Prognostic Nutritional Index as a Predictive Biomarker of Post-Operative Infectious Morbidity in Gynecological Cancer Patients: A Prospective Cohort Study.

Malnutrition significantly impacts the post-operative process of gynecological cancer patients. A prominent variable for determining perioperative morbidity is the Prognostic Nutritional Index (PNI). To investigate PNI's predictive value on the risk of post-operative infections, we conducted a prospective cohort study involving women who underwent surgery for gynecological malignancies. Out of the 208 patients enrolled, 28 (13.5%) were malnourished and post-operative infections occurred in 43 patients. Notably, there was a significant difference in PNI between patients who developed infections and those who did not (p = 0.027), as well as between malnourished patients and those with normal nutritional status (p = 0.043). Univariate analysis showed that preoperative PNI predicts the risk of post-operative infections better than post-operative white blood cell count (AUC of 0.562 vs 0.375). However, the most accurate diagnostic results in the multivariate analysis were obtained from random forest and classification tree models (AUC of 0.987 and 0.977, respectively). Essentially, PNI and post-operative white blood cell count provided the best information gain according to rank probabilities. In conclusion, PNI appears to be a critical parameter that merits further investigation during the preoperative evaluation of gynecological malignancies.

Lower Urinary Tract Symptoms in Greek Women After Menopause: The LADY Study.

INTRODUCTION AND HYPOTHESIS: The genitourinary syndrome of menopause (GSM), apart from symptoms related to vulvovaginal atrophy (VVA), also consists of lower urinary tract symptoms (LUTS). Based on the common embryological origin of the genital and lower urinary system, the presence of estrogen receptors, and the high prevalence of VVA and LUTS in the menopausal population, the two conditions can coexist. This study is aimed at investigating the prevalence and risk factors of LUTS in a sample of Greek peri- and postmenopausal women. METHODS: Four hundred and fifty (450) women, aged 40-70 years, attending three outpatient gynecology clinics for routine examination, completed a structured interview and responded to a validated questionnaire (International Consultation on Incontinence Questionnaire Female Lower Urinary Tract Symptoms, ICIQ-FLUTS). RESULTS: Urinary urgency or frequency affected 51.6% and dysuria 43.6% of the participants. Mild urgency or frequency was described by 25.6%, moderate by 14.4%, and severe by 11.6% of the women. Mild dysuria was reported by 26.26%, moderate by 5.8%, and severe by 11.6%. Age, weight, BMI, and number of pregnancies and abortions correlated with a higher ICIQ-FLUTS score. Women with moderate/severe symptoms of VVA, such as irritation, a burning sensation, and pruritus of the vulva or vagina, had a higher ICIQ-FLUTS score than women without such symptoms (beta coefficient 2.42, CI 1.204, 3.635, p < 0.001). CONCLUSIONS: Lower urinary tract symptoms are very common among peri- and postmenopausal women and are linked to symptoms of VVA. Our data support the need for prompt evaluation of women transitioning to menopause, as these symptoms compromise the quality of life.

Awareness, knowledge and attitudes of human papillomavirus infection, screening and vaccination: a survey study in Greece.

PURPOSE: To evaluate the awareness and existing knowledge of a portion of the Greek population about prevention, screening, and HPV vaccination. METHODS: A questionnaire designed in Google forms has been distributed through social media between June 2021 and December 2021 in men and women aged > 16 years old. Statistical analysis was performed using the SPSS 20.0 program. Inferential analysis was performed to evaluate differences in responses among men and women. RESULTS: We enrolled 2685 participants. Of those, 2285 were women, 386 were men, while 14 respondents chose not to respond to this question. Various age groups were detected with those aged between 26 and 30 years old being the predominant one. Participants with a higher education constituted 36.5% of the population. Most respondents were married (59.8%). In socioeconomic terms 75.5% of participants were employed whereas, monthly income ranged between 1000 and 1500 euros in the predominant group (36.8%). Only 40% of females and 3.9% of males were vaccinated against HPV. Adolescent immunization, acceptability rates reached 92.7% among female and 82.1% among male responders. Although, only a small proportion of the participants were not aware of the existence of HPV, 24.1% of males and 23.4% of females had the impression that condom use may provide absolute immunity to HPV and only 51.6% of males and 60.4% of females were aware about the high prevalence of HPV in the general population. Logistic regression analysis indicated that male participants as well as those aged > 50 years and those choosing to reject vaccination had decreased knowledge of the basic pathophysiology of HPV infection, as well as knowledge related to the existence and use of HPV DNA as a screening tool and the existence and efficacy of HPV vaccination. CONCLUSION: Our results indicate that although awareness of the existence of HPV infection is high in Greek general population, the actual perception of the pathophysiology of transmission and importance of HPV testing and vaccination is low. Targeting specific population groups is essential to help increase HPV coverage and screening.

