Evolving trends in the management of pelvic inflammatory disease (PID) during SARS-CoV-2 pandemic: A multicenter retrospective cohort study.

BACKGROUND AND AIM: Pelvic inflammatory disease (PID) is usually managed by conservative treatment, but in selected cases, especially in the presence of a tubo-ovarian abscess (TOA), surgical management is a recognized treatment option. We compared the trends in managing PID and short-term outcomes before and during the SARS-CoV-2 pandemic. METHODS: This is a retrospective study performed in three Italian gynecological centers. We included patients admitted to hospital with a diagnosis of PID. Demographic characteristics, management, time to diagnosis, and time to treatment were compared before versus during the SARS-CoV-2 pandemic. RESULTS: One hundred nineteen PID patients were screened, eighty-one before the SARS-CoV-2 pandemic, and thirty-eight after the onset. At admission, leukocytosis (median 19.73 vs. 13.99 WBC/mm3, p-value = 0.02) was significantly higher in patients who underwent surgery after the onset of the pandemic. TOA incidence was higher in patients who underwent surgery during the SARS-CoV-2 pandemic, but the difference did not reach statistically significance (p = 0.06). The proportion of patients treated with surgery dropped to 26.3% after the onset from 46% of patients before the onset of pandemic (p = 0.03). Furthermore, a higher percentage of emergency surgical procedures on day 0 of hospital admission were performed after the onset of the pandemic (50% vs. 13.1%, p = 0.01). CONCLUSIONS: In this retrospective cohort study, we found that the SARS-CoV-2 pandemic influenced the clinical presentation and management of PID in favor of conservative treatment. Patients who underwent surgery during the SARS-CoV-2 pandemic had higher inflammatory markers.

Minimally Invasive Approaches in Locally Advanced Cervical Cancer Patients Undergoing Radical Surgery After Chemoradiotherapy: A Propensity Score Analysis.

PURPOSE: Chemoradiation (CT/RT) followed by radical surgery (RS) may play a role in locally advanced cervical cancer (LACC) patients with suboptimal response to CT/RT or in low-income countries with limited access to radiotherapy. Our aim is to evaluate oncological and surgical outcomes of minimally invasive radical surgery (MI-RS) compared with open radical surgery (O-RS). PATIENTS AND METHODS: Data for stage IB2-IVA cervical cancer patients managed by CT/RT and RS were retrospectively analyzed. RESULTS: Beginning with 686 patients, propensity score matching resulted in 462 cases (231 per group), balanced for FIGO stage, lymph node status, histotype, tumor grade, and clinical response to CT/RT. The 5-year disease-free survival (DFS) was 73.7% in the O-RS patients and 73.0% in the MI-RS patients (HR 1.034, 95% CI 0.708-1.512, p = 0.861). The 5-year locoregional recurrence rate was 12.5% (O-RS) versus 15.2% (MI-RS) (HR 1.174, 95% CI 0.656-2.104, p = 0.588). The 5-year disease-specific survival (DSS) was 80.4% in O-RS patients and 85.3% in the MI-RS group (HR 0.731, 95% CI 0.438-1.220, p = 0.228). Estimated blood loss was lower in the MI-RS group (p < 0.001), as was length of hospital stay (p < 0.001). Early postoperative complications occurred in 77 patients (33.3%) in the O-RS group versus 88 patients (38.1%) in the MI-RS group (p = 0.331). Fifty-six (24.2%) patients experienced late postoperative complications in the O-RS group, versus 61 patients (26.4%) in the MI-RS group (p = 0.668). CONCLUSION: MI-RS and O-RS are associated with similar rates of recurrence and death in LACC patients managed by surgery after CT/RT. No difference in early or late complications was reported.

Laparoscopic sacrocolpopexy plus ventral rectopexy as combined treatment for multicompartment pelvic organ prolapse.

