Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

Advanced bipolar vessel sealing devices vs conventional bipolar energy in minimally invasive hysterectomy: a systematic review and meta-analysis.

PURPOSE: To compare conventional bipolar electrosurgery with advanced bipolar vessel sealing (ABVS) devices for total laparoscopic hysterectomy (TLH). METHODS: A systematic review was conducted by searching Scopus, PubMed/MEDLINE, ScienceDirect, and Cochrane Library from January 1989 to November 2021. We identified all studies comparing ABVS devices with conventional bipolar electrosurgery in TLH and reporting at least one of the following outcomes: total blood loss, total operative time, hospital stay, perioperative complications, or costs. Meta-analysis was conducted with a random effect model reporting pooled mean differences and odds ratios (ORs) with related 95% confidence intervals (CIs). RESULTS: Two randomized controlled trials and two retrospective studies encompassing 314 patients were included out of 615 manuscripts. The pooled estimated total blood loss in the ABVS devices group was lower than conventional bipolar electrosurgery of 39 mL (95% CI - 65.8 to - 12.6 mL; p = .004). The use of ABVS devices significantly reduced the total operative time by 8 min (95% CI - 16.7 to - 0.8 min; p = .033). Hospital stay length did not differ between the two groups, and a comparable overall surgical complication rate was observed [OR of 0.9 (95% CI 0.256 - 3.200; p = .878]. CONCLUSIONS: High-quality evidence comparing ABVS devices with conventional bipolar electrosurgery for TLH is lacking. ABVS devices were associated with reduced total blood loss and operative time; however, observed differences seem clinically irrelevant. Further research is required to clarify the advantages of ABVS devices over conventional bipolar electrosurgery and to identify cases that may benefit more from their use.

Antimicrobial Resistance Pattern and Empirical Antibiotic Treatments in Neonatal Sepsis: A Retrospective, Single-Center, 12-Year Study.

Neonatal sepsis is an important cause of morbidity and mortality in neonatal intensive care units (NICUs). Continuous evaluation of antimicrobial resistance (AMR) profiles is advised to implement antimicrobial stewardship (AMS) programs and establish effective empiric antibiotic protocols. AMS may reduce AMR in NICUs and improve sepsis outcomes. In this retrospective observational study, we report data on culture-positive neonatal sepsis, assessing differences after the implementation of an AMS program (2011-2016 vs. 2017-2022). A total of 215 positive bacterial cultures from 169 infants were retrieved, with 79 early-onset (36.7%) and 136 late-onset (63.3%) sepsis episodes. Frequent causative agents for early-onset sepsis were S. agalactiae and E. coli, all susceptible to empiric treatment. Late-onset sepsis was mainly caused by Enterobacterales and S. aureus. Aminoglycosides, cefotaxime, and piperacillin-tazobactam resistance among Enterobacterales was substantially low; S. aureus was mostly susceptible to oxacillin and vancomycin. There were no differences in mortality and multidrug-resistant pathogens rates between the two study periods. There were five episodes of fungal late-onset sepsis, mostly due to C. albicans, of which one was fatal. The microbial distribution pattern and AMR profiles overlapped with other European studies. Because susceptibility patterns are rapidly changing worldwide, with the emerging threat of Methicillin-resistant S. aureus and extended-spectrum beta-lactamases producers, infection prevention and control practices and AMS strategies require continuous optimization to limit selection pressure and AMR escalation.

Diagnosis, Treatment and Prognosis of Mesonephric Adenocarcinoma of the Vagina: A Literature Review and a Case Report.

BACKGROUND: Mesonephric adenocarcinoma (MA) of the vagina is a rare tumor that arises from mesonephric remnants (Wolffian) in the female genital tract. It is a neoplasm with no significant evidence about its diagnosis, treatment, follow-up and prognosis. METHODS: Systematic research of the literature was conducted in Scopus, PubMed/MEDLINE, ScienceDirect and the Cochrane Library, including observational prospective and retrospective studies, case series and case reports. We collected data regarding studies related to diagnosis and treatment options evaluating the following aspects: study design, population, treatment type, rate of surgical complications and fertility outcome. We further included a case report of laparoscopic management of MA with pictorial assays. RESULTS: Thirteen cases of MA of the vagina are available in the literature, including our case report. The median age at diagnosis was 52 years old; the majority of patients reported vaginal bleeding as a symptom (38%); and ultrasound, followed by a magnetic resonance and CT scan were the diagnostic tools most used. In 54% of the cases, a surgical biopsy was performed, and 92% of the patients underwent upfront surgery with an open access or vaginal resection except one case fully managed by minimally invasive surgery. Most of the patients (68%) received adjuvant treatment with chemotherapy or radiotherapy or a combination of them. The mean follow-up period was 6 years. CONCLUSIONS: Despite the rarity of this cancer and bizarre location, a minimally invasive approach seems feasible after multidisciplinary evaluation. According to the rarity of this tumor, any future case and follow-up data must be reported in the literature in order to enlarge the knowledge about it.

