Physical and psychological impact of surgery on the operating surgeon.

The impact of surgery on the surgeon's well-being encompasses both physical and psychological aspects. Physically, surgeons are at risk of work-related musculoskeletal symptoms due to the nature of their work, and this risk can be impacted by theater environment, equipment design, and workload. Many symptoms will be self-limiting, but work related musculoskeletal symptoms can lead to the development of an injury, which can have far reaching effects, including the need for medical or surgical treatment, time away from work, or a change in clinical duties. Additionally, surgery can place a significant cognitive workload on the lead operator and this can be exacerbated, or alleviated, by the surgical environment, experience of the assistance, surgical modality, and case complexity. Measuring and quantifying the impact of surgery on the surgeon is a challenging undertaking. Tools such as motion capture, physiological markers, including heart rate variability and salivary cortisol, and questionnaires can provide insights into understanding the overall impact of surgery on the surgeon. A holistic approach that incorporates injury prevention strategies, communication, and support, is vital in assessing and mitigating risk factors. Injury prevention assessment tools and interventions that can be used within the busy surgical environment are needed, alongside increased ergonomic awareness. Addressing the impact of surgery on the surgeon is a multifaceted challenge, and long term positive changes can only be sustained with the support of the whole surgical team and healthcare organizations by developing and maintaining a supportive working environment.

A qualitative exploration of physical and psychosocial well-being in the short and long term after treatments for cervical cancer.

OBJECTIVE: Cervical cancer is predominantly a cancer of younger women, and improvements in oncological outcomes have led to an increase in cervical cancer survivors living with the long-term effects of treatment. Understanding the recovery process after treatment is essential to increase awareness of the short- and long-term needs of survivors. The aim of this study was to qualitatively explore the recovery process and return to daily activity of cervical cancers survivors from a biopsychosocial perspective. METHODS: Participants were 21 women treated for cervical cancer between the ages of 18 and 60 years, living in the United Kingdom. Interviews were undertaken face to face and via the telephone using a semi-structured interview schedule. RESULTS: Data analysis revealed themes which represented participants' experience and perceptions of treatment as a paradox; emotional needs after treatment; and a journey of adversarial growth. A key finding from this analysis was the nuanced experiences between treatment modalities, with physical changes perceived to be more disruptive following radical treatments, whilst psychological repercussions were significant regardless of treatment type. CONCLUSION: This study provides novel insight into the varied recovery experiences of those treated with surgery and/or chemoradiotherapy for cervical cancer, which can be used to improve the survivorship experience.

Development of a patient-derived explant model for prediction of drug responses in endometrial cancer.

OBJECTIVE: To undertake a pilot study to develop a novel Patient-Derived-Explant (PDE) model system for use in endometrial cancer (EC) that is capable of monitoring differential drug responses in a pre-clinical setting. METHODS: Fresh tumour was obtained post-hysterectomy from 27 patients with EC. Tumours were cut into 1-3 mm3 explants that were cultured at the air-liquid interface for 16-24 h in culture media. Explants were cultured in different media conditions to optimise viability. Explants were also treated with carboplatin/paclitaxel or pembrolizumab for 24 h and processed into histology slides. Multiplexed immunofluorescence for Ki67 (proliferation marker), cPARP (apoptosis marker) and CAM 5.2 (tumour mask) was performed followed by image analysis and quantitation of biomarker expression. RESULTS: EC samples are amenable to PDE culture with preserved histological architecture and PDE viability for up to 48 h, with the addition of autologous serum in culture media facilitating EC-PDE viability. Our PDE platform provides evidence of differential drug-response to conventional chemotherapeutics and immune checkpoint inhibition, and these responses can be assessed in the context of a preserved tumour microenvironment. CONCLUSIONS: Our PDE platform represents a rapid, low-cost pre-clinical model which can be easily integrated into drug development pipelines. PDE culture preserves original tumour architecture and enables evaluation of spatial relationships in the tumour microenvironment. PDE culture has the potential for personalised drug-testing in a pre-clinical setting which is increasingly important in an era of personalised medicine in the treatment of EC.

Impact of past obstetric history and cervical excision on preterm birth rate.

