Minimally invasive sacrocolpopexy: efficiency of robotic assistance compared to standard laparoscopy.

Minimally invasive abdominal sacrocolpopexy (SC) is the treatment of choice for symptomatic, high-grade, apical or multi-compartmental pelvic organ prolapse (POP), in terms of anatomical correction and treatment durability. Robot-assisted sacrocolpopexy (RASC) could be an attractive alternative to the gold standard laparoscopic sacrocolpopexy (LSC), for its ergonomic advantages in such a technically demanding procedure. However, it has not yet proven its superiority, consequently raising cost-effectiveness issues. Our primary objective was to assess if RASC can achieve better overall operative time (OOT) over LSC, with at least equivalent perioperative results. This was a single-center retrospective study including 100 patients (58 consecutive RASC cases and 42 LSC within the same time-period), with primary endpoint the OOT in both groups. Secondary results included complication rate, hospital stay, short-term anatomic results and OOT within and beyond the RASC learning curve. A multivariate linear regression was carried out for our primary outcome. The groups had comparable characteristics, except for BMI, which was lower in RASC group. The mean OOT was significantly lower in the RASC group (188 vs. 217 min, p ≤ 0.01), even after adjusting for possible confounders. Short-term anatomic results, complication rate, and blood loss were similar in the two groups. Mean hospital stay was significantly longer in the RASC group. Average RASC OOT was significantly shorter after the first 20 cases realized. This study demonstrated a significant reduction of OOT for RASC compared to LSC, with similar perioperative results, encouraging further use of the robotic technology for this indication.

Lymph Node Involvement in Recurrent Serous Borderline Ovarian Tumors: Current Evidence, Controversies, and a Review of the Literature.

Borderline ovarian tumors (BOTs) account for 10-20% of epithelial ovarian neoplasms. They are characterized by their lack of destructive stromal invasion. In comparison to invasive ovarian cancers, BOTs occur in younger patients and have better outcome. Serous borderline ovarian tumor (SBOT) represents the most common subtype of BOT. Complete surgical staging is the current standard management but fertility-sparing surgery is an option for SBOT patients who are at reproductive age. While most cases of SBOTs have an indolent course with favorable prognosis, late recurrence and malignant transformation can occur, usually in the form of low-grade serous carcinoma (LGSC). Thus, assessment of the recurrence risk is essential for the management of those patients. SBOTs can be associated with lymph node involvement (LNI) in up to 30% of patients who undergo lymph node dissection at diagnosis, and whether LNI affects prognosis is controversial. The present review suggests that recurrent SBOTs with LNI have poorer oncological outcomes and highlights the biases due to the scarcity of reports in the literature. Preventing SBOTs from recurring and becoming invasive overtime and a more profound understanding of the underlying mechanisms at play are necessary.

Comparison of pelvic floor dysfunction 6 years after uncomplicated vaginal versus elective cesarean deliveries: a cross-sectional study.

Clinicians and patients have traditionally believed that elective cesarean section may protect against certain previously ineluctable consequences of labor, including a plethora of urinary, anorectal and sexual dysfunctions. We aimed to evaluate fecal, urinary and sexual symptoms 6 years postpartum, comparing uncomplicated vaginal delivery and elective cesarean delivery, and to assess their impact on quality of life. We conducted a cross-sectional study to compare perineal functional symptomatology between women having singleton elective cesarean deliveries (eCS) and singleton uncomplicated vaginal deliveries (uVD). Women who delivered 6 years before this study were chosen randomly from our hospital database. This database includes demographic, labor, and delivery information, as well as data regarding maternal and neonatal outcomes, all of which is collected at the time of delivery by the obstetrician. Four validated self-administrated questionnaires were sent by post to the participants: the short forms of the Urogenital Distress Inventory, Incontinence Impact Questionnaire, Wexner fecal incontinence scale, and Female Sexual Function Index. Current socio-demographic details, physical characteristics, obstetrical history and mode of delivery at subsequent births were also registered using a self-reported questionnaire. A total of 309 women with uVD and 208 with eCS returned postal questionnaires. The response rate was 49%. Socio-demographic characteristics and fecal incontinence were similar between groups. After eCS, women reported significantly less urgency urinary incontinence (adjusted Relative Risk 0.55; 95% confidence interval 0.34-0.88) and stress incontinence (adjusted Relative Risk 0.53; 95% confidence interval 0.35-0.80) than after uVD. No difference in total Incontinence Impact Questionnaire score was found between both modes of delivery. Lower abdominal or genital pain (adjusted Relative Risk 1.58; 95% confidence interval 1.01-2.49) and pain related to sexual activity (adjusted Relative Risk 2.50; 95% confidence interval 1.19-5.26) were significantly more frequent after eCS than uVD. Six years postpartum, uVD is associated with urinary incontinence, while eCS is associated with sexual and urination pain.

