP, and tapasin, to the susceptibility, onset, and severity of endometriosis. These elements can induce significant changes in MHC-I-bound peptidomes that may influence the response of immune cells to ectopic endometrial cells.

Safe dose escalation and reduction of the fraction number of uterine cervical brachytherapy using a gel spacer in the rectovaginal and vesicouterine septum: A planning study

PURPOSETo evaluate the possibility of dose escalation and reduction of fraction number in cervical brachytherapy using a gel spacer. MATERIAL AND METHODSTwenty patients with uterine cervical cancer treated with image-guided adaptive brachytherapy (IGABT) were selected. Hyaluronic acid gel injection (HGI) was performed in the rectovaginal and vesicouterine septum for 10 patients. The other ten patients were not with HGI. Both groups were treated with IGABT involving tandem/ovoid or cylindrical applicators along with additional interstitial needles. Dose distributions approved by radiation oncologists were retrospectively analyzed, and a dose summation of 45 Gy/25 of external beam radiation therapy and IGABT was performed. Dose constraints for D2cc of bladder, rectum, and sigmoid were 80, 70, and 70 Gy, respectively. Equivalent dose in 2-Gy fractions calculations used α/β = 10 Gy for high-risk clinical target volume (CTVHR) D90 and α/β = 3 Gy for organs at risks (OARs). As a planning study, dose distribution rescaling was conducted to deliver as much dose to CTVHR D90 as possible within the dose constraint limitation for OARs when IGABT was performed for four, three, and two fractions in both groups. RESULTSThe median CTVHR D90 was >80 Gy in the non-HGI group and >85 Gy in the HGI group for virtual two and three fractions. Rectum D2cc was significantly lower in the HGI group for three fractions (p < 0.01). CONCLUSIONSIn the HGI group, adequate dose delivery to CTVHR could be achieved with a reduced IGABT fraction number while meeting the dose constraints of OARs.

Gynecological technical notes for appropriate spacer injections

BackgroundDespite its efficacy, if adherence to dose constraints for surrounding normal tissues proves unattainable, the risk of late radiation-related adverse events after primary radiotherapy involving brachytherapy remains a noteworthy concern. Some studies suggest that similar to prostate radiotherapy, spacers may potentially reduce doses to surrounding healthy rectal or bladder tissues. However, guidance on spacer injections for gynecologic brachytherapy is scarce, and the optimal anatomical location for spacer placement remains undefined. We discuss maximizing the effects of spacers from an anatomical perspective. FindingsAs vesicovaginal and rectovaginal septa form part of the endopelvic fascia and are not uniform tissues, spacer injection resistance varies. In pelvic organ prolapse surgery, saline is injected into the anterior and posterior vaginal walls as a spacer, and the vagina, vesicovaginal septum, and bladder can be fluidly dissected. Relatively firm vesicovaginal septum tissue is used as a reconstructive organ, whereas rectovaginal septum tissue is less dense. Cervical cancer is invasive, involving surrounding fascia and ligaments. Ideally, the vesicovaginal and rectovaginal septa should be resected in radical hysterectomy. Here, spacer adaptation and the technical details of injection are described. When using ultrasound guidance for spacer injection, the target site should be adequately magnified, and the spacer ideally injected into the incision layer during radical hysterectomy. Finally, posthysterectomy, the intestinal tract may adhere to the vaginal cuffs. Therefore, artificial ascites may be useful; however, the spread depends on perioperative manipulation. ConclusionsAnatomical and surgical viewpoints are advantageous for safe, therapeutic, and replicable spacer injection administration.

Treatment of pediatric H-type rectovestibular fistula with tension-free repair of rectal seromuscular layer

ObjectiveThis study aimed to assess the outcomes of a 7-year experience with tension-free repair of the rectal seromuscular layer for H-type rectovestibular fistula in female children with a normal anus. MethodsBetween May 2016 and January 2023, 86 patients with H-type rectovestibular fistula underwent a standardized surgical procedure conducted by the same surgical team. The procedure involved: (1) Identifying and locating the vestibular orifice. (2) Dissecting the fistula. (3) Dissecting the anterior rectal wall. (4) Repairing the fistula. (5) Closing the internal opening of the fistula. During the dissection of the rectovaginal septum, care was taken to avoid any harm to the posterior wall of the vagina while exposing the anterior rectal wall by 10–25 mm. ResultsFollow-up, conducted via telephone or outpatient visits, ranged from 3 months to 6 years and 11 months (median, 3.5 years). In 82 cases (95.35% of 86), primary healing was achieved, resulting in satisfactory perineal appearance, smooth stool passage, and regular defecation. In 4 cases (4.65% of 86), fistula recurrence occurred within 5 to 10 days post-surgery. One case healed within 3 weeks with 3% boric acid sitz baths. The other 2 cases underwent debridement 7 days after the initial operation, leading to successful recovery. The final case experienced a recurrence 1 year after surgery following resection and repair of the perineal fistula, and no further surgical intervention was pursued. ConclusionTension-free repair of the rectal seromuscular layer represents a straightforward, safe, and effective surgical approach for managing H-type rectovestibular fistula with a normal anus in female children.