The Role of Micronutrients in Human Papillomavirus Infection, Cervical Dysplasia, and Neoplasm.

There is evidence that diet and nutrition are modifiable risk factors for several cancers. In recent years, attention paid to micronutrients in gynecology has increased, especially regarding Human papillomavirus (HPV) infection. We performed a review of the literature up until December 2022, aiming to clarify the effects of micronutrients, minerals, and vitamins on the history of HPV infection and the development of cervical cancer. We included studies having as their primary objective the evaluation of dietary supplements, in particular calcium; zinc; iron; selenium; carotenoids; and vitamins A, B12, C, D, E, and K. Different oligo-elements and micronutrients demonstrated a potential protective role against cervical cancer by intervening in different stages of the natural history of HPV infection, development of cervical dysplasia, and invasive disease. Healthcare providers should be aware of and incorporate the literature evidence in counseling, although the low quality of evidence provided by available studies recommends further well-designed investigations to give clear indications for clinical practice.

Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review.

PURPOSE: To summarize available evidence comparing the transdermal and the oral administration routes of hormone replacement therapy (HRT) in postmenopausal women. METHODS: We performed a systematic review of the literature on multiple databases between January 1990 and December 2021. We included randomized controlled trials and observational studies comparing the transdermal and oral administration routes of estrogens for HRT in postmenopausal women regarding at least one of the outcomes of interest: cardiovascular risk, venous thromboembolism (VTE), lipid metabolism, carbohydrate metabolism, bone mineral density (BMD), and risk of pre-malignant and malignant endometrial lesions, or breast cancer. RESULTS: The systematic literature search identified a total of 1369 manuscripts, of which 51 were included. Most studies were observational and of good quality, whereas the majority of randomized controlled trials presented a high or medium risk of bias. Oral and transdermal administration routes are similar regarding BMD, glucose metabolism, and lipid profile improvements, as well as do not appear different regarding breast cancer, endometrial disease, and cardiovascular risk. Identified literature provides clear evidence only for the VTE risk, which is higher with the oral administration route. CONCLUSIONS: Available evidence comparing the transdermal and oral administration routes for HRT is limited and of low quality, recommending further investigations. VTE risk can be considered the clearest and strongest clinical difference between the two administration routes, supporting the transdermal HRT as safer than the oral administration route.

First Human Case of Tick-Borne Encephalitis in Non-Endemic Region in Italy: A Case Report.

Tick-borne encephalitis (TBE), a human viral infectious disease caused by the tick-borne encephalitis virus (TBEV), is emerging in Italy, especially in the north-eastern area. No human cases of autochthonous TBE have been reported in Italy's central regions (such as Emilia-Romagna, Italy). However, here we describe the first human case of TBEV infection in this region, pointing to endemic transmission of TBEV, supporting the concept of circulation of TBEV and of the presence of a possible hot spot in the Serramazzoni region in the Emilian Apennines.

Tranexamic acid for the prevention and the treatment of primary postpartum haemorrhage: a systematic review.

Tranexamic acid (TA) has been proposed for preventing or treating primary postpartum haemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. We conducted a systematic literature search to the TA role in managing PPH in vaginal and caesarean delivery. Twenty-seven randomised controlled trials (RCTs) (33,302 women) were identified. Three RCTs investigated TA for preventing PPH after vaginal delivery and 22 after caesarean section. None demonstrated a preventive effect on secondary clinical outcomes related to blood loss. Two trials evaluated TA for treating PPH after vaginal and caesarean delivery. Only the WOMAN trial showed that 1 g of TA is effective. In conclusion, TA is considered useful and is recommended or advised for treating PPH. Conversely, available evidence on the prophylactic role is still limited, and this use is not supported. Further investigation is recommended. In this regard, stronger and more reliable outcomes than blood loss should be considered.

Uterine torsion and intrauterine growth restriction: Case report and systematic literature review.

PURPOSE: Uterine torsion (UT) in pregnancy is a rare condition in obstetric practice. It is defined as a rotation of the uterus of more than 45° around its long axis. Presentations are varied and, most of the time, this condition is recognized at laparotomy or cesarean section (CS). The aim of this study is to summarize the latest evidence about UT in pregnancy. METHODS: A systematic research of the literature was conducted fetching all papers published from March 2006 to June 2020. We collected data regarding clinical features, treatment, and feto-maternal outcomes. Finally, we reported data of a case of UT associated with intrauterine growth restriction (IUGR) diagnosed and treated at our institution. RESULTS: According to our search strategy, 38 articles were included. In 66% of the cases, acute symptomatology was present at the onset, most frequently abdominal pain was reported. In one-third of the cases, UT was diagnosed during CS without clinical suspicion. Only in two cases, including our case, IUGR was reported. Most (66%) of the cases presented a 180° torsion. In the majority of the cases, a CS was performed also with a deliberate or accidental posterior hysterotomy. One and six cases of maternal and fetal death were, respectively, reported. CONCLUSION: UT is an infrequent obstetric condition but should be considered in case of abdominal pain, vomiting, or shock presentation during pregnancy. It could lead to a reduction in uterine blood flow contributing to poor placental perfusion, even though more evidence is needed to clarify this link.

