Pediatric Epistaxis-Effectiveness of Conservative Management.

OBJECTIVES: Epistaxis is an emergency medical condition that sometimes requires admission to the emergency department. Pediatric epistaxis differs from epistaxis in the older population in terms of etiology, severity, and management. Our objective was to identify the distinctive features of pediatric epistaxis and determine the appropriate management. METHODS: This was a retrospective study of 231 medical records of children (<18 years old) with epistaxis of a total of 1171 cases in the general population who presented to our medical center's emergency department between 2013 and 2018. RESULTS: Among 231 admissions, 10 children (4.3%) presented more than once. Male patients accounted for the majority of cases (64.5%), and the average age was 9.4 years. Two children were treated with aspirin because of cardiac valve disease. Anterior bleeding was detected in 101 cases (43.7%), whereas posterior origin was observed in 8 cases (3.5%). In 122 cases (52.8%), there was no active bleeding observed. Nose injury was the cause of epistaxis in 24 cases (10.4%), and 16 admissions (6.9%) followed nasal surgical interventions. Nineteen children (8%) had abnormal coagulation tests, and 7 patients (3%) received blood transfusions. Chemical cauterization was performed in 89 cases (39.3%), and anterior packing was needed in only 9 cases (3.9%). Nine children required hospitalization (3.9%), and 2 needed surgical intervention to control bleeding. Compared with the adult population, there were significantly fewer cases of active bleeding, recurrent epistaxis, anterior packing, or need for hospitalization in the pediatric population. CONCLUSIONS: Epistaxis is significantly less severe in the pediatric population, with only a few cases requiring major intervention. Endoscopic examination of the entire nasal cavity and routine coagulation tests are not mandatory unless there is a history of recurrent epistaxis, known coagulopathy, antiplatelet/anticoagulation therapy, or a suspicion of juvenile idiopathic angiofibroma. We suggest using absorbable packs, which offer advantages over cauterization or nonabsorbable packs.

The association of endometrial closure during cesarean section to the risk of developing uterine scar defect: a randomized control trial.

PURPOSE: The surgical technique for uterine closure following cesarean section influences the healing of the cesarean scar; however, there is still no consensus on the optimal technique regarding the closure of the endometrium layer. The aim of this study was to compare the effect of closure versus non-closure of the endometrium during cesarean section on the risk to develop uterine scar defect and associated symptoms. METHODS: A randomized prospective study was conducted of women undergoing first elective cesarean section at a single tertiary medical center. Exclusion criteria included previous uterine scar, preterm delivery and dysmorphic uterus. Women were randomized for endometrial layer closure versus non-closure. Six months following surgery, women were invited to the ambulatory gynecological clinic for follow-up visit. 2-D transvaginal ultrasound examination was performed to evaluate the cesarean scar characteristics. In addition, women were evaluated for symptoms that might be associated with uterine scar defect. Primary outcome was defined as the residual myometrial thickness (RMT) at the uterine cesarean scar. Data are presented as median and interquartile range. RESULTS: 130 women were recruited to the study, of them follow-up was achieved in 113 (86.9%). 61 (54%) vs. 52 (46%) of the women were included in the endometrial closure vs. non-closure groups, respectively. Groups were comparable for patient's demographic, clinical characteristics and follow-up time for postoperative evaluation. Median RMT was 5.3 (3.0-7.7) vs. 4.6 (3.0-6.5) mm for the endometrial closure and non-closure groups, respectively (p = 0.38). Substantially low RMT (< 2.5 mm) was measured in four (6.6%) women in the endometrial closure group and three (5.8%) of the women in the non-closure group (p = 0.86). All other uterine scar sonographic measurements, as well as dysmenorrhea, pelvic pain and intermenstrual bleeding rates were comparable between the groups. CONCLUSION: Closure versus non-closure of the endometrial layer during cesarean uterine incision repair has no significant difference in cesarean scar characteristics and symptom rates at 6 months follow-up.

Ethnic disparities in the incidence of gynecologic malignancies among Israeli Women of Arab and Jewish Ethnicity: a 10-year study (2010-2019).