New boundaries for fertility sparing management in endometrial cancer.

PURPOSE OF REVIEW: The increasing rates of endometrial cancer in premenopausal women that accompanies modern lifestyle options that enhance the prevalence of obesity as well as the trend of delayed childbearing are expected to increase the need for fertility sparing techniques. Currently, the cornerstone of fertility sparing treatment is hormonal handling with progestin treatment and is reserved for women with well differentiated endometrioid lesions that are limited in the myometrial layer. RECENT FINDINGS: Innovative approaches in the surgical treatment of patients with the use of operative hysteroscopy seem to offer decreased intervals to remission of lesions and longer progression free survival. Recent small case series also dictate that patients with endometrioid lesions of medium differentiation as well as those with superficial myometrial invasion may be adequately treated with the use of operative hysteroscopy. Moreover, the novel classification system may help better understand patients that will likely respond better to hormonal treatment. SUMMARY: In the near future, further data from clinical trials will be available that will help optimize patient selection as well select surgical and medical options that will help establish a personalized approach of fertility preservation in endometrial cancer patients.

Thoracic epidural analgesia as part of an enhanced recovery program in gynecologic oncology: a prospective cohort study.

OBJECTIVE: To evaluate the safety and the effectiveness of thoracic epidural analgesia as part of the enhanced recovery after surgery (ERAS) multimodal analgesic protocol in patients with gynecologic oncology who have undergone laparotomy for suspected or confirmed malignancy. METHODS: We conducted a prospective cohort study, following an enhanced recovery after surgery pathway, among patients who had undergone laparotomy for confirmed or suspected gynecological malignancy between January 2020 and September 2021. All patients who underwent laparotomy at the gynecologic oncology department for the aforementioned reason during that time were considered eligible. Patients (n=217) were divided into two groups: epidural (n=118) and non-epidural (n=99) group. Both groups were treated with the standard ERAS departmental analgesic protocol. The primary outcomes were length of hospital stay, complications, and readmission rates. RESULTS: Data from 217 patients (epidural group, n=118 vs non-epidural group, n=99) with median age of 61 years (IQR 53-68) were analyzed. The most common type of cancer was of ovarian origin (85/217, 39.2%, p=0.055) and median (Aletti) surgical complexity score was 3 (p=0.42). No differences were observed in the patients' demographics, clinical, and surgical characteristics. Primarily, median length of stay was 4 days in both groups with statistically significant lower IQR in the epidural group (3-5 vs 4-5, p=0.021). Complication rates were more common in the non-epidural group (38/99, 38.3% vs 36/118, 30.5%, p<0.001) with similar rates of grade III (p=0.51) and IV (0%) complications and readmission rates (p=0.51) between the two groups. Secondarily, the epidural group showed lower pain scores (p<0.001) on the day of surgery and in the first post-operative day (p<0.001), higher mobilization rates on the day of surgery (94.1% vs 57.6%, p<0.001), faster removal of urinary catheter (p<0.001), shorter time to flatus (p<0.001), and less nausea on the day of surgery (p<0.001). CONCLUSION: In this study we showed that thoracic epidural analgesia, when used as part of an ERAS protocol, is safe and offers more favorable pain relief along with a number of additional benefits, improving the peri-operative experience of patients with gynecologic cancer.

ESGO/ESHRE/ESGE Guidelines for the fertility-sparing treatment of patients with endometrial carcinoma.