The Impact of COVID-19 on UNAIDS 90-90-90 Targets: Calls for New HIV Care Models.

We compared 90-90-90 targets in 2020, during the coronavirus disease 2019 (COVID-19) pandemic, with the targets across the period 2017-2019 in people with HIV. We observed a significant loss in the 90-90-90 objectives in 2020 when compared with 2017-2019 that might be attributable to the COVID-19 crisis.

Holographic Reconstructions for Preoperative Planning before Partial Nephrectomy: A Head-to-Head Comparison with Standard CT Scan.

BACKGROUND: Preoperative surgical planning before partial nephrectomy (PN) is a time-consuming and fragmentary process. OBJECTIVES: To evaluate the differences in the perception of renal anatomy between holographic reconstruction (HR) versus computed tomography (CT) in patients who are candidate to PN. METHODS: CT scans of 10 consecutive patients with intermediate/high complexity renal masses (R.E.N.A.L. score > 8) scheduled for robot-assisted PN were translated into HR. Seven raters independently described how they interpreted several anatomical details from CT and HR respectively. The exams were presented unpaired and randomly. Inter-observer agreement and evaluation time were assessed. A questionnaire inquired clinical utility of CT and HR. Inter-observer agreement was measured by the Cohen's kappa test. Evaluation time for CT and HR was compared by the Kruskal-Wallis test, overall and per rater. Examiners answered to the questionnaire following a Likert scale. RESULTS: HR showed a higher inter-observer agreement, reaching a good level (k > 0.6) for almost all the anatomical details considered. Conversely, CT generally provided a fair or poor agreement (k < 0.6). The evaluation time was shorter for HR (mean 1.7 vs. 3.4 min, p < 0.0001). All raters declared that HR could facilitate preoperative planning before PN. CONCLUSIONS: HR can be useful for preoperative surgical planning before PN to ease the understanding of anatomy.

Safety of physical examination alone for managing well-appearing neonates ≥ 35 weeks' gestation at risk for early-onset sepsis.

OBJECTIVE: The published data to support recommendations for prevention and management of well-appearing at-risk newborns (WAARNs) for early-onset sepsis (EOS) are limited. METHODS: Retrospective cohort study comparing two different strategies for managing WAARNs (≥ 35 weeks' gestation) during a 6-year period (Period 1, from 2005 to 2007; Period 2, from 2009 to 2011). WAARNs were defined as healthy-appearing neonates evaluated because of risk factors for EOS. Laboratory evaluation plus simplified physical examination (Period 1) was compared with physical examination alone (PEA, Period 2). The use of antibiotics, the length of stay, the timeliness of diagnosis and the risk of falling ill immediately after hospital discharge in both periods were also compared. RESULTS: WAARNs receiving empirical antibiotics were 14/500 (Period 1) and 3/500 (Period 2, p = 0.01). Median length of stay was 4 (Period 1) and 3 days (Period 2, p = 0.04). Symptoms of EOS were earlier than laboratory evaluation results in 42/44 neonates. Severe disease was diagnosed within 6 h of life in all neonates. No WAARNs presented with EOS following hospital discharge. CONCLUSIONS: WAARNs managed through PEA received less unnecessary antibiotics and had a shorter length of stay. They had no increased risk of severe complications or increased risk of becoming ill following hospital discharge.

Factors associated with intrapartum transmission of group B Streptococcus.

BACKGROUND: Data regarding the minimum duration of intrapartum antibiotic prophylaxis (IAP) required for preventing group B Streptococcus (GBS) early-onset sepsis are conflicting. Understanding factors that influence neonatal colonization (NC) might help us understand factors associated with failure of prophylaxis. METHODS: This is a 14-month prospective cohort study conducted at a single tertiary care center with a screening-based strategy. Women were enrolled if they had ≥ 35 weeks' gestation and were GBS-positive at the vaginal site on admission. Their neonates were cultured from the throat and rectum at 24-48 h after birth. Colony growth was graded semiquantitatively (from 1+ to 4+). Uni- and multivariate logistic regression analyses were performed to evaluate risk factors for NC. RESULTS: There were 502 neonates, 458 of whom were exposed to IAP. All cases of NC were associated with a lack of IAP exposure (P < 0.01), intrapartum fever ≥ 37.5°C (P < 0.01) and African ethnicity (P < 0.01). In the 458 IAP-exposed neonates, the rates of NC were low and did not vary significantly in the range of less than 1-12 h before delivery (score test for trend of odds, P = 0.13). The only independent factors associated with NC were intrapartum fever ≥ 37.5°C and heavy maternal colonization (P < 0.01 and P = 0.03, respectively). CONCLUSIONS: Heavy maternal colonization, intrapartum fever, African ethnicity and lack of IAP exposure were associated with GBS transmission in neonates born to women who were tested positive on admission. Low rates of NC were found among IAP-exposed neonates irrespective of IAP duration.