Background: Ethnic disparities in healthcare outcomes persist, even when populations share the same environmental factors and healthcare infrastructure. Gynecologic malignancies are a significant health concern, making it essential to explore how these disparities manifest in terms of their incidence among different ethnic groups. Objective: To investigate ethnic disparities in the incidence of gynecologic malignancies incidence among Israeli women of Arab and Jewish ethnicity. Design: Our research employs a longitudinal, population-based retrospective cohort design. Method: Data on gynecologic cancer diagnoses among the Israeli population from 2010 to 2019 was obtained from a National Registry. Disease incidence rates and age standardization were calculated. A comparison between Arab and Jewish patients was performed, with Poisson regression models being used to analyze significant rate changes. Results: Among Jewish women, the age-standardized ratio (ASR) for gynecologic malignancies decreased from 288 to 251 (p < 0.001) between 2014 and 2019. However, there was no significant change in the ASR among Arab women during the same period, with rates going from 192 to 186 (p = 0.802). During the study period, the incidence of ovarian cancer decreased significantly among Jewish women (p = 0.042), while the rate remained stable among Arab women (p = 0.102). A similar trend was observed for uterine cancer. The ASR of CIN III (Cervical Intraepithelial Neoplasia Grade 3) in Jewish women notably increased from 2017 to 2019, with an annual growth rate of 43.3% (p < 0.001). A similar substantial rise was observed among Arab women, with an annual growth rate of 40.5% (p < 0.001). In contrast, the incidence of invasive cervical cancer remained stable from 2010 to 2019 among women of both ethnic backgrounds. Conclusion: Our findings indicate that Arab women in Israel have a lower incidence rate of gynecologic cancers, warranting further investigation into protective factors. Both ethnic groups demonstrate effective utilization of cervical screening.

Incidence and Risk Factors for Low Anterior Resection Syndrome following Trans-Anal Total Mesorectal Excision.

BACKGROUND: Trans-anal total mesorectal excision (Ta-TME) is a novel approach for the resection of rectal cancer. Low anterior resection syndrome (LARS) is a frequent functional disorder that might follow restorative proctectomy. Data regarding bowel function after Ta-TME are scarce. The aim of this study was to evaluate the incidence and risk factors for the development of LARS following Ta-TME. METHODS: A prospectively maintained database of all patients who underwent Ta-TME for rectal cancer at our institution was reviewed. All patients who were operated on from January 2018 to December 2021 were evaluated. The LARS score questionnaire was used via telephone interviews. Incidence, severity and risk factors for LARS were evaluated. RESULTS: Eighty-five patients underwent Ta-TME for rectal cancer between January 2018 and December 2021. Thirty-five patients were excluded due to ostomy status, death, local disease recurrence, ileal pouch or lack of compliance. Fifty patients were included in the analysis. LARS was diagnosed in 76% of patients. Anastomosis distance from dentate line was identified as a risk factor for LARS via multivariate analysis (p = 0.042). Neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. CONCLUSION: LARS is a frequent condition following ta-TME, as it is used for other approaches to low anterior resection. Anastomosis distance from dentate line is an independent risk factor for LARS. In this study neo-adjuvant therapy, hand sewn anastomosis and anastomotic leak did not increase the risk of LARS. Further studies with longer follow-up times are required to better understand the functional outcomes following Ta-TME.

Gender leadership in gynecologic oncology professional societies worldwide.

OBJECTIVE: We aim to study gender representation among the different national gynecologic oncology (GO) societies' presidents over the past decade. METHODS: A cross-sectional study examining the period 2013-2022. The leadership positions in 11 GO societies in the USA (SGO), internationally (IGCS), Europe (ESGO), Australia (ASGO), Israel (ISGO), Japan (JSGO), Asia-Oceania (AOGIN), India (INSGO), Latin America (SLAGO), South Africa (SASGO), and Turkey (TRSGO) was studied. The proportion of leadership positions held by women was calculated and trends were evaluated. RESULTS: Overall, the average rate of women's representation during the study period was 26.4%, and for the different organizations was: SASGO 70.0%, SGO 50.0%, ESGO 40.0%, ASGO 30.0%, INSGO 30.0%, and IGCS, ISGO, and SLAGO 20.0% each, TRSGO 10%, and no representation of women in JSGO and AOGIN. There was a significant decrease from 2013 to 2016 (63.6% to 9.1%) (P = 0.009) in women's representation as presidents of societies. From 2017 to 2022, there was no difference in women's representation (ranging from 9.1% to 36.4%) (P = 0.13). CONCLUSIONS: This study demonstrates that women are significantly under-represented in leadership positions in GO professional societies; however, in South Africa and the USA their representation in the last decade was close to equality.