The standard surgical treatment of endometrial carcinoma, consisting of total hysterectomy with bilateral salpingo-oophorectomy, drastically affects the quality of life of patients and creates a challenge for clinicians. Recent evidence-based guidelines of the European Society of Gynaecological Oncology (ESGO), the European SocieTy for Radiotherapy and Oncology (ESTRO), and the European Society of Pathology (ESP) provide comprehensive information on all relevant issues of diagnosis and treatment in endometrial carcinoma in a multidisciplinary setting. While addressing also work-up for fertility preservation treatments and the management and follow-up for fertility preservation, it was considered relevant to further extend the guidance on fertility-sparing treatment.A collaboration was set up between the ESGO, the European Society of Human Reproduction and Embryology (ESHRE), and the European Society for Gynaecological Endoscopy (ESGE), aiming to develop clinically relevant and evidence-based guidelines focusing on key aspects of fertility-sparing treatment (patient selection, tumor clinicopathological characteristics, treatment, special issues) in order to improve the quality of care for women with endometrial carcinoma across Europe and worldwide.ESGO/ESHRE/ESGE nominated an international multidisciplinary development group consisting of practicing clinicians and researchers who have demonstrated leadership and expertise in the care and research of endometrial carcinoma (11 experts from across Europe). To ensure that the guidelines are evidence-based, the literature published since 2016, identified by a systematic search, was reviewed and critically appraised. In the absence of any clear scientific evidence, judgment was based on the professional experience and consensus of the development group. The guidelines are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines were reviewed by 95 independent international practitioners in cancer care delivery and patient representatives.

Cervical Cerclage vs. Pessary in Women with a Short Cervix on Ultrasound.

PURPOSE: In the present study we sought to compare the efficacy of cervical pessary to that of cerclage in terms of reducing preterm birth rates among women with a short (<25 mm) or ultra-short (<15 and <10 mm) cervix during the ultrasonographic second-trimester assessment. METHOD: We retrospectively searched the hospital records for singleton pregnancies diagnosed with cervical insufficiency during the second trimester of pregnancy. The McDonald cerclage using a 5mm Mersilene tape was used in all women. An Arabin pessary was used uniformly. In all cases 80 mg of vaginal progesterone gel were administered daily until 37 weeks of gestation. RESULTS: Overall, 294 women (124 (42.2%) with a McDonald cerclage and 170 (57.8%) with placement of an Arabin pessary) were selected for analysis. Preterm birth rates <37 weeks were similar in both groups (C: 30/122 vs. P: 35:165, p=.581) as well as PTB <34 weeks (C: 16/122 vs. 15/150, p=.278). Admission to the NICU and need for CPAP were more prevalent in the cerclage group (p<.001). Analysis of cases with a cervix <15 mm and <10 mm indicated that preterm birth rates remained equal among the groups, while an increased risk of NICU admission was seen in cases with a cervical length <10 mm that were treated with cerclage. DISCUSSION AND CONCLUSION: Cervical pessary may be an alternative to cervical cerclage for women with second-trimester cervical shortening and its effect may persist even among cases with an ultra-short cervix. Future randomized trials are needed to ascertain these findings.

Identification of Risk Factors of Recurrence Among Patients With Vulvar Paget Disease Treated With Conservative Surgery.

OBJECTIVES: Vulvar Paget disease (VPD) is a benign disease with high recurrence rates. Standard treatment involves conservative surgery with wide local excision of the lesion. The purpose of the present study is to identify factors that increase the risk of relapse. MATERIALS AND METHODS: We conducted a retrospective study and included patients treated with conservative surgery for noninvasive VPD. Cox regression analysis was carried out to assess the independent effect of age, presence of positive margins, tumor size greater than 4 cm, bilateral lesions, and compositive morbidity and pathology on recurrence free survival. Post hoc power analysis was performed with the G-power tool using an α error of 0.05. RESULTS: Overall, 39 patients were included with a median age of 70 years (46-85 years). Of those, 19 patients relapsed within a median duration of 30.5 months (5-132 months). Twelve patients (63%) experienced at least a second relapse. The presence of composite comorbidity significantly affected the interval to recurrence (30.09 vs 71.80 months, p = .032). Univariate Cox regression analysis revealed that the presence of composite pathology features was indicative of a higher risk of recurrence (hazard ratio = -3.71, p = .024). The sample size did not allow for adequate power for this latter finding. Microscopically involved tumor margins and tumor size greater than 4 cm did not predict patients at risk of experiencing relapsing disease. CONCLUSIONS: Patients with noninvasive VPD experience high relapse rates. The presence of concurrent benign vulvar pathology may increase these rates, although larger sample sizes are needed to ascertain our findings.

sFLT1, PlGF, the sFLT1/PlGF Ratio and Their Association with Pre-Eclampsia in Twin Pregnancies-A Review of the Literature.