INTRODUCTION: To determine the impact on preterm birth (PTB) of a history of large loop excision of the transformation zone (LLETZ)-alone compared with a history of previous preterm birth-alone (PPTB) or a history of both (LLETZ+PPTB). Secondary analyses were performed to evaluate the impact of antenatal interventions, depth of cervical excision, and patient risk factors on PTB rate in each cohort. MATERIAL AND METHODS: A retrospective observational cohort study of women referred to a tertiary Antenatal Prematurity Prevention Clinic with a history of LLETZ, PPTB, or LLETZ+PPTB. Information was collated from routinely collected clinical data on patient demographics, previous obstetric history, LLETZ dimensions, antenatal investigations/interventions, and gestation at delivery. RESULTS: A total of 1231 women with singleton pregnancies were included, 543 with history of LLETZ-alone, 607 with a history of PPTB-alone and 81 with a history of LLETZ+PPTB. PTB rates were 8.8% in the LLETZ-alone group, which mirrored the PTB rate in the local background obstetric population (8.9%) compared with 28.7% in the PPTB-alone and 37.0% in the LLETZ+PPTB cohorts. PTB rates were higher in LLETZ cohorts treated with antenatal intervention (cervical cerclage or progesterone pessary) and there was no evidence of an effect of intervention on risk of PTB in post-excision patients with identified shortened mid-trimester cervical length. Logistic regression modeling identified PPTB as a strong predictor of recurrent PTB. Excision depth was correlated with gestation at delivery in the LLETZ-alone group (r = -0.183, p < 0.01) although this only reached statistical significance at depths of 20 mm or more (odds ratio [OR] 3.40, 95% CI 1.04-1.11, p = 0.04). Depth of excision was not correlated with delivery gestation in the LLETZ+PPTB group (r = -0.031, p = 0.82). CONCLUSIONS: PPTB has a greater impact on subsequent PTB risk compared with depth of cervical excisional treatment. The value and nature of antenatal interventions should be investigated in the post-excision population.

Patient acceptability of circulating tumour DNA testing in endometrial cancer follow-up.

OBJECTIVE: Circulating tumour DNA (ctDNA) is emerging as a potential option to detect disease recurrence in many cancer types, however, ensuring patient acceptability of changing clinical practice and the introduction of new technology is paramount. METHODS: Patients enrolled in a non-intervention cohort study determining the ability of ctDNA to detect recurrent endometrial cancer (EC) were invited to participate in a semi-structured interview. Analysis was performed by Template Analysis. RESULTS: Eighteen patients were interviewed. A ctDNA blood test was viewed by participants as more physically and psychologically acceptable than clinical examination to monitor for EC recurrence. In particular, participants expressed overwhelming preference for a blood test rather than pelvic examination. Although participants acknowledged that an abnormal ctDNA result could cause anxiety, they expressed a preference to be informed of their results, even if a recurrence was too small to detect radiologically. Explanations for these opinions were a desire for certainty whether their cancer would recur or not, and knowledge would help them be more aware of symptoms that should be reported to their clinician. CONCLUSIONS: ctDNA monitoring to identify EC recurrence appears to be acceptable to patients, and for many, it may be preferable to clinical examination.

Patient-initiated follow-up for low-risk endometrial cancer: a cost-analysis evaluation.

OBJECTIVE: Risk stratification has resulted in patient-initiated follow-up being introduced for low-risk endometrial cancer in place of routine hospital follow-up. The financial benefit to the patient and the healthcare economy of patient-initiated follow-up, as compared with hospital follow-up, has yet to be explored. In this study, we explored the potential impact for both the healthcare economy and patients of patient-initiated follow-up. METHODS: Women diagnosed with low-risk endometrial cancer enrolled on a patient-initiated follow-up scheme between November 2014 and September 2018 were included. Data on the number of telephone calls to the nurse specialists and clinic appointments attended were collected prospectively. The number of clinic appointments that would have taken place if the patient had continued on hospital follow-up, rather than starting on patient-initiated follow-up, was calculated and costs determined using standard National Health Service (NHS) reference costs. The time/distance traveled by patients from their home address to the hospital clinic was calculated and used to determine patient-related costs. RESULTS: A total of 187 patients with a median of 37 (range 2-62) months follow-up after primary surgery were enrolled on the scheme. In total, the cohort were scheduled to attend 1673 appointments with hospital follow-up, whereas they only attended 69 clinic appointments and made 107 telephone contacts with patient-initiated follow-up. There was a 93.5% reduction in costs from a projected £194 068.00 for hospital follow-up to £12 676.33 for patient-initiated follow-up. The mean patient-related costs were reduced by 95.6% with patient-initiated follow-up. The total mileage traveled by patients for hospital follow-up was 30 891.4 miles, which was associated with a mean traveling time per patient of 7.41 hours and clinic/waiting time of 7.5 hours compared with 1165.8 miles and 0.46 hours and 0.5 hours, respectively, for patient-initiated follow-up. CONCLUSION: The introduction of a patient self-management follow-up scheme for low-risk endometrial cancer was associated with financial/time saving to both the patient and the healthcare economy as compared with hospital follow-up.

