Splenic artery aneurysm in obstetrical patients: A series of four cases with different clinical presentation and outcome.

OBJECTIVE: To describe four consecutive cases of splenic artery aneurysm (SAA) with different clinical patterns of presentation among obstetrical patients. METHODS: A series of four cases of SAA diagnosed in pregnant or postpartum women at our University center between January 1998 and December 2020. Clinical and radiologic data were retrospectively obtained by reviewing paper and electronic medical records after acquiring patient's consent. RESULTS: One case was completely asymptomatic and incidentally identified at the beginning of pregnancy, thus allowing for multidisciplinary treatment. The other three cases were unknown: two manifested with maternal collapse due to aneurysm rupture in the third trimester of gestation, whereas one presented with acute abdominal pain during the postpartum period and was successfully managed before rupture occurred. CONCLUSION: Although extremely rare, SAA rupture in obstetrical patients can be associated with dramatic consequences. Early suspicion and prompt intervention are essential to avoid fatal outcomes, so promotion of knowledge of all the potential clinical patterns of presentation of SAA rupture among obstetrical patients is mandatory.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management.

INTRODUCTION AND HYPOTHESIS: Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal. METHODS: The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal. RESULTS: The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced. CONCLUSION: This represents a valid surgical approach for the late management of this mesh-related complication.

Telephone interview in urogynecology in the era of COVID-19 pandemic

Objective: During the Coronavirus disease-2019 (COVID-19) pandemic deferable access, including non-urgent outpatient visits, have been suspended. In our practice non-urgent routine visits for pelvic floor symptom assessment were discontinued and rescheduled, and telephone interview was performed. The aim was to evaluate patients' satisfaction for this alternative approach. Material and Methods: Telephone interviews were conducted using a validated questionnaire to investigate pelvic floor symptoms. Patients were also asked if they had other symptoms or disorders, to identify patients who may need urgent hospital evaluation. At the end of the phone call, patients were asked to score their satisfaction with the telephone interview by grading their response to three questions from 0 (minimum) to 10 (maximum). The questions were: 1) "Was the telephone interview useful to check your state of health?"; 2) "Was the telephone interview an adequate healthcare tool in consideration of COVID-19 outbreak?"; 3) "Could the telephone interview replace the conventional visit?". Results: Fifty-three patients were evaluated. All patients showed great satisfaction with telephone interview (Q1 median: 10, IQ range: 10-10) and were similarly positive in response to the second question (Q2 median: 10, IQ range: 10-10). Although fewer patients felt that telephone interview could replace conventional clinic visits most remained positive (Q3 median: 7; IQ range: 6-8). Conclusion: This simple experience showed that phone interviews with validated questionnaires are appreciated and effective to safely perform interview of selected urogynecologic patients.

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up.

INTRODUCTION AND HYPOTHESIS: Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time. METHODS: This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time. RESULTS: The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time. CONCLUSIONS: Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.

Urodynamic predictors of de novo overactive bladder after single-incision sling.

OBJECTIVE: To identify urodynamic predictors for de novo overactive bladder (OAB) after single-incision sling implantation. METHODS: This retrospective study analyzed women with pure, urodynamically proven stress urinary incontinence, without OAB, between 2008 and 2015, in a university hospital. De novo OAB was investigated during clinical interviews. RESULTS: A total of 192 patients were analyzed; 21 patients with de novo OAB were considered as group A while 171 control patients formed group B. Univariate analysis demonstrated that patients with de novo OAB have the first desire to void at a lower bladder volume (124 mL versus 160 mL, P = 0.0052), smaller maximum cystometric capacity (357 mL versus 406 mL, P = 0.0061), lower maximum flow (17 mL/s versus 23 mL/s, P = 0.0006), and higher bladder outlet obstruction index (BOOI; -11 versus -23, P = 0.0022) compared with controls. According to multivariate analysis, maximum cystometric capacity (parameter estimate [PE] =0.008, P = 0.04) and BOOI (PE = -0.029, P = 0.01) were independent urodynamic predictors of de novo OAB. The final model showed good predictive accuracy (area under the curve =0.81). CONCLUSION: The present study identified maximum cystometric capacity and BOOI as independent predictors of de novo overactive bladder after single-incision sling implantation. Therefore, preoperative urodynamics may be useful to improve preoperative counseling and to tailor surgical treatment.

Surgical management of bladder erosion and pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse.

INTRODUCTION AND HYPOTHESIS: Mesh-augmented lateral suspension for prolapse repair seems to be associated with few complications. However, mesh-related complications can negatively affect the quality of life and may be challenging to manage. This video is aimed at presenting the surgical management of a case of severe pelvic pain and dyspareunia after lateral laparoscopic suspension associated with mesh erosion in the bladder. METHODS: A 46-year-old woman was referred to our Unit for severe pelvic pain and inability to have sexual intercourses since undergoing a uterus-sparing laparoscopic lateral suspension procedure for genital prolapse 2 years before in another hospital. Moreover, she reported bladder pain and recurrent urinary tract infections. Cystoscopy showed mesh erosion in the bladder. She was admitted to laparoscopic hysterectomy plus subtotal mesh excision and bladder reconstruction (video). RESULTS: No surgical complications were observed. The postoperative course was uneventful. At the current follow-up, the patient reported complete resolution of her symptoms. CONCLUSION: The featured video shows laparoscopic subtotal mesh excision, concomitant hysterectomy and bladder repair for pelvic pain, dyspareunia and bladder erosion after lateral suspension. This video may be useful in providing anatomical views and surgical steps necessary for achieving successful surgical management of this mesh-related complication.