Surgical outcomes in patients aged 70 years and older following uterosacral ligament suspension: a comparative study.

PURPOSE: The number of elderly patients bothered by pelvic organ prolapse symptoms is growing rapidly. The aim of this study was to evaluate the relationship between age and surgical outcomes in women undergoing uterosacral ligament suspension for treatment of apical prolapse. METHODS: We performed a retrospective cohort study including women who underwent uterosacral ligament suspension between 2010 and 2020. The cohort was divided into two groups: (1) Patients 70 years or older; (2) Patients under the age of 70. Outcome measures included clinical, anatomical, and composite outcomes as well as patient satisfaction. RESULTS: A total of 271 patients were included in the final analysis. Of them 209 patients were under age 70 and 62 patients 70 years or older. Mean age was 59 ± 6 vs. 73 ± 3 for the young and elderly age groups, respectively. Clinical success was high for both groups, reaching 94% vs. 89% for elderly and young patients, respectively (p = 0.34). Anatomical and composite outcome success were higher in the young age group (76% vs. 56%, p < 0.01 and 70% vs. 54%, p = 0.02, respectively); however, following multivariate analysis these differences were no longer statistically significant. Following multivariate logistic regression analysis for the dependent parameter of anatomical success, increased pre-operative genital hiatus and vaginal surgical route were associated with anatomical failure while performing a concomitant posterior colporrhaphy increased likelihood for anatomical success. CONCLUSION: Women over the age of 70 undergoing uterosacral ligament suspension for treatment of apical prolapse have comparable outcomes to younger patients.

The effect of uterine volume on surgical outcomes following uterine preserving apical prolapse repair.

OBJECTIVE: In recent years uterine preservation has become a popular option in women undergoing pelvic organ prolapse repair. The aim of this study was to evaluate the effect of uterine volume on outcomes following uterine preserving surgical treatment for apical prolapse. METHODS: We performed a retrospective comparative study at a tertiary university hospital. Included were women who had uterine preserving surgical treatment for apical prolapse. The cohort was divided into two groups: 1) Patients with a uterine volume ≥ 35 cm3 (large uterus group); 2) Patients with uterine volume < 35 cm3 (small uterus group). Pre-, intra-, and post-operative data were compared between groups. Our primary outcome was composite outcome success including clinical and anatomical success and no need for reoperation. Secondary outcomes included clinical success, anatomical success, and patient satisfaction evaluated using the PGI-I questionnaire. RESULTS: Eighty-four patients were included in the final analysis. The large uterus group (≥35 cm3) consisted of 37 patients as opposed to 47 in the small uterus group (<35 cm3). Clinical (91.9 % vs 87.1 %, p = 0.725) and anatomical success (84.8 % vs 90.9 %, p = 0.508) were high and did not differ between groups. Composite outcome success was 76.1 % in the small uterus group compared to 87.9 % in the large uterus group, but this difference was not statistically significant. Post-operative points Ba, C and Bp were similar between groups. No difference was found in patient satisfaction measured using the PGI-I questionnaire. CONCLUSION: Women undergoing uterine preserving apical prolapse repair with uterine volume ≥ 35 cm3 have comparable surgical outcomes to patients with a smaller uterus.

Pregnancy-Associated Ovarian Torsion - a Single-Center Case-Control Study.