Impact of Obesity on Surgeon Ergonomics in Robotic and Straight-Stick Laparoscopic Surgery.

STUDY OBJECTIVE: Work-related musculoskeletal symptoms (WMSs) are reported to be increasing in surgeons performing minimally invasive procedures. Therefore, we investigated the use of inertial measurement units (IMUs) and electromyography (EMG) sensor recorders to record real-time information on the muscle movement/activity required to perform training exercises in simulated in normal and high body mass index (BMI) models. DESIGN: Prospective study. SETTING: University hospital. PARTICIPANTS: Four consultant gynecologic oncology surgeons experienced in complex straight-stick (SS) laparoscopic and robotically assisted (RA) surgery. INTERVENTIONS: Three exercises (hoops onto pegs and wire chase) using SS and RA surgery on 2 abdominal models: normal BMI and high BMI. MEASUREMENTS AND MAIN RESULTS: We measured time to complete exercise and surgeon muscle movement/activity. The time to complete all exercises was significantly lower for RA surgery as compared with SS laparoscopy (p <.05 or better). The movement of the surgeons' core was significantly greater in high BMI SS laparoscopy compared with normal BMI SS laparoscopy for exercises 1 and 2 (p <.001). Muscle usage, as determined by EMG peak, was significantly higher in normal BMI SS laparoscopy and even higher in high BMI SS laparoscopy but was generally flat for all normal and high BMI RA surgery exercises (p <.05 or better). CONCLUSION: Detailed real-time information can be collected through IMUs/EMG sensors. Our results indicate that RA surgery requires less surgeon movements and muscle activity to complete tasks compared with SS laparoscopy, particularly in a high BMI model. The implications of these results are that RA surgery in high BMI patients may therefore have less physical impact on the surgeon compared with SS laparoscopy and may result in lower WMS rates.

Acceptability and utilisation of patient-initiated follow-up for endometrial cancer amongst women from diverse ethnic and social backgrounds: A mixed methods study.

INTRODUCTION: A shift in focus towards risk stratification and survivorship in early stage endometrial cancer (EC) has led to the replacement of hospital follow-up (HFU) with patient-initiated follow-up (PIFU) schemes. METHODS: A mixed methods study was undertaken prospectively to investigate utility and patient satisfaction with a newly introduced PIFU scheme. RESULTS: Two hundred and twenty-eight women were enrolled onto PIFU in the first 18 months, median age 65 years (range 42-90 years). Twenty-four (10.5%) women were non-British White ethnicity. Forty-five women contacted the Clinical Nurse Specialist (CNS) at least once (19.7%), the primary reason being vaginal bleeding/discharge (42%). Contact was greater in first six months on the scheme compared to the second 6 months, and women who made contact were significantly younger than those who did not (57 years vs. 65 years, p < 0.001). CONCLUSIONS: PIFU appears to be well received by the majority of women. Although many of the CNS contacts were due to physical symptoms, a number were for psychological support or reassurance. Younger women had greater CNS contact indicating that they may benefit from a greater level support. Patient feedback of the PIFU scheme was positive, with many women reporting that it enabled them to have more control over their own health.

HPV primary cervical screening in England: Women's awareness and attitudes.