Twin pregnancies demonstrate a 2-3-fold higher chance of developing PE compared to singletons, and recent evidence has demonstrated that the sFLT1/PIGF ratio is strongly associated with PE, adverse pregnancy outcomes, as well as imminent deliveries due to PE complications. The primary objective of this systematic review was to summarise the available data on the levels of sFLT1, PlGF and their ratios in twin pregnancies and to investigate their association with the development of PE, adverse pregnancy outcomes and the timing of the delivery. A systematic search of Ovid Embase, Web of Science, Science Direct, PubMed, Ovid Medline, Google Scholar and CINAHL was carried out. sFLT1 levels and the sFLT1/PIGF ratio appeared higher in twins compared to singleton pregnancies, especially in the third trimester, while PlGF levels appeared higher up until the third trimester, with their values showing no difference or being even lower than in singletons thereafter. The sFLT1/PIGF ratio has been reported to be an independent marker of adverse outcomes related to pre-eclampsia and is associated with the mean time until delivery in an inverse manner. Further research is required in order to establish the optimal sFLT1/PIGF cut-off values and to stratify the risk of adverse outcomes in twin pregnancies.

Perineural Invasion as a Predictive Biomarker of Groin Metastases and Survival Outcomes in Vulvar Cancer: A Meta-Analysis.

We searched international databases to identify evidence that refer to the impact of perineural invasion on survival outcomes of patients with squamous cell vulvar cancer. We identified six retrospective cohort studies that investigated 887 patients. Of those, 234 (26.4%) had perineural invasion in the pathology analysis. Women with perineural invasion were more likely to have inguinal lymph node metastases (HR 3.45, 95% CI 1.12, 10.67). The impact of perineural invasion on progression-free survival rates was significant (HR 1.61, 95% CI 1.21, 2.15) as well as its impact on overall survival rates (HR 2.73, 95% CI 1.94, 3.84).

Quality of life of ovarian cancer patients treated with combined platinum taxane chemotherapy: a systematic review of the literature.

PURPOSE: Chemotherapy is the cornerstone of adjuvant therapy in ovarian cancer. Its impact on the quality of life (QoL) has been addressed in several studies; however, several misperceptions concerning this affect patient counseling and physicians' ability to overcome patient fears. In the present systematic review, we sought to accumulate current evidence in the field in order to help establish robust information that will help physicians answer patients' questions. METHODS: The present systematic review is based on the PRISMA guidelines. Studies that evaluated patient QoL pre-, during, and post-chemotherapy with the use of the QLQC-30 were selected for inclusion. Their methodological quality was assessed with the before-after studies tool that is proposed by the National Institute of Health (NIH). RESULTS: Ten studies that involved 5181 patients were included in the present systematic review. The risk of bias and methodological quality of included studies was of good and fair overall quality. Retrieved data suggest there is substantial evidence that points toward improved global QoL among ovarian cancer patients treated with taxanes-platinum combination therapy. Individual outcomes evaluated with the QLQ-C30 also provide positive results, although underreporting was noted. CONCLUSION: Despite the significant heterogeneity in outcome reporting, the findings of this study reveal the significant benefit of combined platinum taxane chemotherapy on the QoL of ovarian cancer patients and can be used for patients counseling in order to reduce refusals that arise from fear of adverse effects that may negatively affect QoL. Graphical abstract.

Healthcare workers' attitudes about vaccination of pregnant women and those wishing to become pregnant.