Cost-analysis of Enhanced Recovery After Surgery (ERAS) program in gynecologic surgery.

OBJECTIVES: Enhanced recovery after surgery (ERAS) programs has shown clinical benefits in gynecologic surgery. The aim of the present study was to compare costs before and after implementation of an ERAS program for gynecologic surgery. METHODS: Retrospective study comparing perioperative costs between consecutive patient groups undergoing gynecologic surgery (benign, staging or debulking) (I, 2012-13) prior, (II) immediately after, and (III, 2014-16) the three years after ERAS implementation. Preoperative, intraoperative, and postoperative real costs were collected for each patient via hospital administration. A bootstrap independent t-test was used for comparison. RESULTS: Demographics and preoperative characteristics were similar between group I (n = 42), II (n = 51), and III (ERAS I; n = 122, II; n = 134, III; n = 90). Average ERAS-specific costs were $687 per patient. Total mean individual costs per patient were $13'329 (95% confidence interval (CI): 11'301-15'213) and $17'710 (95% CI: 14'452-21'605) in the ERAS and pre-ERAS groups respectively, resulting in net savings of $4'381 (95% CI: 549-8'752, p = 0.043) in favour of ERAS group. Cost savings were explained by lower pre- and postoperative costs (difference: $5'011 95% CI: 1'587-8'998, p = 0.019). Total costs continued to decrease by $2'520 (mean: $15'190, 95% CI: 13'791-16'631) in year 1, by $3'077 (mean: $14'633, 95% CI: 13'378-16'250) and $5'070 (mean: $12'640, 95% CI: 11'460-14'015) (p = 0.03) respectively, in year 2 and 3 after implementation. CONCLUSION: Based on real costs and including specific costs due to ERAS implementation, ERAS program in gynecologic surgery induced significant decrease of overall costs by $4'381 per patient. Total costs continued to decrease in the three years after implementation.

International validation of Enhanced Recovery After Surgery Society guidelines on enhanced recovery for gynecologic surgery.