BACKGROUND: Primary human papillomavirus (HPV) cervical screening is due to be implemented in England within the next 2 years; however, the acceptability of HPV testing as the primary screening test is unclear. This study explores women's awareness and attitudes toward HPV testing/screening. METHODS: Qualitative interviews (semistructured and focus group) were conducted with 46 women (aged 25-65 years) from community and secondary care settings. Data were analyzed by using the inductive-framework method. RESULTS: Women were unaware that cervical screening currently includes HPV testing and lacked HPV-related knowledge. Emotions of shock, fear, and anxiety were reported upon receiving a positive HPV result. For women in long-term relationships, the realization that HPV is a sexually transmitted infection was seen as a barrier to primary HPV testing. Knowledge that HPV testing is a screening test to prevent cervical cancer did not change their attitudes. Women debated the need for continued screening following a negative result. Women feared judgment by the community if they participated with primary HPV screening because they were being tested for a sexually transmitted infection, with the possible attendant perception that they had adopted a high-risk lifestyle in comparison to nonattenders. CONCLUSIONS: The acceptability of HPV testing may be a limiting factor in encouraging participation with screening in the future.

Incomplete excision of cervical precancer as a predictor of treatment failure: a systematic review and meta-analysis.

BACKGROUND: Incomplete excision of cervical precancer is associated with therapeutic failure and is therefore considered as a quality indicator of clinical practice. Conversely, the risk of preterm birth is reported to correlate with size of cervical excision and therefore balancing the risk of adequate treatment with iatrogenic harm is challenging. We reviewed the literature with an aim to reveal whether incomplete excision, reflected by presence of precancerous tissue at the section margins, or post-treatment HPV testing are accurate predictors of treatment failure. METHODS: We did a systematic review and meta-analysis to assess the risk of therapeutic failure associated with the histological status of the margins of the tissue excised to treat cervical precancer. We estimated the accuracy of the margin status to predict occurrence of residual or recurrent high-grade cervical intraepithelial neoplasia of grade two or worse (CIN2+) and compared it with post-treatment high-risk human papillomavirus (HPV) testing. We searched for published systematic reviews and new references from PubMed-MEDLINE, Embase, and CENTRAL and did also a new search spanning the period Jan 1, 1975, until Feb 1, 2016. Studies were eligible if women underwent treatment by excision of a histologically confirmed CIN2+ lesion, with verification of presence or absence of CIN at the resection margins; were tested by cytology or HPV assay between 3 months and 9 months after treatment; and had subsequent follow-up of at least 18 months post-treatment including histological confirmation of the occurrence of CIN2+. Primary endpoints were the proportion of positive section margins and the occurrence of treatment failure associated with the marginal status, in which treatment failure was defined as occurrence of residual or recurrent CIN2+. Information about positive resection margins and subsequent treatment failure was pooled using procedures for meta-analysis of binomial data and analysed using random-effects models. FINDINGS: 97 studies were eligible for inclusion in the meta-analysis and included 44 446 women treated for cervical precancer. The proportion of positive margins was 23·1% (95% CI 20·4-25·9) overall and varied by treatment procedure (ranging from 17·8% [12·9-23·2] for laser conisation to 25·9% [22·3-29·6] for large loop excision of the transformation zone) and increased by the severity of the treated lesion. The overall risk of residual or recurrent CIN2+ was 6·6% (95% CI 4·9-8·4) and was increased with positive compared with negative resection margins (relative risk 4·8, 95% CI 3·2-7·2). The pooled sensitivity and specificity to predict residual or recurrent CIN2+ was 55·8% (95% CI 45·8-65·5) and 84·4% (79·5-88·4), respectively, for the margin status, and 91·0% (82·3-95·5) and 83·8% (77·7-88·7), respectively, for high-risk HPV testing. A negative high-risk HPV test post treatment was associated with a risk of CIN2+ of 0·8%, whereas this risk was 3·7% when margins were free. INTERPRETATION: The risk of residual or recurrent CIN2+ is significantly greater with involved margins on excisional treatment; however, high-risk HPV post-treatment predicts treatment failure more accurately than margin status. FUNDING: European Federation for Colposcopy and Institut national du Cancer (INCA).

Knowledge of human papillomavirus and the human papillomavirus vaccine in European adolescents: a systematic review.