OBJECTIVES: We designed an electronic query that was distributed to healthcare workers in order to evaluate their attitudes towards COVID-19 vaccination of women that wish to conceive and those that are pregnant. METHODS: An electronic survey was designed and distributed through a network of 5.654 e-mails. The query was uploaded in Google Forms. RESULTS: Overall, 1,226 answers were retrieved. Ninety percent of respondents replied that they prescribe COVID-19 vaccination in women that wish to conceive, however, the rate falls to 80% for those that have schedules for imminent artificial reproductive techniques. Approximately 1 in 2 physicians (obstetricians and pediatricians) suggests that a delay in assisted reproduction following immunization is not recommended. At least 13% of women of reproductive age and 30% of women wishing to conceive with ART declined to do so according to respondents, report. Only 75% of respondents favored immunization during pregnancy and of those 48% responded that vaccination could be done in all trimesters of pregnancy. Approximately 40% of women decline; however, to receive vaccination. CONCLUSIONS: Despite the directions provided by international organizations; physician and patient hesitancy towards vaccination during pregnancy (and particularly the first trimester) remains an issue that deserves further attention.

The impact of vaginal pH on induction of labour outcomes: a meta-analysis of observational studies.

The present meta-analysis evaluates the impact of an acidic vaginal pH on the progress of labour induction with dinoprostone and misoprostol. We searched Medline, Scopus, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL, Clinicaltrials.gov and Google Scholar databases for relevant studies. Meta-analysis was performed with Rstudio using the meta function and trial sequential analysis was used to evaluate the adequacy of sample size. Nine studies were retrieved that involved 809 patients. An acidic vaginal pH did not influence the efficacy of misoprostol or dinoprostone in terms of accomplishing a successful vaginal delivery (OR 0.62, 95% CI 0.29, 1.30). The interval to delivery was unaffected by the acidity of vaginal pH (Mean Difference 4.18 h, 95% CI -2.09, 10.45). In conclusion, vaginal pH does not seem to affect the potency of vaginally administered prostaglandins; therefore, moistening of vaginal tables with acetic acid does not seem reasonable until further evidence becomes available.

Myomectomy during pregnancy; diagnostical dilemmas: two case reports and a systematic review of the literature.

Myomectomy in pregnancy, until this day, remains very controversial. We present two cases of successful antepartum myomectomies performed in the second trimester of gestation. In both cases, the initial suspected origin of these tumours was the ovaries. However, as it was shortly after confirmed, since both women underwent laparotomy, the diagnosis of these masses was uterine fibroids. Both cases resulted on the live birth of two healthy infants via caesarean section. Secondarily, we conducted a thorough review of current data of myomectomies performed during pregnancy, including the characteristics and diagnosis of the myomas of pregnant women, the surgical details and complications, along with the outcomes of these gestations. Overall, the analysis of cases published in international literature, suggests that the surgical removal of myomas during pregnancy can be considered safe, given certain indications and considerations. Our review comprises of 71 women undergoing excision of fibroids during pregnancy. Only three cases ended in a miscarriage while the remaining 68 resulted in a second or third trimester delivery. However, the data concerning the safety of the procedure are scarce and originate mostly from case reports. Thus, conclusions on the exact maternal and obstetrical complication rates cannot be drawn.

Cephalad-caudad versus transverse blunt expansion of the low transverse hysterotomy during cesarean delivery decreases maternal morbidity: a meta-analysis.