BACKGROUND: Enhanced Recovery After Surgery Society publishes guidelines on perioperative care, but these guidelines should be validated prospectively. OBJECTIVE: To evaluate the association between compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guideline elements and postoperative outcomes in an international cohort. STUDY DESIGN: The study comprised 2101 patients undergoing elective gynecologic/oncology surgery between January 2011 and November 2017 in 10 hospitals across Canada, the United States, and Europe. Patient demographics, surgical/anesthesia details, and Enhanced Recovery After Surgery protocol compliance elements (pre-, intra-, and postoperative phases) were entered into the Enhanced Recovery After Surgery Interactive Audit System. Surgical complexity was stratified according to the Aletti scoring system (low vs medium/high). The following covariates were accounted for in the analysis: age, body mass index, smoking status, presence of diabetes, American Society of Anesthesiologists class, International Federation of Gynecology and Obstetrics stage, preoperative chemotherapy, radiotherapy, operating time, surgical approach (open vs minimally invasive), intraoperative blood loss, hospital, and Enhanced Recovery After Surgery implementation status. The primary end points were primary hospital length of stay and complications. Negative binomial regression was used to model length of stay, and logistic regression to model complications, as a function of compliance score and covariates. RESULTS: Patient demographics included a median age 56 years, 35.5% obese, 15% smokers, and 26.7% American Society of Anesthesiologists Class III-IV. Final diagnosis was malignant in 49% of patients. Laparotomy was used in 75.9% of cases, and the remainder minimally invasive surgery. The majority of cases (86%) were of low complexity (Aletti score ≤3). In patients with ovarian cancer, 69.5% had a medium/high complexity surgery (Aletti score 4-11). Median length of stay was 2 days in the low- and 5 days in the medium/high-complexity group. Every unit increase in Enhanced Recovery After Surgery guideline score was associated with 8% (IRR, 0.92; 95% confidence interval, 0.90-0.95; P<.001) decrease in days in hospital among low-complexity, and 12% (IRR, 0.88; 95% confidence interval, 0.82-0.93; P<.001) decrease among patients with medium/high-complexity scores. For every unit increase in Enhanced Recovery After Surgery guideline score, the odds of total complications were estimated to be 12% lower (P<.05) among low-complexity patients. CONCLUSION: Audit of surgical practices demonstrates that improved compliance with Enhanced Recovery After Surgery Gynecologic/Oncology guidelines is associated with an improvement in clinical outcomes, including length of stay, highlighting the importance of Enhanced Recovery After Surgery implementation.

Prevalence and Consequences of Preoperative Weight Loss in Gynecologic Surgery.

Preoperative malnutrition and weight loss negatively impact postoperative outcomes in various surgical fields. However, for gynecologic surgery, evidence is still scarce, especially if surgery is performed within enhanced recovery after surgery (ERAS) pathways. This study aimed to assess the prevalence and impact of preoperative weight loss in patients undergoing major gynecologic procedures within a standardized ERAS pathway between October 2013 and January 2017. Out of 339 consecutive patients, 33 (10%) presented significant unintentional preoperative weight loss of more than 5% during the 6 months preceding surgery. These patients were less compliant to the ERAS protocol (>70% of all items: 70% vs. 94%, p < 0.001) presented more postoperative overall complications (15/33 (45%) vs. 69/306 (22.5%), p = 0.009), and had an increased length of hospital stay (5 ± 4 days vs. 3 ± 2 days, p = 0.011). While patients experiencing weight loss underwent more extensive surgical procedures, after multivariate analysis, weight loss ≥5% was retained as an independent risk factor for postoperative complications (OR 2.44; 95% CI 1.00-5.95), and after considering several surrogates for extensive surgery including significant blood loss (OR 2.23; 95% CI 1.15-4.31) as confounders. The results of this study suggest that systematic nutritional screening in ERAS pathways should be implemented.

Compliance with enhanced recovery after surgery program in gynecology: are all items of equal importance?

INTRODUCTION: Enhanced recovery after surgery (ERAS) guidelines in gynecologic surgery are a set of multiple recommendations based on the best available evidence. However, according to previous studies, maintaining high compliance is challenging in daily clinical practice. The aim of this study was to assess the impact of compliance to individual ERAS items on clinical outcomes. METHODS: Retrospective cohort study of a prospectively maintained database of 446 consecutive women undergoing gynecologic oncology surgery (both open and minimally invasive) within an ERAS program from 1 October 2013 until 31 January 2017 in a tertiary academic center in Switzerland. Demographics, adherence, and outcomes were retrieved from a prospectively maintained database. Uni- and multivariate logistic regression was performed, with adjustment for confounding factors. Main outcomes were overall compliance, compliance to each individual ERAS item, and impact on post-operative complications according to Clavien classification. RESULTS: A total of 446 patients were included, 26.2 % (n=117) had at least one complication (Clavien I-V), and 11.4 % (n=51) had a prolonged length of hospital stay. The single independent risk factor for overall complications was intra-operative blood loss > 200 mL (OR 3.32; 95% CI 1.6 to 6.89, p=0.001). Overall compliance >70% with ERAS items (OR 0.15; 95% CI 0.03 to 0.66, p=0.12) showed a protective effect on complications. Increased compliance was also associated with a shorter length of hospital stay (OR 0.2; 95% CI 0.435 to 0.93, p=0.001). CONCLUSIONS: Compliance >70% with modifiable ERAS items was significantly associated with reduced overall complications. Best possible compliance with all ERAS items is the goal to achieve lower complication rates after gynecologic oncology surgery.