BACKGROUND: The human papillomavirus (HPV) vaccine is recommended for adolescent girls in many European countries, however there is huge variation in vaccine uptake. METHODS: A mixed methods systematic review to ascertain the level of HPV and HPV vaccine knowledge that exists among European adolescents. Two electronic databases, Ovid Medline and PsychInfo, were searched from origin to September 2014. Meta-analysis was performed for the two primary outcome measures ('have you heard of HPV?' and 'have you heard of the HPV vaccine?'), assessing for the correlation between gender and knowledge. This was supplemented with meta-synthesis for the remaining associations and secondary outcomes. RESULTS: 18 papers were included in the final review. Overall European adolescents had poor understanding of basic HPV and HPV vaccine knowledge. Meta-analysis identified that female adolescents are more likely to have heard of HPV (n=2598/5028 girls versus n=1033/3464 boys; OR 2.73, 95% CI 1.86-3.99) and the HPV vaccine (n=1154/2556 girls versus n=392/2074 boys; OR 5.64, 95% CI 2.43-13.07), compared to males. Age, higher education and a positive vaccination status were also associated with increased awareness. There was limited appreciation of more detailed HPV knowledge and uncertainty existed regarding the level of protection offered by the vaccine and the need for cervical screening post vaccination. CONCLUSIONS: The delivery of HPV education to European adolescents needs to be re-evaluated, since at present there appears to be significant deficiencies in their basic knowledge and understanding of the subject. Increasing HPV knowledge will empower adolescents to make informed choices regarding participation with HPV related cancer prevention health strategies.

The Use of the Colposcopically Directed Punch Biopsy in Clinical Practice: A Survey of British Society of Colposcopy and Cervical Pathology (BSCCP)-Accredited Colposcopists.

OBJECTIVES: The colposcopically directed punch biopsy has been an integral component of colposcopic practice. In light of the changing landscape of the cervical screening programme, a study was conducted to investigate the current practice of British Society of Colposcopy and Cervical Pathology-accredited colposcopists on technique and rationale for performing a punch biopsy. MATERIALS AND METHODS: A web-based questionnaire survey was e-mailed to all British Society of Colposcopy and Cervical Pathology-accredited colposcopists. Questions included selection criteria for performing a punch biopsy, number of biopsies, and technique. Results were analyzed by specialty, experience, and workload. RESULTS: A total of 749 colposcopists responded, 50.2% of the 1,493 total. The respondents were obstetrician and gynecologists (42.9%), gynecologists/oncologists (33.6%), and nurse colposcopists (19.8%). Most colposcopists (78.3%) had more than 5-year colposcopy experience and saw in excess of 11 new cases (73.4%) of abnormal cervical cytology/month. Most colposcopists (56%) aimed to take 2 biopsies to diagnose cervical intraepithelial neoplasia, and very few (16.2%) reported routinely taking random biopsies from normal areas of cervix. Looking at the trends in management in the case scenarios, there was a lower threshold for performing punch biopsy before large loop excision of the transformation zone in younger (age, <25 years) or nulliparous women versus older women (age, >40 years; p < .05). Colposcopists were more likely to take biopsies in women with low-grade cytology/colposcopic findings (71.2%, always or most of the times) as compared with high-grade cytology/colposcopic findings (40.3%, never or rarely). CONCLUSIONS: Colposcopically directed punch biopsy is routinely used by colposcopists; however, techniques, number of biopsies taken, and rationale for performing a biopsy vary greatly between colposcopists.

Validation of endogenous control reference genes for normalizing gene expression studies in endometrial carcinoma.

Real-time quantitative RT-PCR (qRT-PCR) is a powerful technique used for the relative quantification of target genes, using reference (housekeeping) genes for normalization to ensure the generation of accurate and robust data. A systematic examination of the suitability of endogenous reference genes for gene expression studies in endometrial cancer tissues is absent. The aims of this study were therefore to identify and evaluate from the thirty-two possible reference genes from a TaqMan(®) array panel their suitability as an internal control gene. The mathematical software packages geNorm qBasePLUS identified Pumilio homolog 1 (Drosophila) (PUM1), ubiquitin C (UBC), phosphoglycerate kinase (PGK1), mitochondrial ribosomal protein L19 (MRPL19) and peptidylpropyl isomerase A (cyclophilin A) (PPIA) as the best reference gene combination, whilst NormFinder identified MRPL19 as the best single reference gene, with importin 8 (IPO8) and PPIA being the best combination of two reference genes. BestKeeper ranked MRPL19 as the most stably expressed gene. In addition, the study was validated by examining the relative expression of a test gene, which encodes the cannabinoid receptor 1 (CB1). A significant difference in CB1 mRNA expression between malignant and normal endometrium using MRPL19, PPIA, and IP08 in combination was observed. The use of MRPL19, IPO8 and PPIA was identified as the best reference gene combination for the normalization of gene expression levels in endometrial carcinoma. This study demonstrates that the arbitrary selection of endogenous control reference genes for normalization in qRT-PCR studies of endometrial carcinoma, without validation, risks the production of inaccurate data and should therefore be discouraged.