A simple contaminant fate and transport modelling tool for management and risk assessment of groundwater pollution from contaminated sites.

Contaminated sites pose a significant threat to groundwater resources. The resources that can be allocated by water regulators for site investigation and cleanup are limited compared to the large number of contaminated sites. Numerical transport models of individual sites require large amounts of data and are labor intensive to set up, and thus they are likely to be too expensive to be useful in the management of thousands of contaminated sites. Therefore, simple tools based on analytical solutions of contaminant transport models are widely used to assess (at an early stage) whether a site might pose a threat to groundwater. We present a tool consisting of five different models, representing common geological settings, contaminant pathways, and transport processes. The tool employs a simplified approach for preliminary, conservative, fast and inexpensive estimation of the contamination levels of aquifers. This is useful for risk assessment applications or to select and prioritize the sites, which should be targeted for further investigation. The tool is based on steady-state semi-analytical models simulating different contaminant transport scenarios from the source to downstream groundwater, and includes both unsaturated and saturated transport processes. The models combine existing analytical solutions from the literature for vertical (from the source to the top of the aquifer) and horizontal (within the aquifer) transport. The effect of net recharge causing a downward migration and an increase of vertical dispersion and dilution of the plume is also considered. Finally, we illustrate the application of the tool for a preliminary assessment of two contaminated sites in Denmark and compare the model results with field data. The comparison shows that a first preliminary assessment with conservative, and often non-site specific parameter selection, is qualitatively consistent with broad trends in observations and provides a conservative estimate of contamination.

A systematic model identification method for chemical transformation pathways - the case of heroin biomarkers in wastewater.

This study presents a novel statistical approach for identifying sequenced chemical transformation pathways in combination with reaction kinetics models. The proposed method relies on sound uncertainty propagation by considering parameter ranges and associated probability distribution obtained at any given transformation pathway levels as priors for parameter estimation at any subsequent transformation levels. The method was applied to calibrate a model predicting the transformation in untreated wastewater of six biomarkers, excreted following human metabolism of heroin and codeine. The method developed was compared to parameter estimation methods commonly encountered in literature (i.e., estimation of all parameters at the same time and parameter estimation with fix values for upstream parameters) by assessing the model prediction accuracy, parameter identifiability and uncertainty analysis. Results obtained suggest that the method developed has the potential to outperform conventional approaches in terms of prediction accuracy, transformation pathway identification and parameter identifiability. This method can be used in conjunction with optimal experimental designs to effectively identify model structures and parameters. This method can also offer a platform to promote a closer interaction between analytical chemists and modellers to identify models for biochemical transformation pathways, being a prominent example for the emerging field of wastewater-based epidemiology.

Indocyanine Green versus Radiotracer with or without Blue Dye for Sentinel Lymph Node Mapping in Stage >IB1 Cervical Cancer (>2 cm).

STUDY OBJECTIVE: To compare sentinel lymph node (SLN) mapping in women with cervical cancer stage >IB1 (tumor size >2 cm) using indocyanine green (ICG) versus the standard technique using radioisotope technetium 99m radiocolloid (Tc99m) radiotracer with or without blue dye. DESIGN: European multicenter, retrospective observational study (Canadian Task Force classification II-2). SETTING: Four academic medical centers. PATIENTS: Ninety-five women with stage IB1 cervical cancer (>2 cm) who underwent SLN mapping with Tc99m with or without blue dye or ICG and radical hysterectomy. INTERVENTION: The detection rate and bilateral mapping rate were compared between ICG and standard Tc99m radiotracer with or without blue dye. Lymphadenectomy was performed, and the false-negative rate was assessed. MEASUREMENTS AND MAIN RESULTS: Forty-seven patients underwent SLN mapping with Tc99m with or without blue dye, and 48 did so with ICG. All patients underwent radical hysterectomy with or without bilateral salpingo-oophorectomy between 2008 and 2016. The overall detection rate of SLN mapping was 91.5% for Tc99m with or without blue dye and 100% for ICG. A 91.7% rate of bilateral migration was achieved for ICG, significantly higher than the 66% obtained with Tc99m with or without blue dye (p = .025). Nine of the 23 SLN-positive patients (39.1%) were diagnosed exclusively as a result of the ultrastaging used to identify micrometastases or isolated tumor cells only. CONCLUSIONS: In advanced cervical cancer (stage IB1 >2 cm), the detection rate and bilateral migration rate on real-time fluorescent SLN mapping were higher with ICG than with Tc99m radiotracer with or without blue dye. SLN mapping and ultrastaging can provide additional information for nodal staging in advanced cervical cancer. In this setting, ICG is a promising tool for mapping, appearing less affected by higher disease stage compared with traditional methods.