Counseling after perineal laceration: does it improve functional outcome?

INTRODUCTION AND HYPOTHESIS: Since 2006, the Lausanne University Hospital (CHUV) has offered a 12-week post-partum perineum consultation for patients with third-/fourth-degree tears, providing advice for future deliveries. This study consisted of a retrospective follow-up of these patients, focused on subsequent deliveries and current urinary and anorectal incontinence symptoms. METHODS: Patients meeting eligibility criteria were invited to complete a questionnaire on their deliveries, along with validated questionnaires grading urinary (UDI-6 and IIQ-7) and anorectal (Wexner-Vaizey score) incontinence. RESULTS: Sixty-two percent of third-/fourth-degree tears occurred following operative vaginal deliveries. Of 160 participants, 45.6% did not redeliver, 5.6% of whom felt traumatized by their first delivery and reluctant to have another children; 33.2% had a second vaginal delivery, 19.4% had a cesarean section (CS), and 1.2% had both vaginal and CS deliveries; 28% of the CS were not medically indicated. The recurrence rate of third-/fourth-degree tears for subsequent vaginal deliveries was 3.6%. Most patients were mildly or not affected by incontinence symptoms. Symptomatic patients reported urinary incontinence during physical activity and gas leakages; 50-60% saw no change of symptoms since the consultation, 30-40% reported partial or complete recovery. Patients redelivering by CS reported significantly less urinary incontinence (p = 0.046) and less anorectal incontinence (p = 0.069). CONCLUSION: Anal sphincter laceration is associated with urinary and anorectal incontinence, but symptoms improve or disappear in most cases and are globally not invalidating. Perineal physiotherapy seems to contribute to this positive evolution. Fertility rate among these patients is unaffected, but the CS rate is higher than average. Further consideration of sexual and emotional sequelae could improve our current service.

Impact of HPV vaccination with Gardasil® in Switzerland.

BACKGROUND: Gardasil®, a quadrivalent vaccine targeting low-risk (6, 11) and high-risk (16, 18) human papillomaviruses (HPV), has been offered to 11-14 year-old schoolgirls in Switzerland since 2008. To evaluate its success and its potential impact on cervical cancer screening, HPV genotypes were examined in 18-year-old girls five years later (sub-study 1) and in outpatients participating to cervical cancer screening before and after vaccine implementation (sub-study 2). METHODS: For sub-study 1, 3726 females aged 18 in 2013 were invited to fill a questionnaire on personal demographics and HPV risk factors and to provide a self-collected cervicovaginal sample for HPV genotyping and Chlamydia trachomatis PCR. Personal data were evaluated by univariable and multivariable statistics. In sub-study 2, the proportion of the vaccine-type HPV among anogenital HPV was examined with archived genotyping data of 8039 outpatients participating to cervical cancer screening from 1999 till 2015. The yearly evolution of this proportion was evaluated by segmented logistic regression. RESULTS: 690 (18.5%) women participated to sub-study 1 and 327 (8.8%) provided a self-collected sample. Prevalence of Chlamydia trachomatis (4.6%) and demographics confirmed that the subjects were representative of sexually-active Swiss young women. Vaccine (five-year coverage: 77.5%) was preferentially accepted by contraceptive-pill users (P = 0.001) and samples were mainly provided by sexually-active subjects (P < 0.001). The proportion (4%) of the vaccine-type HPV in this population was lower than in sub-study 2 outpatients (n = 849, <26 years old) in the pre-vaccine era (25.7%). The proportion of the high-risk vaccine-type HPV decreased significantly (59%, P = 0.0048) in the outpatients during the post-vaccine era, yet this decrease was restricted to those aged less than 26 years (n = 673, P < 0.0001). CONCLUSIONS: The low proportion of vaccine-type HPV in 18-year-old females and its rapid decrease in young women participating to cervical cancer screening extend the success of HPV vaccination to Switzerland. Our data suggest that cervical cancer screening is now entering a stage of reduced proportion of HPV16 and/or 18 in samples reported positive by cytology. In view of the high likelihood of reduced clinical specificity of cytology, primary screening modalities involving HPV testing and cytology should now be re-evaluated in Switzerland.

