Effect of Preoperative Bilateral Ultrasound-guided Quadratus Lumborum Nerve Block on Quality of Recovery after Minimally Invasive Hysterectomy in an Enhanced Recovery after Surgery (ERAS) Setting.

STUDY OBJECTIVE: To assess the effect of preoperative bilateral ultrasound-guided quadratus lumborum nerve block (QLB) on quality of recovery after minimally invasive hysterectomy, in an enhanced recovery after surgery setting. DESIGN: Randomized, controlled, double-blinded trial (Canadian Task Force level I). SETTING: University-affiliated tertiary medical center. PATIENTS: All women undergoing an elective robotic or laparoscopic hysterectomy. Women with chronic pain, chronic anticoagulation, and body mass index >50 kg/m2 were excluded. INTERVENTION: Patients were randomized with a 1:1 allocation, to one of the following 2 arms, and stratified based on robotic versus laparoscopic approach. 1. QLB: QLB (bupivacaine) + sham local trocar sites infiltration (normal saline) 2. Local infiltration: sham QLB (normal saline) + local infiltration (bupivacaine) MEASUREMENTS AND MAIN RESULTS: The primary outcome was defined as the quality of recovery score based on the validated questionnaire Quality of Recovery, completed 24 hours postoperatively. Secondary outcomes included dynamic pain scores, accumulated opioid consumption up to 24 hours, postoperative nausea and vomiting, surgical complications, length of hospital stay, time to first pain medication administration in the postanesthesia care unit, and adverse events. A total of 76 women were included in the study. Demographic characteristics were similar in both groups. Median age was 44 years (interquartile range 39-50), 47% of the participants were African American, and mean body mass index was 32.8 kg/m2 (standard deviation [SD] 8.1). The mean Quality of Recovery score was 179.1 (SD ± 10.3) in the QLB and 175.6 (SD ± 9.7) for the local anesthesia group (p = .072). All secondary outcomes were comparable between groups. CONCLUSIONS: QLBs do not significantly improve quality of recovery after elective robotic or laparoscopic hysterectomy compared with local anesthetic port site infiltration.

Excess use of surgical supplies in minimally invasive benign gynecology surgery: an observational study.

BACKGROUND: Single-use materials and equipment are regularly opened by the surgical team during procedures but left unused, potentially resulting in superfluous costs and excess environmental waste. OBJECTIVE: This study aimed to estimate the excess use of surgical supplies in minimally invasive benign gynecologic surgeries. STUDY DESIGN: This is a prospective observational study conducted at a university-affiliated single tertiary medical center. Designated study personnel were assigned to observe surgical procedures performed during July to September 2022. Surgical teams were observed while performing surgeries for benign indications. The teams were not informed of the purpose of the observation to avoid potential bias. Disposable materials and equipment opened during the procedure were documented. Excess supplies were defined as those opened but left unused before being discarded. Costs per item of the excess supplies were estimated on the basis of material and equipment costs provided by the hospital. RESULTS: A total of 99 surgeries were observed, including laparoscopic (32%), robotic (39%), hysteroscopic (14%), vaginal (11%), and laparotomy procedures (3%). Excess use of surgical supplies was documented in all but one procedure. The total cost across all surgeries reached $6357. The contained tissue extraction bag was the most expensive item not used (Applied Medical, Rancho Santa Margarita, CA; $390 per unit) in 4 procedures, contributing 25.54% to the total cost. Raytec was the most common surgical waste, with a total of n=583 opened but unused (average n=5.95 per surgery). A significant difference was found in the rate of excess supplies across the surgical approaches, with robotic surgery contributing 52.19% of the total cost (P=.01). CONCLUSION: Excess use of disposable materials and equipment is common in minimally invasive benign gynecologic surgeries and contributes to superfluous costs and excess environmental waste. It is predominantly attributed to the opening of inexpensive materials that are left unused during the procedure. Increased awareness of costs and generated waste may reduce excess use of surgical supplies and should be further explored in future research.