BACKGROUND: Pelvic organ prolapse (POP) is a dynamic disorder that affects the entire pelvic diaphragm. POP may often involve multiple organs. Abdominal sacrocolpopexy is considered the gold standard to treat female anterior and apical prolapse. Abdominal ventral mesh rectopexy has gained increasing acceptance as an effective treatment for rectal prolapse. The aim of the present study was to assess the safety, feasibility and 1-year outcomes of laparoscopic sacrocolpopexy plus ventral rectopexy as a combined treatment of multicompartment POP. METHODS: All female patients at our institution with anterior and apical prolapse with symptoms of obstructed defecation were examined by an urogynecologist and a colorectal surgeon, and were judged suitable for the study. Patients with Pelvic Organ Prolapse Quantification (POP-Q) system stage III and IV and concomitant rectal prolapse were treated by laparoscopic sacrocolpopexy plus ventral rectopexy. After surgery, 1- and 12-month follow-up was performed and the data were retrospectively analyzed. Patients' symptoms were evaluated using the Female Sexual Distress Scale (FSDS), Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ-12), and Wexner-Agachan constipation score. RESULTS: A total of 98 patients underwent surgery. No intraoperative or postoperative morbidity occurred. At the time of follow-up, all women expressed great satisfaction with the surgical treatment: all the patients had at most POP-Q Stage 1 and 78.8% had a Patient Global Impression of Improvement (PGI-I) score < 3. Significant improvement of symptoms related to POP and to obstructed defecation syndrome, as shown by the FSDS, PISQ-12, and Wexner-Agachan constipation score, was observed in all patients at follow-up CONCLUSIONS: Laparoscopic sacrocolpopexy with ventral rectopexy is a feasible and safe procedure for the combined surgical management of anterior, apical, and posterior prolapse, and provides excellent objective and subjective outcomes.

Clinical outcome of recurrent locally advanced cervical cancer (LACC) submitted to primary multimodality therapies.

OBJECTIVES: Recurrence of disease represents a clinical challenge in cervical cancer patients, especially when all available treatment modalities have been used in the primary setting. The aim of this study was to analyze the patterns of recurrence and their association with clinical outcome in locally advanced cervical cancer (LACC) patients submitted to primary chemoradiation (CTRT) followed by radical surgery (RS). METHODS: This study was conducted on 364 LACC patients treated with CTRT plus RS since January 1996 to July 2012. For each relapse, information on date of clinical/pathological recurrence, and pattern of disease presentation were retrieved. Post-relapse survival (PRS) was recorded from the date of recurrence to the date of death for disease or last seen. Survival probabilities were compared by the log rank test. Cox's regression model with stepwise variable selection was used for multivariate prognostic analysis for PRS. RESULTS: Within a median follow-up of 42months, 75 recurrences (20.6%) and 54 disease-associated deaths (14.8%) were recorded. By analysing the pattern of relapse, most of the recurrences were outside the irradiated field (n=43, 57.3%) and the most frequently observed site was visceral (n=16, 21.3%). Among the parameters of the recurrence associated with PRS including the pattern of recurrence, the size of recurrence, SCC-Ag serum levels at recurrence, and secondary radical surgery, only the last one retained an independent predictive role in reducing the risk of death (p=0.037). CONCLUSIONS: The feasibility of secondary radical resection positively impacts on PRS of LACC patients submitted to multimodality primary treatments.

Laparoscopic staging of apparent early stage ovarian cancer: results of a large, retrospective, multi-institutional series.

