The da Vinci robotic surgery system for the management of endometrial cancer: a single-center experience.

The aim of this study was to report our single-center experience of the da Vinci robotic surgery system in the management of endometrial cancer (EC) patients during 2019-2023. We descriptively summarized the preoperative, intraoperative, and postoperative outcomes. Moreover, we conducted subgroup analyses based on obesity (BMI ≥ 30 kg/m2) and the intraoperative use of indocyanine green dye (ICG). Overall, 100 patients were analyzed. Eighty-five patients (85%) were obese. The mean operative time and estimated blood loss (EBL) were 240.84 ± 70.08 min (range: 110-720) and 104.2 ± 80.3 ml (range: 20-500), respectively. The mean number of retrieved pelvic LNs was 3.01 ± 3.06 (range: 0-15). The use of ICG was employed in 58 (58%). Only a single patient (1%) underwent conversion to laparotomy. Besides, only three (3%) patients experienced vaginal laceration intraoperatively, respectively. The mean hospital stay was 1.34 ± 0.69 days (range: 1-5). No patient experienced postoperative complications. Most tumors had endometrioid histology (82%), grade-1 tumor (49%), and stage-1A disease (67%). At 3-year follow-up, only two patients (2%) developed recurrence. Patients who received the ICG had significantly lower operative time (225.86 vs. 261.52 min, p = 0.011), estimated blood loss (90 vs. 123.81 ml, p = 0.037), and hospital stay (1.12 vs. 1.64 days, p < 0.001) compared with patients who did not receive it. However, there was no significant difference between both groups regarding the number of retrieved pelvic LNs. Obesity had no significant impact on the rates of intraoperative complications, postoperative complications, and 3-year recurrence incidence. In conclusion, robotic surgery was technically feasible and safe. The use of ICG was statistically linked to favorable outcomes, in terms of decreased operative time, EBL, and hospital stay. Obesity did not impact the perioperative surgical outcomes.

CO2 laser therapy for management of stress urinary incontinence in women: a systematic review and meta-analysis.

Background: Carbon dioxide (CO2) laser therapy is an emerging treatment for women with stress urinary incontinence (SUI). Objectives: To examine the efficacy of CO2 laser therapy for management of SUI-related symptoms in women. Design: A systematic review and meta-analysis of randomized controlled trials and cohort studies. Data sources and methods: Four databases were screened until January 2023. All efficacy continuous endpoints were assessed via subtraction of the posttreatment from pretreatment values. The data were summarized as mean difference (MD) with 95% confidence interval (CI) using the random-effects model. Results: A total of 15 studies with 700 patients were analyzed. CO2 laser therapy significantly decreased the 1-h pad weights at 3 months [n = 5 studies, MD = -3.656 g, 95% CI (-5.198, -2.113), p < 0.001], 6 months [n = 6 studies, MD = -6.583 g, 95% CI (-11.158, -2.008), p = 0.005], and 12 months [n = 6 studies, MD = -3.726 g, 95% CI (-6.347, -1.106), p = 0.005]. Moreover, CO2 laser therapy significantly decreased the International Consultation of Incontinence Questionnaire-Urinary Incontinence Short Form Scores at 3 months [n = 10 studies, MD = -4.805, 95% CI (-5.985, -3.626), p < 0.001] and 12-months [n = 6 studies, MD = -3.726, 95% CI (-6.347, -1.106), p = 0.005]. Additionally, CO2 laser therapy significantly decreased the Pelvic Floor Impact Questionnaire scores at 6 months [n = 2 studies, MD = -11.268, 95% CI (-18.671, -3.865), p = 0.002] and 12 months [n = 2 studies, MD = -10.624, 95% CI (-18.145, -3.103), p = 0.006]. Besides, CO2 laser therapy significantly decreased the Urogenital Distress Inventory-6 scores at 3 months [n = 2 studies, MD = -21.997, 95% CI (-32.294, -11.699), p < 0.001], but not at 6 months [n = 3 studies, MD = -3.034, 95% CI (-7.357, 1.259), p = 0.169]. Lastly, CO2 laser therapy significantly increased the Vaginal Health Index Score at 6 months [n = 2 studies, MD = 2.826, 95% CI (0.013, 5.638), p = 0.047] and 12 months [MD = 1.553, 95% CI (0.173, 2.934), p = 0.027]. Conclusion: CO2 laser therapy improved the SUI-related symptoms in women. To obtain solid conclusions, future studies should be well-designed with standardized settings, consistent therapeutic protocols, and long-term follow-up periods.