[Long term consequences of obstetrical anal sphincter injuries on sexual function]. / Conséquences à long terme des déchirures périnéales obstétricales sévères sur la fonction sexuelle.

Obstetrical anal sphincter injuries (OASIS) can lead to sexual dysfunction. Literature is poor concerning long-term consequences of OASIS on female sexuality. The objective of this paper is to clarify long-term consequences of OASIS on sexual function. Dyspareunia and lubrication troubles are constantly reported based on articles reviewed in literature through Pubmed. Nevertheless, global sexual function seems not to be influenced by OASIS on a long-term basis. Therefore, sexual dysfunctions must be specifically analysed in women's follow-up after OASIS.

Une déchirure obstétricale du sphincter anal (OASIS) peut conduire à une dysfonction sexuelle. Peu d'études évaluent la fonction sexuelle à long terme après OASIS. L'objectif de cet article est de clarifier les conséquences à long terme des OASIS sur la fonction sexuelle. Cela a été effectué au moyen d'une recherche de littérature dans Pubmed. La dyspareunie et les troubles de la lubrification sont rapportés de façon constante dans les études analysées, tandis que la fonction sexuelle globale ne semble pas influencée à long terme. Ces dysfonctions sexuelles doivent donc être recherchées spécifiquement dans le suivi des femmes après OASIS.

Impact of Pressurized Intraperitoneal Aerosol Chemotherapy on Quality of Life and Symptoms in Patients with Peritoneal Carcinomatosis: A Retrospective Cohort Study.

Background. Peritoneal cancer treatment aims to prolong survival, but preserving Quality of Life (QoL) under treatment is also a priority. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive repeatable treatment modality. The aim of the present study was to assess QoL in our cohort of PIPAC patients. Methods. Analysis of all consecutive patients included from the start of PIPAC program (January 2015). QoL (0-100: optimal) and symptoms (no symptom: 0-100) were measured prospectively before and after every PIPAC procedure using EORTC QLQ-C30. Results. Forty-two patients (M : F = 8 : 34, median age 66 (59-73) years) had 91 PIPAC procedures in total (1 : 4x, 17 : 3x, 12 : 2x, and 12 : 1x). Before first PIPAC, baseline QoL was measured as median of 66 ± 2.64. Prominent complaints were fatigue (32 ± 4.3) and digestive symptoms as diarrhea (17 ± 3.75), constipation (17 ± 4.13), and nausea (7 ± 2.54). Overall Quality of Life was 64 ± 3.75 after PIPAC#1 (p = 0.57), 61 ± 4.76 after PIPAC#2 (p = 0.89), and 70 ± 6.67 after PIPAC#3 (p = 0.58). Fatigue symptom score was 44 ± 4.86 after PIPAC#1 and 47 ± 6.69 and 34 ± 7.85 after second and third applications, respectively (p = 0.40). Diarrhea (p = 0.31), constipation (p = 0.76), and nausea (p = 0.66) did not change significantly under PIPAC treatment. Conclusion. PIPAC treatment of peritoneal carcinomatosis had no negative impact on patients' overall QoL and its components or on main symptoms. This study was registered online on Research Registry (UIN: 1608).

Continuous recording of intrarectal pressures during the second phase of labour: correlations with postpartum pelvic floor complaints. A biomechanical-clinical study.