OBJECTIVE: Cesarean delivery is the most prevalent surgical procedure worldwide, reaching approximately 29.7 million cases in 2015. It is directly associated with an increased risk of maternal and neonatal morbidity rates in the absence of malpresentation. Several techniques have been investigated, and there is evidence that cephalad-caudad expansion of the uterine incision might be associated with improved maternal outcomes compared with traditional transverse blunt expansion. The purpose of this meta-analysis was to evaluate the impact of cephalad-caudad expansion on adverse maternal outcomes, including intraoperative blood loss, risk of uterine vessel injury, and tearing of the lower uterine segment. DATA SOURCES: We searched Medline, Scopus, the Cochrane Central Register of Controlled Trials, Google Scholar, and Clinicaltrials.gov databases from inception to January 2021. STUDY ELIGIBILITY CRITERIA: Randomized controlled trials that assessed the impact of the cephalad-caudad blunt expansion of the low transverse uterine incision during cesarean delivery rather than those of transverse blunt expansion were selected for inclusion. METHODS: Effect sizes were calculated with the Hartung-Knapp-Sidik-Jonkman random-effects model in R. Trial sequential analysis was performed to evaluate the adequacy of sample sizes. RESULTS: Cephalad-caudad blunt expansion of the uterine incision was associated with a lower prevalence of unintended incision extension (relative risk, 0.62; 95% confidence interval, 0.45-0.86) and uterine vessel injury (relative risk, 0.55; 95% confidence interval 0.41-0.73). However, these complications were not accompanied by the increased need for additional suture placement (relative risk, 0.62; 95% confidence interval, 0.31-4.12) or transfusion rates (relative risk, 0.75; 95% confidence interval, 0.28-2.03). Similarly, the intraoperative duration was comparable with cases treated with transverse blunt expansion (mean difference = -0.45 minutes; 95% confidence interval -2.12 to 1.21) and the risk of intentional incision extension in the form of an inverted T (relative risk, 0.38; 95% confidence interval, 0.09-1.52). Trial sequential analysis revealed that the required sample size was reached in the unintended incision extension and uterine vessel injury outcomes. CONCLUSION: The findings of our study suggested that cephalad-caudad blunt expansion of the uterine incision is superior to transverse expansion in terms of reducing unintended incision extension and uterine vessel injury.

Covid-19 and pregnancy: the experience of a tertiary maternity hospital.

OBJECTIVES: The aim of our study is to present the effect of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in pregnancy and evaluate its impact on maternal and neonatal outcomes. METHODS: We retrospectively reviewed the medical records of all COVID-19 positive pregnant women who were admitted to "Alexandra" maternity hospital from March to December 2020 (n=40). The infection status was determined via real-time polymerase chain reaction (RT-PCR) of nasopharyngeal swab specimen. We documented the demographic features, clinical status, pregnancy characteristics and maternal and fetal outcomes. RESULTS: Forty COVID-19 positive pregnant women were admitted to our clinic during the study period. Mean maternal age was 27.6 years. Gestational age (GA) ranged from 10-42 weeks of pregnancy with mean GA calculated at 38+3 weeks. Associated comorbidities included hypertension, hypothyroidism, epilepsy, hepatitis B and asthma. Thirty-five out of 40 women delivered within the study period. Cesarean section was performed in 57.1% of the cases. Most of the cases (87.5%) were asymptomatic while ventilation was required for only one patient. All neonates tested negative for SARS-CoV-2. Neither maternal nor neonatal deaths occurred. CONCLUSIONS: In alignment to other studies, our data show that the course of coronavirus disease 2019 (COVID-19) during pregnancy in the majority of cases is mild and neonatal outcomes also appear favorable.

Lymphocytic infiltration and Chemotherapy Response Score as prognostic markers in ovarian cancer patients treated with Neoadjuvant chemotherapy.

Neoadjuvant Chemotherapy (NACT) followed by Interval Debulking Surgery (IDS) is an accepted frontline treatment in patients with advanced Epithelial Ovarian Cancer (EOC). Histopathologic assessment of tumor post NACT may provide a surrogate for response to treatment. The present study aims to characterize the pathological response and to examine its prognostic significance in these patients. Medical records of women with EOC treated in our institution from 2011 to 2016 were retrospectively identified. IDS specimens were reviewed by study pathologist and Chemotherapy Response Score (CRS), lymphocytic infiltration, necrosis and mitosis were assessed. 55 patients with EOC treated with NACT were identified and 48 had complete clinical and pathological data. Median age was 63 years. CRS assessed at omentum predicted PFS when adjusted for age, stage, debulking status (complete, optimal, suboptimal) and post IDS bevacizumab administration (mPFS CRS 1 vs 2 vs 3: 10.3-14-18.7 months 95% CI [7.4-15.7], [12.2-22.9], [13.5-31.3]). Presence of lymphocytic infiltration was associated with improved OS (log-rank test P = 0.015). Post IDS bevacizumab was associated with shorter PFS in patients with lymphocytic infiltration. BRCA status was known for 25 patients and presence of BRCA1/2 mutations was strongly correlated with lymphocytic infiltration (P = 0.011) but not CRS omentum (P = 0.926). Our study confirms the predictive value of CRS in EOC patients treated with NACT and IDS, but also demonstrates the prognostic significance of lymphocytic infiltration as well as its possible interaction with bevacizumab treatment.