Overactive Bladder Symptoms After Pelvic Organ Prolapse Repair.

OBJECTIVES: This study aimed to identify the characteristics associated with overactive bladder (OAB) symptoms perioperatively in patients undergoing pelvic organ prolapse (POP) surgery with and without slings and to determine the rate of OAB symptom resolution postoperatively. METHODS: This retrospective, single-institution study involved women undergoing prolapse surgery with and without concomitant midurethral sling from 2011 to 2016. A validated questionnaire was used to determine OAB symptoms preoperatively and postoperatively. The primary outcome was rate of resolution in OAB symptoms after POP surgery with and without midurethral sling. Baseline characteristics and surgery type were presented, and univariate and multivariate logistic regression models were applied to evaluate characteristics associated with OAB symptoms at the first postoperative visit. RESULTS: The analysis included 203 patients. Among those with baseline OAB symptoms, 103 (61%) had symptom resolution, whereas 66 (39.1%) reported persistent symptoms. Among 34 patients without baseline OAB symptoms, 6% developed de novo symptoms. Older age was found to be a significant risk factor for persistence of symptoms postoperatively both on univariate (odds ratio, 0.97; 95% confidence interval, 0.94-1; P = 0.038) and multivariate logistic regression (odds ratio, 0.96, 95% confidence interval, 0.92-1; P = 0.049). The rate of medication discontinuation postoperatively was 25%. CONCLUSIONS: Approximately 61% of patients undergoing POP surgery had resolution of OAB symptoms postoperatively whether or not an incontinence procedure was performed. Older age was significantly related to persistent OAB symptoms in both univariate (P = 0.038) and multivariate (P = 0.049) models. The rate of de novo OAB symptoms was 6%.

Epithelial ovarian cancer and type of peritoneal insult: a case-control study.

OBJECTIVE: To evaluate the association between different types of peritoneal insults and the development of sporadic epithelial ovarian cancer (EOC) subtypes in the general population. STUDY DESIGN: Hospital based case control study comparing sporadic cases of EOC with age matched control group between 2003 and 2008. Medical, surgical, and gynecological histories were compared between 208 women with histological diagnosis of EOC and 224 women in the control group matched for age at presentation for well woman examination. RESULTS: 18% patients in the study population and 5% patients in the control group had history of diverticulosis (OR 7.3, 95% CI 2.8-19.1). 10% patients in the study populations and 39% patients in the control group had history of diabetes mellitus (OR 0.41, 95% CI 0.23-0.75). Sub classification of EOC into type 1 and type 2 further revealed 12% patients (OR 0.44, 95% CI 0.22-0.87) in type 1 group, 35% patients (OR 0.43, 95% CI 0.27-0.69) in type 2 group, and 71% patients in the control group had no prior surgical history. Furthermore, 3% patients (OR 0.27; 95% CI 0.08-0.9) in the type 1 group, 48% patients (OR 2.0, CI 95% 1.24-3.24) in the type 2 group, and 41% patients in the control group had history of bilateral tubal ligation (BTL). CONCLUSION: A significant association was found between diverticulosis, hysterectomy and endometriosis increasing the likelihood of type 1 EOC; while diverticulosis, exploratory laparotomy and hysterectomy increased the likelihood of type 2 EOC. BTL was significantly associated with decreasing the likelihood of type 1 EOC, but increasing the likelihood of type 2 EOC. Diabetes mellitus and no prior surgical history were found to significantly decrease the likelihood of all EOC.

Nonsurgical Management of Neuroendocrine Cancer of the Cervix: Brief Report.