The etiology of OT is largely unknown. Any predisposition to rotation of the infundibulopelvic ligament and utero-ovarian ligament should be considered a possible etiology. Information with respect to ovarian torsion (OT) among pregnant is underreported and based on small studies. We aim to compare characteristics of confirmed OT to laparoscopies performed for the indication of suspected OT, in which no OT was found among pregnant women. This is a retrospective case-control study. We included pregnant women who underwent laparoscopy for a suspected OT between March 2011 and August 2020. Pregnant women with confirmed OT (torsion group) were compared to those without (no torsion group). There were 169 women with suspected OT. OT was confirmed in 140 (82.8%) women. There was higher proportion of assisted reproductive technology (ART) gestation in the torsion group [76 (54.3%) vs. 5 (17.2%), p < 0.001]. The rate of pregnant approaching evaluation within 8 h of symptoms onset was higher in the torsion group [57 (40.7%) vs. 2 (6.9%), p < 0.001]. The mean visual analogue score (VAS) was higher in the torsion group (8.5 vs. 7.1, p = 0.002). The mean pulse was lower in the torsion group (79 vs. 88 bpm, p < 0.001). From sonographic characteristics examined, the following was higher in the torsion group; mean maximal size of the ovary (70 mm in the torsion group vs. 54 mm in the no torsion group, p = 0.011). In a multivariable logistic regression analysis, number of hours of symptoms was negatively associated with AT [aOR, 95% CI 0.95 (0.91-0.98)] and pulse was negatively associated with OT [aOR, 95% CI 0.78 (0.63-0.95)]. Among the 29 cases in which no OT was found during laparoscopy, the following findings were noted: 16 (55.2%) no abnormality at all, 5 (17.2%) functional ovarian cyst, 2 (6.9%) mature teratoma and 6 cases of peritoneal adhesions (20.7%). The time from pain onset to approaching evaluation and women's pulse should be considered and acknowledged in the evaluation of OT during pregnancy.

The Effect of Age on Surgical Outcomes Following Uterine Preserving Surgery for Treatment of Apical Prolapse.

STUDY OBJECTIVE: The aim of this study was to evaluate the effect of age on outcomes after uterine-preserving surgical treatment for apical prolapse. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a tertiary, university-affiliated teaching medical center. PATIENTS: Women who underwent surgical management of apical prolapse with uterine preservation between 2010 and 2020. Excluded were women who had ≤1 month of follow-up and those for whom medical records were substantially incomplete. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Included in the study were 140 women who underwent apical prolapse repair with uterine preservation and who met the inclusion criteria. The cohort was divided into 2 groups: (1) women aged 65 years and older (≥65 group) and (2) women younger than 65 years of age (<65 group). Pre-, intra-, and postoperative data were compared between the groups. A total of 103 women (73.6%) were in the <65 group and 37 women (26.4%) in the ≥65 group. Mean age for the entire cohort was 58 ± 9.8 years, body mass index 25.9 ± 4.8 kg/m2, and duration of follow-up was 25.9 ± 21.0 months. Women in the ≥65 group had more comorbidities, were less sexually active, and were less likely to have a midurethral sling performed during their surgery. Clinical and anatomical success rates were somewhat higher in the ≥65 group; however, these differences did not reach statistical significance (97.3% vs 85.4%, p = .069 and 89.2% vs 81.2%, p = .264, respectively). Composite outcome success was higher in the ≥65 group (89.2% vs 72.5%, p = .039). Patient satisfaction recorded using the Patient Global Impression of Improvement questionnaire was high for both groups. A multivariable logistic regression analysis for the dependent parameter of composite outcome success was performed, during which none of the parameters investigated reached statistical significance. Subgroup analysis was performed including only women who were postmenopausal. This was done to address the possible confounding effect that menopausal status may have had on our results. No differences were found between the groups with regard to clinical, anatomical, and composite outcomes. CONCLUSION: Uterine-preserving surgery is a safe and effective surgical treatment for women aged ≥65 years.

Absorbable versus Permanent Suture for Vaginal Uterosacral Ligament Suspension for Treatment of Apical Prolapse.

STUDY OBJECTIVE: The aim of this study was to compare surgical outcomes in women undergoing vaginal uterosacral ligament suspension using permanent as opposed to absorbable sutures. We also aimed to assess for specific risk factors for suture complications. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. PATIENTS: Women with apical prolapse who underwent vaginal hysterectomy with uterosacral ligament suspension during the study period. INTERVENTIONS: none. MEASUREMENTS AND MAIN RESULTS: A total of 197 women were included in the study. Of them, 118 (59.9%) underwent the procedure using a permanent suture and 79 (40.1%) using an absorbable suture. Women in the permanent suture group were less sexually active and had less prolapse of point C on pre-operative exam. With regard to intra-operative and postoperative data, women in the permanent suture group had increased frequency of concomitant procedures, regional anesthesia, surgical time, duration of hospital stay, and change in hemoglobin. Clinical, anatomical, and composite success did not differ between groups. Patient satisfaction recorded using the Patient Global of Improvement Questionnaire was similar as well. Women in the permanent suture group had a higher frequency of suture exposure compared with the absorbable suture group (9.3% vs 0.0%, p = .006). In order to assess for risk factors leading to suture complications, a comparison was performed between women who had suture exposure or granulation tissue and those who did not. Increasing parity by 1 increased the odds of having suture exposure or granulation tissue by a factor of approximately 1.2 (adjusted odds ratio = 1.24; Confidence interval, 1.05-1.47). Women with stage IV prolapse had 3.4 times the odds of suture complication compared with women with stage III prolapse (adjusted odds ratio = 3.4; Confidence interval, 1.1-10.6). CONCLUSION: Use of an absorbable suture affords comparable success and lower frequency of suture exposure compared with permanent sutures in women undergoing vaginal uterosacral ligament suspension for treatment of apical prolapse.