Views of general practitioners on the role of CA125 in primary care to diagnose ovarian cancer.

BACKGROUND: NICE guidance on the investigation and treatment of ovarian cancer advocates that the tumour marker CA125 should be the first line investigation for women suspected of having ovarian cancer. METHODS: An internet-based survey, of primary care doctors in the West Midlands, was conducted in order to ascertain the views of general practitioners (GPs) of NICE guidance on the use of CA125 to triage suspected ovarian cancer cancers and the impact that this may have on referral pathways. RESULTS: In total 258 GPs responded to the questionnaire. Although 219 (84.9%) responders reported awareness of the NICE guidance only 146 (56.6%) had personally read the document. The majority 187 (72.5%) of respondents anticipated that their use of CA125 would increase as a result of the new guidance. Abdominal bloating (>50 years), persistent abdominal distension and the presence of an abdominal or pelvic mass/swelling were the symptoms felt to be most associated with ovarian cancer. When questioned on the management of a woman with a raised CA125 the majority of respondents reported that a normal ultrasound scan would not stop an urgent secondary care referral if the CA125 was raised. There was no significant difference in the opinions of GPs with <5 years primary care experience compared to GPs with 6+ years. CONCLUSION: The symptoms associated with ovarian cancer are well understood by the GPs that responded however, a coordinated programme of education and training is needed for GPs on the role of CA125 in ovarian cancer, in addition to clearly defined referral pathways, in order to address a likely significant increase in suspected ovarian cancer referrals to secondary care, most of whom will not have ovarian cancer.

Impact of minimally invasive surgery on surgeon health (ISSUE) study: protocol of a single-arm observational study conducted in the live surgery setting.

INTRODUCTION: The rapid evolution of minimally invasive surgery has had a positive impact on patient outcomes; however, it is reported to be associated with work-related musculoskeletal symptoms (WMS) in surgeons. Currently there is no objective measure to monitor the physical and psychological impact of performing a live surgical procedure on the surgeon. METHODS AND ANALYSIS: A single-arm observational study with the aim of developing a validated assessment tool to quantify the impact of surgery (open/laparoscopic/robotic-assisted) on the surgeon. Development and validation cohorts of major surgical cases of varying levels of complexity performed by consultant gynaecological and colorectal surgeons will be recruited. Recruited surgeons wear three Xsens DOT monitors (muscle activity) and an Actiheart monitor (heart rate). Salivary cortisol levels will be taken and questionnaires (WMS and State-Trait Anxiety Inventory) completed by the participants preoperatively and postoperatively. All the measures will be incorporated to produce a single score that will be called the 'S-IMPACT' score. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by the East Midlands Leicester Central Research Ethics Committee REC ref 21/EM/0174. Results will be disseminated to the academic community through conference presentations and peer-reviewed journal publications. The S-IMPACT score developed within this study will be taken forward for use in definitive multicentre prospective randomised control trials.

Risk Stratified Follow-Up for Endometrial Cancer: The Clinicians' Perspective.

Risk-stratified follow-up for endometrial cancer (EC) is being introduced in many cancer centres; however, there appears to be diversity in the structure and availability of schemes across the UK. This study aimed to investigate clinicians' and clinical specialist nurses' (CNS) experiences of follow-up schemes for EC, including patient-initiated follow-up (PIFU), telephone follow-up (TFU) and clinician-led hospital follow-up (HFU). A mixed-methods study was conducted, consisting of an online questionnaire to CNSs, an audience survey of participants attending a national "Personalising Endometrial Cancer Follow-up" educational meeting, and qualitative semi-structured telephone interviews with clinicians involved in the follow-up of EC. Thematic analysis identified three main themes to describe clinicians' views: appropriate patient selection; changing from HFU to PIFU schemes; and the future of EC follow-up schemes. Many participants reported that the COVID-19 pandemic impacted EC follow-up by accelerating the transition to PIFU/TFU. Overall, there was increasing support for non-HFU schemes for patients who have completed primary treatment of EC; however, barriers were identified for non-English-speaking patients and those who had communication challenges. Given the good long-term outcome associated with EC, greater focus is needed to develop resources to support patients post-treatment and individualise follow-up according to patients' personal needs and preferences.