OBJECTIVE: The aim of this study is to analyze the safety, adequacy, perioperative and survival figures in a large series of laparoscopic staging of patients with apparent early stage ovarian malignancies (ESOM). PATIENTS AND METHODS: Retrospective data from seven gynecologic oncology service databases were searched for ESOM patients undergoing immediate laparoscopic staging or delayed laparoscopic staging after an incidental diagnosis of ESOM. Between May 2000 and February 2014, 300 patients were selected: 150 had been submitted to immediate laparoscopic staging (Group 1), while 150 had undergone delayed laparoscopic staging (Group 2) of ESOM. All surgical, pathologic, and oncologic outcome data were analyzed in each group and a comparison between the two was carried out. RESULTS: Longer operative time, higher blood loss, more frequently spillage/rupture of ovarian capsule and conversion to laparotomy occurred in Group 1. No significant differences of post-operative complications were observed between the two groups. Histological data revealed more frequently serous tumors (0.06), Grade 3 (p=0.0007) and final up-staging (p=0.001) in Group 1. Recurrence and death of disease were documented in 25 (8.3%), and 10 patients (3.3%%), respectively. The 3-year disease free survival (DFS) and overall survival (OS) rates were 85.1%, and 93.6%, respectively in the whole series. There was no difference between Group 1 and Group 2 in terms of DFS (p value=0.39) and OS (p value=0.27). CONCLUSION: In this very large multi-institutional study, it appears that patients with apparent ESOM can safely undergo laparoscopic surgical management.

Imaging in gynecological disease. 10: Clinical and ultrasound characteristics of decidualized endometriomas surgically removed during pregnancy.

OBJECTIVES: To describe the clinical history and ultrasound findings in women with decidualized endometriomas surgically removed during pregnancy. METHODS: In this retrospective study, women with a histological diagnosis of decidualized endometrioma during pregnancy who had undergone preoperative ultrasound examination were identified from the databases of seven ultrasound centers. The ultrasound appearance of the tumors was described on the basis of ultrasound images, ultrasound reports and research protocols (when applicable) by one author from each center using the terms and definitions of the International Ovarian Tumor Analysis (IOTA) group. In addition, two authors reviewed together available digital ultrasound images and used pattern recognition to describe the typical ultrasound appearance of decidualized endometriomas. RESULTS: Eighteen eligible women were identified. Median age was 34 (range, 20-43) years. Median gestational age at surgical removal of the decidualized endometrioma was 18 (range, 11-41) weeks. Seventeen women (94%) were asymptomatic and one presented with pelvic pain. In three of the 18 women an ultrasound diagnosis of endometrioma had been made before pregnancy. The original ultrasound examiner was uncertain whether the mass was benign or malignant in 10 (56%) women and suggested a diagnosis of benignity in nine (50%) women, borderline in eight women (44%), and invasive malignancy in one (6%) woman. Seventeen decidualized endometriomas contained a papillary projection, and in 16 of these at least one of the papillary projections was vascularized at power or color Doppler examination. The number of cyst locules varied between one (n = 11) and four. No woman had ascites. When using pattern recognition, most decidualized endometriomas (14/17, 82%) were described as manifesting vascularized rounded papillary projections with a smooth contour in an ovarian cyst with one or a few cyst locules and ground-glass or low-level echogenicity of the cyst fluid. CONCLUSIONS: Rounded vascularized papillary projections with smooth contours within an ovarian cyst with cyst contents of ground-glass or low-level echogenicity are typical of surgically removed decidualized endometriomas in pregnant women, most of whom are asymptomatic.

Intravesical misplacement of vaginal contraceptive ring: a video report and review of the literature.

Background: The NuvaRing®, a hormonal vaginal contraceptive device, has gained widespread usage due to its favourable efficacy and safety profiles. Exceedingly rare instances of unintended misplacement in the bladder have been reported. This study presents a review of the literature and the first video report illustrating the extraction of an intravesical NuvaRing®, discussing diagnostic and therapeutic approaches. Objective: To illustrate an effective method for intravesical NuvaRing® retrieval and raise awareness about this unusual complication. Materials and Methods: A 27-year-old patient with low urinary tract symptoms related to NuvaRing® misplacement underwent diagnostic procedures, including ultrasound and diagnostic cystoscopy. A cystoscopic extraction under general anaesthesia was performed. Main outcome measures: The effectiveness of pelvic ultrasound for diagnosing an intravesical foreign body, successful cystoscopic removal of NuvaRing® from the bladder, and symptom resolution were assessed. Results: The intravesical NuvaRing® was identified through pelvic ultrasound. During cystoscopy, the ring was detected inside the bladder. Multiple attempts with cystoscopic alligator graspers were made; the NuvaRing® was eventually extracted using transurethral Heiss forceps. The patient experienced minimal blood loss and was discharged the following day, reporting relief from symptoms. Conclusions: Unintentional NuvaRing® placement in the bladder is an extremely rare event that healthcare providers should consider when patients present with urinary symptoms and pelvic pain. Pelvic ultrasound is an efficient diagnostic tool, possibly averting the need for further imaging techniques. Cystoscopy remains the preferred method for diagnosis and treatment. This video report illustrates an effective technique for NuvaRing ® extraction, especially when appropriate graspers are unavailable. Adequate instruction on NuvaRing® insertion should always be emphasised.

Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer.

Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.

Locally advanced squamous cervical carcinoma (M0): management and emerging therapeutic options in the precision radiotherapy era.

Squamous cervical carcinoma (SCC) requires particular attention in diagnostic and clinical management. New diagnostic tools, such as (positron emission tomography-magnetic resonance imaging) PET-MRI, consent to ameliorate clinical staging accuracy. The availability of new technologies in radiation therapy permits to deliver higher dose lowering toxicities. In this clinical scenario, new surgical concepts could aid in general management. Lastly, new targeted therapies and immunotherapy will have more room in this setting. The aim of this narrative review is to focus both on clinical management and new therapies in the precision radiotherapy era.

Minimally invasive pelvic exenteration for gynaecological malignancies: the challenge of patients' selection.

Pelvic exenteration is a radical procedure representing a salvage option in patients with recurrent or persistent gynaecological malignancies. It can be performed with an open or minimally invasive approach. Different studies have demonstrated optimal peri-operative outcomes of minimally invasive pelvic exenteration with no survival difference when compared with an open approach. In this article, we discuss the importance and the challenge of patient selection for pelvic exenteration and more specifically for minimally invasive pelvic exenteration.

HUGO(TM) RAS System in urogynaecology: the first nerve sparing Sacral Colpopexy for Pelvic Organ Prolapse.

Background: Minimally invasive sacral colpopexy is considered the gold standard for surgical treatment of Pelvic Organ Prolapse (POP), combining high success rates with low recurrence risk in comparison to other techniques. This is the first case of robotic sacral colpopexy (RSCP) performed with the innovative Hugo™ RAS robotic system. Objectives: The aim of this article is to show the surgical steps of a nerve sparing RSCP performed with the new Hugo™ RAS robotic system (Medtronic), by also evaluating the feasibility of this technique using this novel Robotic System. Materials and Methods: A 50-year-old Caucasian woman with symptomatic pelvic organ prolapse (POP-Q): Aa: +2, Ba: +3, C: +4, D: +4, Bp: -2, Ap: -2 , TVL:10 GH: 3,5 BP:3 underwent RSCP as well as a subtotal hysterectomy with bilateral salpingo-oophorectomy, using the new surgical robot Hugo™ RAS in the Division of Urogynaecology and Pelvic Reconstructive Surgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Main outcome measures: Intraoperative data, docking specifics, objective and subjective outcomes at three months follow up. Results: Surgical procedure was carried out without intra-operative complications, operative time (OT) was 150 minutes, docking time was 9 minutes. No system errors or faults in the robotic arms were registered. Urogynaecological examination at three months follow up showed a complete resolution of the prolapse. Conclusion: RSCP using the Hugo™ RAS system seems to be a feasible and effective approach according to results in terms of operative time, cosmetic results, postoperative pain and length of hospitalisation. Large number of case reports as well as longer follow up are mandatory to better define its benefits, advantages, and costs.

Robotic treatment of colorectal endometriosis: technique, feasibility and short-term results.