Prophylactic tranexamic acid during myomectomy: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: To conduct a systematic review and meta-analysis of randomized controlled trials on the clinical efficacy and safety of prophylactic tranexamic acid (TXA) versus control (normal saline/no treatment) during myomectomy. METHODS: Six databases were screened from inception until 21-February-2022. The eligible studies were assessed for risk of bias. The outcomes were summarized as mean difference (MD) and risk ratio (RR) with 95% confidence intervals (CI) in a random-effects model. RESULTS: Seven studies, comprising eight arms and 571 patients (TXA = 304 patients, control = 267 patients) were analyzed. The included studies had an overall low risk of bias. The mean intraoperative blood loss (MD = -224.34 ml, 95% CI [-303.06, -145.61], p < 0.001), mean postoperative blood loss, and mean total blood loss were significantly reduced in favor of the prophylactic TXA group. Additionally, the mean postoperative hemoglobin (MD = 0.4 mg/dl, 95% CI [0.11, 0.68], p = 0.006) and mean postoperative hematocrit levels were significantly higher in favor of the prophylactic TXA group. While the mean hospital stay was significantly reduced in favor of the prophylactic TXA group (MD = -0.39 d, 95% [-0.74, -0.04], p = 0.03), there was no significant difference between both groups regarding the mean operation time and rate of blood transfusion. None of the participants in both groups developed any incidence of thromboembolic events. The rate of nausea was significantly higher in disfavor of the prophylactic TXA group (RR = 2.68, 95% CI [1.11, 6.43], p = 0.03). CONCLUSION: Among patients undergoing myomectomy, prophylactic TXA was largely safe and linked to substantial reductions in perioperative blood loss and related morbidities.

Vasopressin to Control Blood Loss during Hysterectomy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

OBJECTIVE: Minimizing intraoperative blood loss during hysterectomy is crucial to lessen associated perioperative morbidity. The aim of this investigation is to conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that compared vasopressin versus normal saline in controlling intraoperative blood loss during hysterectomy. DATA SOURCES: We screened 5 major databases (PubMed, Scopus, Web of Science, Embase, and the Cochrane Central Register of Controlled Trials) from inception till July 18, 2021. We used the following query search in all databases: (vasopressin OR arginine vasopressin OR argipressin OR antidiuretic hormone) AND (hysterectomy) AND (saline OR placebo OR control OR no treatment) AND (randomized OR randomised OR randomly). There was no language restriction during database screening. METHODS OF STUDY SELECTION: We considered all studies that met the following evidence-based criteria: (1) patients: individuals undergoing hysterectomy for any indication, (2) intervention: vasopressin, (3) comparator: normal saline, placebo, or no treatment, (4) outcomes: reliable extraction of any of our endpoints, and (5) study design: RCTs. We assessed risk of bias of included studies and pooled endpoints as mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI). We performed statistical analysis using the Review Manager software, version 5.4.0. TABULATION, INTEGRATION, AND RESULTS: Seven RCTs with an overall low risk of bias met the inclusion criteria. This meta-analysis included a total of 455 patients; 232 and 223 patients were allocated to vasopressin and control group, respectively. The majority of RCTs were vaginal hysterectomy (n = 5), few abdominal hysterectomy, (n = 2) and no laparoscopic hysterectomy. The mean estimated intraoperative blood loss was significantly lower in favor of the vasopressin group compared with the control group (n = 6 RCTs, MD = -119.85 mL, 95% CI [-177.55, -62.14], p <.001). However, there was no significant difference between both groups regarding mean operating time, mean change in postoperative hemoglobin, mean hospital stay, rate of febrile morbidity, rate of pelvic infection, rate of perioperative blood transfusion, and rate of perioperative complications. CONCLUSION: Compared with normal saline, vasopressin significantly reduced the estimated blood loss during hysterectomy but did not change any clinically significant outcomes. In addition, vasopressin was safe and did not correlate with an increase in the rates of febrile morbidity or pelvic infection.