OBJECTIVES: The aim of this study was to evaluate disease progression and overall survival in patients diagnosed with neuroendocrine carcinoma of the cervix treated with chemotherapy and radiation without surgical intervention; we hypothesize similar overall survival to the surgical intervened cases. METHODS: This study used a retrospective analysis of patients with neuroendocrine carcinoma of the cervix who were not surgically managed. Review was performed from 1990 to 2014. The data collected included demographics, stage of disease, and outcomes after each treatment. Specific chemotherapy regimen given and radiation dosage were reviewed. Overall survival and recurrence rates were calculated. RESULTS: A total of 16 patients met inclusion criteria. Six patients were diagnosed with stage I; these patients had 83.3% 2-year overall survival, 83.3% 5-year overall survival, and a recurrence rate of 16.6%. Three patients were diagnosed with stage II; these patients had 66.6% 2-year overall survival, 0% 5-year overall survival, and a recurrence rate of 100%. Seven patients were diagnosed with stage IV; these patients had 14.3% 2-year overall survival and 0% 5-year overall survival and never underwent remission. CONCLUSIONS: Our findings noted a comparable overall survival with lower rates of recurrence in patients with early-stage disease using chemotherapy and radiation therapy alone as primary means of treatment. Nonsurgical management of neuroendocrine carcinoma of the cervix may be of benefit in early-stage disease.

Solid papillary carcinoma of the breast with neuroendocrine features in a pregnant woman: a case report.

Solid papillary carcinoma, a special form of breast carcinoma with neuroendocrine differentiation, usually presents in women aged 60 years or more. (Koern 2010). According to our best knowledge, we present the second case of such a tumor in pregnant women.

Expression of vascular endothelial growth factors VEGF- C and D, VEGFR-3, and comparison of lymphatic vessels density labeled with D2-40 antibodies as a prognostic factors in vulvar intraepithelial neoplasia (VIN) and invasive vulvar cancer.

OBJECTIVE: The aim of this study was to compare the immunohistochemical expression of vascular endothelial growth factors VEGF-C and D, as well as the expression of VEGFR-3 in VIN and vulvar invasive cancer and to compare the density of lymphatic marker D2-40 antibody in both groups, and to compare them with different clinicopathologic features. MATERIALS & METHODS: The study was performed using tissue material and clinical data from 100 women diagnosed with VIN and 100 women diagnosed with invasive vulvar cancer. RESULTS: No significant differences were found in the expression of VEGF-C and -D or VEGFR-3 between those patients with VIN and those with invasive vulvar cancers. Weak expression of VEGF-C was confirmed only in two cases of the analyzed series; in all cases, expression of VEGF-D and VEGFR-3 was observed. The strongest expression of VEGF-D and VEGFR-3 was observed in the group of invasive cancers. The highest density of lymphatic vessels per 2 mm was observed in VIN. In the cancer group, small lymphatic vessels with a narrow oval lumen were observed. Moreover, in two cases of vulvar cancer, the presence of intratumoral lymphatic vessels was observed. CONCLUSIONS: These results suggest that lymphangiogenesis begins at the preinvasive stage of vulvar carcinogenesis and suggests the important role of VEGF-C, VEGF-D, VEGFR-3 and LV (D2-40) as prognostic factors in the process of carcinogenesis in the vulvar area.

Overexpression of P53 protein and local hGH, IGF-I, IGFBP-3, IGFBP-2 and PRL secretion by human breast cancer explants.