Impact of Patient Body Mass Index on Post-Operative Recovery from Robotic-Assisted Hysterectomy.

A longitudinal, descriptive, prospective, and prolective study of individuals with endometrial or cervical cancer/pre-cancer diagnoses and high BMI (over 35 kg/m2) undergoing RH was conducted. Of the 53 participants recruited, 3 (6%) were converted to open surgery. The 50 RH participants had median BMI 42 kg/m2 (range 35 to 60): the range 35-39.9 kg/m2 had 17 cases; the range 40-44.9 kg/m2 had 15 cases; 45-49.9 kg/m2 8 cases; and those ≥50 kg/m2 comprised 10 cases. The mean RH operating time was 128.1 min (SD 25.3) and the median length of hospital stay was 2 days (range 1-14 days). Increased BMI was associated with small, but statistically significant, increases in operating time and anaesthetic time, 65 additional seconds and 37 seconds, respectively, for each unit increase in BMI. The median self-reported time for individuals who underwent RH to return to their pre-operative activity levels was 4 weeks (range 2 to >12 weeks). There was a significant improvement in pain and physical independence scores over time (p = 0.001 and p < 0.001, respectively) and no significant difference in scores for overall QOL, pain, or physical independence scores was found between the BMI groups. Patient-reported recovery and quality of life following RH is high in individuals with high BMI (over 35 kg/m2) and does not appear to be impacted by the severity of obesity.

Sclerosing peritonitis associated with a luteinized adult granulosa cell tumor.

Sclerosing peritonitis is an uncommon condition that has been reported in patients with luteinized ovarian thecomas, although some pathologists have suggested that the underlying ovarian pathology is not always neoplastic. We now report sclerosing peritonitis in a patient with an uncommon, luteinized variant of an adult granulosa cell tumor. To the best of our knowledge, this association has not been described previously. We suggest that sclerosing peritonitis may result from the release of substances by luteinized ovarian stromal cells, in the context of hyperplasia or neoplasia, which stimulate the proliferation of submesothelial fibroblasts.

Is the colposcopically directed punch biopsy a reliable diagnostic test in women with minor cytological lesions?

OBJECTIVE: The study aimed to determine the accuracy of the colposcopy-directed punch biopsy (punch) to detect or exclude high-grade cervical intraepithelial neoplasia (CIN 2 or 3) in women with atypical squamous cells of undetermined significance (ASCUS) or low-grade squamous intraepithelial lesion (LSIL) cytological result and minor colposcopic findings. MATERIALS AND METHODS: In a diagnostic test accuracy study, women with ASCUS or LSIL cytological result and minor colposcopic changes had a single colposcopy-targeted punch biopsy was performed immediately followed by a loop electrocautery excision procedure (LEEP) biopsy. The trial was powered to detect a level of κ for a dichotomous outcome of 0.4 (i.e., fair-to-moderate agreement), with a two-sided significance level of 5% and a power of 90%. Accuracy parameters were computed using a cutoff for positive punch biopsy result of CIN 1+ and CIN 2+ for an outcome of CIN 2+ and CIN 3+ assessed in the LEEP specimen. RESULTS: Sixty-eight punch biopsy/LEEP-paired samples were analyzed. Of the 8 CIN 3 lesions, 6 and 4 were detected at cutoff CIN 1+ and CIN 2+, respectively (sensitivity, 50% and 75%). The corresponding specificities were 65% (39/60) and 97% (58/60). The punch biopsies identified only 14 (67%) or 6 (20%) of the 21 CIN 2+ lesions at cutoff CIN 1+ or CIN 2+, respectively. Of the punch biopsies, 31 (45.6%) accurately detected the severity of cervical abnormality. CONCLUSIONS: A single colposcopically directed punch biopsy appears to be insufficient to exclude underlying CIN 2 or 3.