European Society of Gynaecological Oncology quality indicators for surgical treatment of cervical cancer.

BACKGROUND: Optimizing and ensuring the quality of surgical care is essential to improve the management and outcome of patients with cervical cancer.To develop a list of quality indicators for surgical treatment of cervical cancer that can be used to audit and improve clinical practice. METHODS: Quality indicators were developed using a four-step evaluation process that included a systematic literature search to identify potential quality indicators, in-person meetings of an ad hoc group of international experts, an internal validation process, and external review by a large panel of European clinicians and patient representatives. RESULTS: Fifteen structural, process, and outcome indicators were selected. Using a structured format, each quality indicator has a description specifying what the indicator is measuring. Measurability specifications are also detailed to define how the indicator will be measured in practice. Each indicator has a target which gives practitioners and health administrators a quantitative basis for improving care and organizational processes. DISCUSSION: Implementation of institutional quality assurance programs can improve quality of care, even in high-volume centers. This set of quality indicators from the European Society of Gynaecological Cancer may be a major instrument to improve the quality of surgical treatment of cervical cancer.

Management options for vaginal intraepithelial neoplasia.

BACKGROUND: Vaginal intraepithelial neoplasia (VaIN) is a rare disease of the lower genital tract, strongly associated with HPV infection, which may progress to vaginal carcinoma. PURPOSE: The aim of this review is to summarise current treatment options, evaluate their efficacy and make provide recommendations on the optimal management of the disease. MATERIALS AND METHODS: A comprehensive search of the literature was performed using the PubMed database for articles referring to the treatment of VaIN. We restricted our search only in articles written in English with publication dates within the last 10 years. RESULTS: Surgical approach included local excision, CO2 laser ablation, CO2 laser skinning colpectomy and laparoscopic upper vaginectomy. Medical management was based on intravaginally administered topical agents such as 5% imiquimod cream, 5-fluorouracil cream and topical oestrogens. Intracavitary radiation therapy was reported in two forms: Low-dose rate (LDR) brachytherapy and high-dose rate (HDR) brachytherapy. All treatment options were well tolerated, with satisfactory cure rates and acceptable recurrence rates. CONCLUSION: The choice of treatment depends upon many factors. Surgical excision is the mainstay of treatment and should be performed if invasion cannot be excluded. Topical agents are useful for persistent, multifocal lesions or for women that cannot undergo surgical treatment. Brachytherapy is associated with high morbidity rates and should be reserved for women who have multifocal disease, are poor surgical candidates and/or have failed other treatments. CO2 laser ablation achieves minimal scarring and sexual dysfunction; however, invasive disease should be ruled out with biopsies before the initiation of the treatment.

Controversies in preoperative bowel preparation in gynecologic and gynecologic oncology surgery: a review of the literature.

PURPOSE: The purpose of this review is to assess the impact of mechanical and oral antibiotics bowel preparation on surgical performance and to investigate their role before gynecologic surgical procedures regarding the infection rates. We also aim to study the updated evidence regarding the use of these different types of bowel preparation, as well as the current preoperative practice applied. METHODS: An extensive search of the literature was conducted with Medline/PubMed, and the Cochrane Library Database of Systematic Reviews being used for our primary search. RESULTS: To date, due to the conflicting guidelines by the scientific societies, surgeons do not use a specific pattern of bowel preparation regimen. There are no strong evidence supporting mechanical bowel preparation, but instead, in many cases, patients' adverse effects, both physiological and psychological have been noted. On the other hand, the combined use of oral antibiotic and mechanical bowel preparation has been proven beneficial in colorectal surgery in reducing postoperative morbidities. CONCLUSION: Based on current literature, in gynecologic surgeries with minimal probability of intraluminal entry, a regimen without any bowel preparation should be applied. The combined administration of both mechanical and oral antibiotic bowel preparation, or even the use of the oral antibiotics alone, should be preserved for cases of increased complexity, where bowel involvement is highly anticipated, such as in gynecologic oncology, as stated in the ERAS protocols. Nonetheless, further research specific to gynecologic surgery is required.