Clinical Practice Guidelines on the Screening and Treatment of Precancerous Lesions for Cervical Cancer Prevention in Saudi Arabia.

BACKGROUND: Cervical cancer is the third most common gynecological malignancy in Saudi women with an estimated incidence rate of 1.9 cases per 100 000 women-years. More than 40% of cervical cancer cases are diagnosed at advanced stages due to lack of a routine screening program in Saudi Arabia. Thus, national guidelines for routine screening and treatment of precancerous cervical lesions are needed. METHODS: The Saudi Centre for Evidence-Based Healthcare invited a panel of local experts and partnered them with a team from McMaster University in Canada for methodological support, to develop national clinical practice guidelines on the screening and treatment of precancerous lesions for cervical cancer. After the panel identified key clinical questions, the McMaster University working group updated existing systematic reviews that had been used for the 2013 WHO Guidelines for screening and treatment of precancerous lesions for cervical cancer prevention. Recommendations were based on the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach. Those recommendations took into account the available evidence, patient values and preferences, and resource use in the Saudi context. The panel provided recommendations on two major issues: screening for precancerous lesions (cervical intraepithelial neoplasia 2 & 3) and treatment of those lesions to prevent cervical cancer in women who tested positive after screening. CONCLUSIONS: The Saudi expert panel recommends using the HPV DNA test followed by colposcopy or cytology (Pap test) followed by colposcopy to screen for CIN2+ in women at risk of cervical cancer. The panel recommends cryotherapy or loop excision electrosurgery procedure (LEEP) over cold knife cone biopsy to treat women at risk of cervical cancer that tests positive for CIN2+. Universal screening for precancerous cervical dysplasia in women in Saudi Arabia is recommended using HPV testing and or cytology. Either cryotherapy or LEEP are preferred for treatment. LIMITATIONS: National studies on cervical cancer screening modalities and treatment of precancerous cervical lesions, including HPV prevalence and its association with cervical cancer, are scarce.

Comparative study of grade 3/4 toxicity associated with intraperitoneal chemotherapy administered after primary versus interval surgical debulking in ovarian cancer.

OBJECTIVE: To determine the prevalence of grade 3 or 4 toxicity associated with intraperitoneal (IP) chemotherapy subsequent to primary surgical debulking compared to post-neoadjuvant chemotherapy and interval debulking in advanced ovarian cancer. METHODS: Patients receiving IP chemotherapy from 2006 to 2010 were reviewed. Study cohort was stratified by initial treatment (upfront surgery vs neoadjuvant chemotherapy). The National Cancer Institute toxicity grading scale was used to assess treatment-related toxicities immediately before each cycle. The χ² test was used to check for association between categorical variables. RESULTS: Thirty-three patients received IP chemotherapy after optimal debulking. Sixteen patients had upfront surgery. The total number of IP chemotherapy cycles administered was 134. Significantly, more patients treated with IP chemotherapy after intravenous neoadjuvant chemotherapy experienced fatigue (P=0.038) compared to those treated after upfront surgery. During the course of IP regimen, the patients having upfront surgery tended to experience more grade 3/4 hematologic toxicities (P=0.06) and abdominal pain (P=0.08). Twenty-four (73%) of 33 patients completed all prescribed IP chemotherapy cycles. There was no significant difference between the 2 groups in need for dose reduction or delays, use of paclitaxel on day 8, neurologic/gastrointestinal/metabolic toxicities, and IP port complications. CONCLUSIONS: Intraperitoneal chemotherapy can be given after optimal primary surgery or interval surgery after neoadjuvant chemotherapy with similar toxicity profile. Toxicity data can be used to plan for optimal IP chemotherapy delivery, patient counseling, and ongoing supportive care.