INTRODUCTION AND HYPOTHESIS: We correlated intrarectal pressure parameter recordings during the second phase of labour in primiparous women with postpartum pelvic floor (PF) complaints to try to define a critical pressure threshold for the occurrence of permanent PF injury. METHODS: Using a microsystem device, the duration of bearing-down efforts, the area under the pressure curve and the peak pressure during bearing-down efforts were continuously recorded in 43 women with spontaneous delivery (group one) and in 17 women with forceps-assisted delivery (group two). PF complaints were assessed using ICS-validated questionnaires established before delivery and 14 ± 6 months after delivery. RESULTS: Postpartum PF complaints were not significantly different between the groups. The first and second phases of labour were longer in women of group two. The three parameters measured were not correlated with the baby's weight or mode of delivery. The duration of bearing-down efforts was correlated with difficulty voiding and lower abdominal discomfort in women of group one only. The area under the pressure curve was correlated with feeling of urgency to void, urge incontinence, drops escape, decreased frequency of orgasm and difficulties in reaching orgasm in women of group two only. Peak pressure values were not correlated with any PF dysfunction. CONCLUSIONS: Intrarectal pressure parameters during second phase of labour show no significant correlations with obstetric parameters, but were significantly correlated with some urinary and sexual PF complaints 14 months after spontaneous and forceps-assisted delivery with a higher incidence of significant correlations in women of group two with forceps-assisted delivery, probably because of the longer first and second phases of labour.

Human papillomavirus (HPV) contamination of gynaecological equipment.

OBJECTIVE: The gynaecological environment can become contaminated by human papillomavirus (HPV) from healthcare workers' hands and gloves. This study aimed to assess the presence of HPV on frequently used equipment in gynaecological practice. METHODS: In this cross-sectional study, 179 samples were taken from fomites (glove box, lamp of a gynaecological chair, gel tubes for ultrasound, colposcope and speculum) in two university hospitals and in four gynaecological private practices. Samples were collected with phosphate-buffered saline-humidified polyester swabs according to a standardised pattern, and conducted twice per day for 2 days. The samples were analysed by a semiquantitative real-time PCR. Statistical analysis was performed using Pearson's χ(2) test and multivariate regression analysis. RESULTS: Thirty-two (18%) HPV-positive samples were found. When centres were compared, there was a higher risk of HPV contamination in gynaecological private practices compared with hospitals (OR 2.69, 95% CI 1.06 to 6.86). Overall, there was no difference in the risk of contamination with respect to the time of day (OR 1.79, 95% CI 0.68 to 4.69). When objects were compared, the colposcope had the highest risk of contamination (OR 3.02, 95% CI 0.86 to 10.57). CONCLUSIONS: Gynaecological equipment and surfaces are contaminated by HPV despite routine cleaning. While there is no evidence that contaminated surfaces carry infectious viruses, our results demonstrate the need for strategies to prevent HPV contamination. These strategies, based on health providers' education, should lead to well-established cleaning protocols, adapted to gynaecological rooms, aimed at eliminating HPV material.

Peritoneal carcinomatosis in primary ovarian cancer staging: comparison between MDCT, MRI, and 18F-FDG PET/CT.

PURPOSE: The aim of this study was to compare multidetector CT (MDCT), MRI, and FDG PET/CT imaging for the detection of peritoneal carcinomatosis (PC) in ovarian cancer. PATIENTS AND METHODS: Fifteen women with ovarian cancer and suspected PC underwent MDCT, MRI, and FDG PET/CT, shortly before surgery. Nine abdominopelvic regions were defined according to the peritoneal cancer index. We applied lesion size scores on MDCT and MR and measured FDG PET/CT standard uptake. We blindly read MDCT, MR, and PET/CT before joint review and comparison with histopathology. Receiver operating characteristics analysis was performed. RESULTS: Ten women had PC (67%). Altogether, 135 abdominopelvic sites were compared. Multidetector CT, MRI, and FDG PET/CT had a sensitivity of 96%, 98%, and 95%, and specificity was 92%, 84%, and 96%, respectively. Corresponding receiver operating characteristics area was 0.94, 0.90, and 0.96, respectively, without any significant differences between them (P = 0.12). FDG PET/CT detected supradiaphragmatic disease in 3 women (20%) not seen by MDCT or MRI. CONCLUSIONS: Although MRI had the highest sensitivity and FDG PET/CT had the highest specificity, no significant differences were found between the 3 techniques. Thus, MDCT, as the fastest, most economical, and most widely available modality, is the examination of choice, if a stand-alone technique is required. If inconclusive, PET/CT or MRI may offer additional insights. Whole-body FDG PET/CT may be more accurate for supradiaphragmatic metastatic extension.