Long-Term Clinical Benefits of Neoadjuvant Chemotherapy in Women With Locally Advanced Cervical Cancer: Validity of Pathological Response as Surrogate Endpoint of Survival.

OBJECTIVE: Neoadjuvant chemotherapy (NACT) is a valid treatment option for women with locally advanced cervical cancer (LACC). This study aims to evaluate the impact of sociodemographic factors, clinical factors, and NACT regimens on survival endpoints. The role of pathological response to NACT as a surrogate endpoint of survival was also assessed. MATERIALS AND METHODS: Retrospective analysis of consecutive sample data from women with LACC (stages Ib2-IVa) who underwent NACT followed by radical surgery was performed. Response was classified as optimal response (including complete response and optimal partial response), suboptimal partial response, stable disease, and progressive disease. RESULTS: Four hundred forty-six women who had undergone surgery from 1992 to 2011 were analyzed. The overall optimal response was 35.4%. At a median follow-up of 12.7 years, 165 women (37.0%) experienced recurrence or died. Increase in patient age at surgery, International Federation of Gynecology and Obstetrics stage III/IV versus stage Ib2, and lymph-node positivity versus negativity seemed to impact negatively on survival, whereas neoadjuvant platinum-Taxol-containing regimens (compared with platinum-based regimens) improved survival. Response to NACT could be considered a surrogate endpoint of survival. CONCLUSIONS: Age, International Federation of Gynecology and Obstetrics stage III/IV, lymph-node involvement, and type of NACT administered have a significant impact on survival. Response to NACT is a good surrogate endpoint of survival in patients with LACC.

Modelling the impact of retention-detention units on sewer surcharge and peak and annual runoff reduction.

Stormwater management using water sensitive urban design is expected to be part of future drainage systems. This paper aims to model the combination of local retention units, such as soakaways, with subsurface detention units. Soakaways are employed to reduce (by storage and infiltration) peak and volume stormwater runoff; however, large retention volumes are required for a significant peak reduction. Peak runoff can therefore be handled by combining detention units with soakaways. This paper models the impact of retrofitting retention-detention units for an existing urbanized catchment in Denmark. The impact of retrofitting a retention-detention unit of 3.3 m³/100 m² (volume/impervious area) was simulated for a small catchment in Copenhagen using MIKE URBAN. The retention-detention unit was shown to prevent flooding from the sewer for a 10-year rainfall event. Statistical analysis of continuous simulations covering 22 years showed that annual stormwater runoff was reduced by 68-87%, and that the retention volume was on average 53% full at the beginning of rain events. The effect of different retention-detention volume combinations was simulated, and results showed that allocating 20-40% of a soakaway volume to detention would significantly increase peak runoff reduction with a small reduction in the annual runoff.

Evaluation of Patient Satisfaction Using the EORTC IN-PATSAT32 Questionnaire and Surgical Outcome in Single-Port Surgery for Benign Adnexal Disease: Observational Comparison with Traditional Laparoscopy.

Laparoscopic surgery has been demonstrated as a valid approach in almost all gynaecologic procedures including malignant diseases. Benefits of the minimally invasive approach over traditional open surgery have been well demonstrated in terms of minimal perioperative morbidity and reduced postoperative pain and hospital stay duration, with consequent quick postoperative recovery (Medeiros et al. (2009)). Single-port surgery resurfaced in gynaecology surgery in recent years and renewed interest among other surgeons and within the industry to develop this field (Podolsky et al. (2009)). Patient satisfaction is emerging as an increasingly important measure of quality which represents a complex entity that is dependent on patient demographics, comorbidities, disease, and, to a large extent, patient expectations (Tomlinson and Ko (2006)). It can be broadly thought to refer to all relevant experiences and processes associated with health care delivery (Jackson et al. (2001)). In this study we aim to compare single-port surgery (SPS) with conventional laparoscopy in terms of patient satisfaction using the EORTC IN-PATSAT32 questionnaire. We also evaluate the main surgical outcomes of both minimally invasive approaches.

Sentinel node mapping in high risk endometrial cancer after laparoscopic supracervical hysterectomy with morcellation.

INTRODUCTION: Occult endometrial cancer after supracervical hysterectomy is very uncommon. Even if optimal management of those rare cases is still unproven, to guide the need for further therapies, restaging should be recommended in this situation. PRESENTATION OF CASE: We report of a 60-year old woman with occult high risk endometrial cancer after supracervical hysterectomy with morcellation. We describe the feasibility of laparoscopic intraoperative sentinel node identification with cervical stump removing to restage the suspicious early stage high risk endometrial cancer. DISCUSSION: In high risk endometrial cancer surgical restaging is important, considering that 10-35% of cases can present pelvic nodal metastasis. To reduce the treatment related morbidity maintaining the benefit of surgical staging, with a negative preoperative PET/CT, we performed a laparoscopic SN mapping with cervical stump removing. CONCLUSION: This report highlight the fact that SN mapping with cervical injection is a feasible and safe technique also without the uterine corpus after supracervical hysterectomy with morcellation.