BACKGROUND: Insulin-like growth factor-I (IGF-I) in concert with insulin-like binding protein 3 (IGFBP-3), insulin-like binding protein 2 (IGFBP-2), human growth hormone (GH) and P53 protein is involved in autocrine/paracrine growth signaling pathways as an adaptive response to environmental stimuli. OBJECTIVE: The study evaluated the local secretion of PRL, hGH, IGF-I, IGFBP-2 and IGFBP-3 by breast cancer tissue explants in relation to the overexpression of P53 protein in breast cancer tissue. MATERIALS AND METHODS: Breast cancer explants were obtained during radical mastectomies. The overexpression of P53 protein was assessed immunohistochemically using monoclonal antibody (DAKO, Anti-Human P53 protein, clone DO-7); the results of the reaction were stratified into 5 groups. The lack of P53 protein overexpression was defined as 0% of cells that overexpressed P53 protein. IGF-I, IGFBP-3, IGFBP-2, and hGH levels were measured with RIA kits, and prolactin was measured with the MEIA kit. RESULTS: The local secretion of hGH by tumour explants - presenting a positive immunohistochemical reaction (IHCR) to the product of P53 gene - was twice as high as those with no IHCR to product of P53 gene; the opposite was noted in the case of IGF-I, IGFBP-2 and IGFBP-3 secretion. In both cases, the level of hGH, IGF-I and IGFBP-3 secretion did not correlate with the ratio of cells overexpressing P53 protein. There was a significant decrease in local, basic IGFBP-2 secretion along with an increased ratio of cells with positive IHCR to product of P53 gene. Furthermore, local PRL secretion was not correlated with the ratio of cells overexpressing P53 protein in breast cancer tissue. Prolactin also exerts no influence on IGF-I secretion. CONCLUSION: Our results may suggest the presence of local hGH/IGF-I feedback in breast tissue as well as the possibility of P53/hGH/IGF-I/IGFBP-3 but not P53/PRL/IGF-I axis.

Results in treatment of early breast cancers and the level of selected metalloproteinases.

BACKGROUND: Breast cancer is the most common malignancy in women in the U.S. and Europe. In the early stages of the disease, women are treated surgically, which is supplemented with hormonal therapy, immuno-, chemo- or radiotherapy. Postoperative qualification for further treatment is based on clinical stage, the pathology of the tumor and classic prognostic factors. Despite that, among patients with breast cancer in early stages of clinical advancement, there is a relatively large proportion of observed tumor recurrence. These observations oblige the search for additional prognostic factors that determine the progression of the disease faster, according to which, could emerge a group of women at increased risk of recurrence of the disease. AIM: The aim of this paper is to determine the meaning of the expression of selected metalloproteinases as prognostic factors in breast cancer. METHODS: The study group consisted of 108 patients ages 26 to 86 years treated surgically from 1994 to 2000 because of primary breast cancer in the early clinical stage, ie stage I and II according to TNM classification. RESULTS: Between two of the tested metalloproteinases (MMP-2 and MMP-11) only MMP-2 appears to have prognostic significance in early forms of breast cancer, and its strong expression is associated with shorter survival.

Discovery of novel microRNAs in female reproductive tract using next generation sequencing.

MicroRNAs (miRNAs) are small non-coding RNAs that mediate post-transcriptional gene silencing. Over 700 human miRNAs have currently been identified, many of which are mutated or de-regulated in diseases. Here we report the identification of novel miRNAs through deep sequencing the small RNAome (<30 nt) of over 100 tissues or cell lines derived from human female reproductive organs in both normal and disease states. These specimens include ovarian epithelium and ovarian cancer, endometrium and endometriomas, and uterine myometrium and uterine smooth muscle tumors. Sequence reads not aligning with known miRNAs were each mapped to the genome to extract flanking sequences. These extended sequence regions were folded in silico to identify RNA hairpins. Sequences demonstrating the ability to form a stem loop structure with low minimum free energy (<-25 kcal) and predicted Drosha and Dicer cut sites yielding a mature miRNA sequence matching the actual sequence were considered putative novel miRNAs. Additional confidence was achieved when putative novel hairpins assembled a collection of sequences highly similar to the putative mature miRNA but with heterogeneous 3'-ends. A confirmed novel miRNA fulfilled these criteria and had its "star" sequence in our collection. We found 7 distinct confirmed novel miRNAs, and 51 additional novel miRNAs that represented highly confident predictions but without detectable star sequences. Our novel miRNAs were detectable in multiple samples, but expressed at low levels and not specific to any one tissue or cell type. To date, this study represents the largest set of samples analyzed together to identify novel miRNAs.