The Phantom Urine: An Unexpected Finding during a Routine Cesarean Section.

We present here an atypical finding during an elective repeat cesarean section. Despite urine flow through an indwelling bladder catheter, bladder remains distended during the whole procedure. Unexpected anatomical variations and malformations can make routine surgery challenging. Urinary tract anomalies should be suspected in cases of unexpected difficult bladder catheterization.

Long-term outcome and late side effects in endometrial cancer patients treated with surgery and postoperative radiation therapy.

BACKGROUND: We retrospectively reviewed the long-term outcome and late side effects of endometrial cancer (EC) patients treated with different techniques of postoperative radiotherapy (PORT). METHODS: Between 1999 and 2012, 237 patients with EC were treated with PORT. Two-dimensional external beam radiotherapy (2D-EBRT) was used in 69 patients (30 %), three-dimensional EBRT (3D-EBRT) in 51 (21 %), and intensity-modulated RT (IMRT) with helical Tomotherapy in 47 (20 %). All patients received a vaginal brachytherapy (VB) boost. Seventy patients (29 %) received VB alone. RESULTS: After a median of 68 months (range, 6-154) of follow-up, overall survival was 75 % [95 % confidence interval (CI), 69-81], disease-free survival was 72 % (95% CI, 66-78), cancer-specific survival was 85 % (95 % CI, 80-89), and locoregional control was 86 % (95 % CI, 81-91). The 5-year estimates of grade 3 or more toxicity and second cancer rates were 0 and 7 % (95 % CI, 1-13) for VB alone, 6 % (95 % CI, 1-11) and 0 % for IMRT + VB, 9 % (95 % CI, 1-17) and 5 % (95 % CI, 1-9) for 3D-EBRT + VB, and 22 % (95 % CI, 12-32) and 12 % (95 % CI, 4-20) for 2D-EBRT + VB (P = 0.002 and P = 0.01), respectively. CONCLUSIONS: Pelvic EBRT should be tailored to patients with high-risk EC because the severe late toxicity observed might outweigh the benefits. When EBRT is prescribed for EC, IMRT should be considered, because it was associated with a significant reduction of severe late side effects.

Pelvic organ prolapse surgery with and without tension-free vaginal tape in women with occult or asymptomatic urodynamic stress incontinence: a randomised controlled trial.

INTRODUCTION: We set out to determine if insertion of a retropubic tension-free vaginal tape (TVT) sling at the time of pelvic organ prolapse surgery improves continence outcomes in women with pre-operative occult stress incontinence (OSI) or asymptomatic urodynamic stress incontinence (USI). METHODS: We conducted a randomised controlled study of prolapse surgery with or without a TVT midurethral sling. The pre- and post-operative assessment at 6 months included history, physical examination and urodynamic testing. Quality of life (QOL) and treatment success was assessed with the UDI-6 SF, IIQ-7 SF and a numerical success score. The primary outcome was symptomatic stress urinary incontinence (SUI) requiring continence surgery (TVT) at 6 months. Long-term follow-up continued to a minimum of 24 months. Secondary outcomes were quality of life parameters. RESULTS: Eighty women received prolapse surgery alone (n = 43) or prolapse surgery with concurrent TVT (n = 37). Six months following prolapse surgery 3 out of 43 (7 %) patients in the no TVT group requested sling surgery compared with 0 out of 37 (0 %) in the TVT group (ARR 7 % [95 %CI: 3 to 19 %], p = 0.11). After 24 months there was one further participant in the no TVT group who received a TVT for treatment of SUI compared with none in the TVT group (4 out of 43, 9.3 % versus 0 out of 37; ARR 9.3 % [95 %CI: -1 to 22 %], p = 0.06). Both groups showed improvement in QOL difference scores for within-group analysis, without difference between groups. CONCLUSION: These results support a policy that routine insertion of a sling in women with OSI at the time of prolapse repair is questionable and should be subject to shared decision-making between clinician and patient.