BACKGROUND: Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Since a medical approach is often insufficient, a minimally invasive approach is considered the gold standard for complete disease excision. Robotic-assisted surgery is a revolutionary approach, with several advantages compared with traditional laparoscopic surgery. METHODS: From March 2010 to May 2011, we performed 22 consecutive robotic-assisted complete laparoscopic excisions of DIE endometriosis with colorectal involvement. All clinical data were collected by our team and all patients were interviewed preoperatively and 3 and 6 months post-operatively and yearly thereafter regarding endometriosis-related symptoms. Dysmenorrhoea, dyschezia, dyspareunia and dysuria were evaluated with a 10-point analog rating scale. RESULTS: There were 12 patients, with a median larger endometriotic nodule of 35 mm, who underwent segmental resection, and 10 patients, with a median larger endometriotic nodule of 30 mm, who underwent complete nodule debulking by colorectal wall-shaving technique. No laparotomic conversions were performed, nor was any blood transfusion necessary. No intra-operative complications were observed and, in particular, there were no inadvertent rectal perforations in any of the cases treated by the shaving technique. None of the patients had ileostomy or colostomy. No major post-operative complications were observed, except one small bowel occlusion 14 days post-surgery that was resolved in 3 days with medical treatment. Post-operatively, a statistically significant improvement of patient symptoms was shown for all the investigated parameters. CONCLUSIONS: To our knowledge, this is the first study reporting the feasibility and short-term results and complications of laparoscopic robotic-assisted treatment of DIE with colorectal involvement. We demonstrate that this approach is feasible and safe, without conversion to laparotomy.

Ultrasound evaluation of intra-abdominal sites of disease to predict likelihood of suboptimal cytoreduction in advanced ovarian cancer: a prospective study.

OBJECTIVES: To analyze in advanced ovarian cancer patients the ability of ultrasound to evaluate the extent of intra-abdominal disease and to predict the likelihood of suboptimal cytoreduction. METHODS: Into this prospective study, 147 patients with advanced ovarian cancer were enrolled consecutively between January 2005 and October 2008. All patients underwent standard laparotomy and maximal surgical effort was attempted. To create a new scoring system to predict suboptimal cytoreduction we considered the following sonographic parameters: peritoneal carcinomatosis, bowel mesentery involvement, omental involvement, massive pelvic involvement, ascites and liver and/or spleen metastases. Those parameters achieving a negative predictive value ≥ 50% and a positive predictive value ≥ 50% in predicting suboptimal cytoreduction were included in the ultrasound scoring system, which was then calculated for each patient. RESULTS: Ultrasound allowed a virtually conclusive diagnosis of massive pelvic involvement (sensitivity, 94%; specificity, 97%), parenchymal liver metastases of any size (sensitivity, 93%; specificity, 98%) and ascites (sensitivity, 98%; specificity, 97%) and a very reliable diagnosis of peritoneal carcinomatosis (sensitivity, 91%; specificity, 88%) and omental involvement (sensitivity, 94%; specificity, 90%), whereas it was not very good at excluding parenchymal spleen metastases or splenic hilum involvement (sensitivity, 75%; specificity, 98%) and bowel mesentery involvement (sensitivity, 67%; specificity, 88%). Ultrasound-assessed peritoneal carcinomatosis, bowel mesentery involvement, omental involvement, massive pelvic involvement and ascites were included in our ultrasound score (which had a range of 0-6 points). With a cut-off value of > 5, the sensitivity and specificity of the ultrasound score with regard to prediction of suboptimal cytoreduction were 31% (20/64) and 92% (46/50), respectively. CONCLUSIONS: Ultrasound examination is able to assess intra-abdominal disease in advanced ovarian cancer patients, with satisfactory concordance with laparotomic findings. Our ultrasound score can predict suboptimal cytoreduction and might be clinically useful.

Laparoscopic sacral hysteropexy for pelvic organ prolapse in a patient affected by marfan syndrome: a case report.