Interstitial pregnancies' diagnosis and management: an eleven cases series.

PRINCIPLES: Interstitial pregnancy represents 2% of ectopic pregnancies, but it is a highly morbid condition with a 2.5% of maternal mortality. Its diagnostic and therapeutic management remains controversial. The aim of this review is to describe the management of interstitial pregnancy in our institution between 2001 and 2011 and to define some general rules for the clinical practice. METHODS: Single institution retrospective study. RESULTS: Eleven women were treated for interstitial pregnancy. The median age was 33 years and the median gestity was 4. Seven patients had a history of gynaecological surgery and four interstitial pregnancies followed in vitro fertilisation. The diagnosis was made at a median gestational age of seven weeks with a median beta-HCG level of 5,838 U/l. Six of the eleven patients received an initial treatment with intracornual methotrexate, three with intramuscular methotrexate and two with surgery. The median time to beta-HCG resolution was 58 days. Three of the eleven patients needed a second line treatment: two after intramuscular methotrexate and one after intracornual methotrexate. Six patients had further pregnancies and delivered by caesarean section. CONCLUSIONS: A high prevalence of previous ectopic pregnancies, gynaecological surgery and of pregnancies resulting from in vitro fertilisation was observed. The earliness of the diagnosis was the factor that allowed a conservative treatment in most cases. Beta-HCG level follow up was fundamental in allowing a second line therapy but beta-HCG can persist over a long period of time and this must be taken into account due to its possible psychological impact. Intracornual methotrexate seems to be more efficacious than intramuscular methotrexate in our series.

Augmented epithelial multidrug resistance-associated protein 4 expression in peritoneal endometriosis: regulation by lipoxin A(4).

OBJECTIVE: To compare the expression of the prostaglandin (PG) E(2) transporter multidrug resistance-associated protein 4 (MRP4) in eutopic and ectopic endometrial tissue from endometriosis patients with that of control subjects and to examine whether MRP4 is regulated by the antiinflammatory lipid lipoxin A(4) (LXA(4)) in endometriotic epithelial cells. DESIGN: Molecular analysis in human samples and a cell line. SETTING: Two university hospitals and a private clinic. PATIENT(S): A total of 59 endometriosis patients and 32 age- and body mass index-matched control subjects undergoing laparoscopy or hysterectomy. INTERVENTION(S): Normal, eutopic, and ectopic endometrial biopsies as well as peritoneal fluid were obtained during surgery performed during the proliferative phase of the menstrual cycle. 12Z endometriotic epithelial cells were used for in vitro mechanistic studies. MAIN OUTCOME MEASURE(S): Tissue MRP4 mRNA levels were quantified by quantitative reverse-transcription polymerase chain reaction (qRT-PCR), and localization was analyzed with the use of immunohistochemistry. Cellular MRP4 mRNA and protein were quantified by qRT-PCR and Western blot, respectively. PGE(2) was measured in peritoneal fluid and cell supernatants using an enzyme immunoassay (EIA). RESULT(S): MRP4 was expressed in eutopic and ectopic endometrium, where it was overexpressed in peritoneal lesions and localized in the cytoplasm of glandular epithelial cells. LXA(4) attenuated MRP4 mRNA and protein levels in endometriotic epithelial cells in a dose-dependent manner, while not affecting the expression of enzymes involved in PGE(2) metabolism. Investigations employing receptor antagonists and small interfering RNA revealed that this occurred through estrogen receptor α. Accordingly, LXA(4) treatment inhibited extracellular PGE(2) release. CONCLUSION(S): We report for the first time that MRP4 is expressed in human endometrium, elevated in peritoneal endometriosis, and modulated by LXA(4) in endometriotic epithelial cells.