BACKGROUND: Marfan Syndrome (MS) is a dominantly inherited connective tissue disorder with consequences on the strength and resilience of connective tissues that may predispose to Pelvic Organ Prolapse (POP). Literature lacks studies investigating POP surgery in patients affected by MS that might help surgical management decisions. OBJECTIVE: The objective of this paper is to describe the surgical procedure of laparoscopic sacral hysteropexy (LSHP) in a 37 years old woman affected by MS with symptomatic POP. MATERIALS AND METHODS AND MAIN OUTCOME MEASURES: We performed a nerve-sparing laparoscopic sacral hysteropexy without complications and looked for anatomical and subjective outcomes. The patient completed The Female Sexual Distress Scale (FSDS), Pelvic Floor Disability Index (PFDI-20), and Wexner questionnaires preoperatively and postoperatively. RESULTS: The patient stated a complete resolution of all POP related symptoms and there was a total correction of the descensus. Furthermore, no perioperative and postoperative complications were noted. CONCLUSIONS: LSHP could be an effective and safe procedure for the treatment of POP in women affected by MS and this case report is the first to describe a reconstructive procedure in this category of patients. WHAT IS NEW?: The literature lacks studies investigating POP surgery in women with MS, that might help surgeons, thus we present this case to describe surgical and functional outcomes in this patient category, underlying the higher risk of complications and relapses related to the weakness of connective tissue. This case report may represent the basis of future studies to confirm the safety, efficacy and feasibility of LSHP and sacral colpopexy in patients with MS.

Step-by-step surgical procedures for a correct identification of the sentinel lymph node in endometrial cancer.

BACKGROUND: In patients with endometrial cancer, the common method for assessing the status of lymph nodes (LN) is lymphadenectomy. The sentinel lymph node (SLN) biopsy is a revolutionary concept and it will play an increasingly important role in surgical practice. The surgical technique of the sentinel lymph node is less destructive than lymphadenectomy, and it requires less anatomical knowledge. METHODS: Step by step technique of cervical injection, the preparation of the anatomical spaces and the identification of the main structures to detect and remove the SLN safely in patients affected by endometrial cancer stage IA. RESULTS: We identify the three different lymphatic pathways drainage from the uterine cervix and show how anatomical retroperitoneal knowledge is essential for the safe dissection of anatomical spaces. In literature it is reported that in about 9% of cases the SLN is located at the lumbo-aortic level, so it is clear how important it is to know the anatomy to follow the highlighted lymph pathway to identify first lymph node absorber of the drainage. CONCLUSION: Anatomical knowledge and the correct preparation of the anatomical spaces make the identification of the sentinel lymph node safe and feasible.

Should laparoscopy be included in the work-up of advanced ovarian cancer patients attempting interval debulking surgery?

OBJECTIVES: Primary: To investigate whether S-LPS could contribute to a better identification of patients to submit to IDS. Secondary: To identify the most appropriate level of laparoscopic index value (PIV) to identify inoperable patients in this subset of patients. METHODS: A prospective single-institutional study including patients with advanced ovarian/peritoneal cancer (FIGO stage IIIC-IV) to be submitted to IDS after NACT. Patients have been considered eligible for surgical exploration in case of complete/partial radiological or serological response; stable disease if primary surgery had been performed in a different hospital; progressive radiological disease in the presence of serological response, young age, and good performance status (ECOG <1); and progressive serological disease with stable clinical and radiological disease. A laparoscopic assessment for each patient has been performed. RESULTS: Ninety-eight consecutive AOC patients submitted to NACT have been eligible for the study. With the addition of S-LPS to the RECIST criteria, a surgical exploration is performed in all patients and the percentage of explorative laparotomies drops to about 10%. The use of S-LPS after the GCIG criteria can reduce the risk of both explorative laparotomies from 30% to 13%, and inappropriate unexplorations from 18% to 0%. Moreover, at a PIV >4 the probability of optimally resecting the disease at laparotomy is equal to 0. CONCLUSIONS: Present data suggest that S-LPS can play a relevant role to discriminate patients with partially/stable disease or referred from other Institutions after NACT, which can be susceptible of successful IDS.