Infected pelvic hematoma following vaginal hysterectomy with uterosacral ligament suspension for treatment of apical prolapse.

OBJECTIVE: Vaginal hysterectomy with uterosacral ligament suspension (VUSLS) is a common procedure for apical prolapse repair. Data regarding pelvic hematoma following this procedure is scarce. The aim of this study was to describe the occurrence of infected and non-infected pelvic hematoma in women following VUSLS and to assess for specific risk factors for infection. METHODS: We performed a retrospective cohort study, including all women who underwent VUSLS for treatment of apical prolapse between 2010 and 2020. Patients with and without pelvic hematoma by ultrasound were compared. A subgroup analysis compared patients with infected vs non infected hematomas. RESULTS: During the study period, 316 women underwent VUSLS for treatment of apical prolapse. Sixty-six (20.9%) were diagnosed with a pelvic hematoma, and in seventeen (5.4%) women the hematoma became infected. The majority (76%) of pelvic hematomas were located above the vaginal cuff. Women in the hematoma group had increased rates of hypothyroidism and concomitant anterior colporrhaphy. However, following multivariate analysis, these differences were no longer significant. Subgroup analysis comparing women with infected versus non-infected pelvic hematoma was performed. No differences were noted with respect to surgical outcomes (clinical, anatomical, or composite). Women with infected hematoma had higher rates of posterior colporrhaphy during surgery (33.3% vs 9.5%, p = 0.039). This difference remained significant following multivariate analysis (aOR = 8.87, CI 1.1-73.0). CONCLUSION: Pelvic hematoma following VUSLS is common as opposed to infected pelvic hematoma which seldom occurs. Concomitant posterior colporrhaphy was associated with infection.

Pediatric and adolescent females are at higher risk of adnexal torsion recurrence-A large-scale retrospective study.

AIM: Recurrence of adnexal torsion (rAT) is reported mainly in small series. Normal and small appearing ovaries are associated with an increased risk for rAT. Nevertheless, updated data of larger cohorts is lacking. We aimed to investigate the predictors for rAT in a cohort of women who had surgical intervention for primary adnexal torsion (pAT). METHODS: A retrospective case-control study from a single institution between 2011 and 2020. Women with a primary occurrence of surgically proven adnexal torsion were included. We compared those who had experienced rAT to those who had not. Univariate and multivariate analysis were performed to study independent predictors for rAT. RESULTS: Overall, 358 women were included. Of those, 35 (9.8%) had a rAT. Women who experienced rAT were younger (mean age 26 vs. 30 years, p = 0.01). Women experiencing rAT had smaller mean ovarian cyst diameter in the pAT episode (42 vs. 59 mm. p < 0.001). Performance of laparoscopic detorsion was only associated with rAT (odds ration [OR] 95% confidence interval [CI] 2.13 [1.02-4.42], p = 0.03), while the performance of additional cystectomy was negatively associated with rAT (OR 95% CI 0.10 [0.01-0.79], p = 0.006). Multivariate analysis demonstrated that age ≤15 and smaller cyst diameter at pAT were independently associated with the risk for rAT (aOR 95% CI 5.0 [1.09-23.2] and 1.47 [1.08-2.0], for every 10 mm decrease in cyst diameter, respectively). CONCLUSIONS: Adolescents and pediatric females and women with smaller ovarian cysts at pAT are at higher risk for future recurrence of adnexal torsion.

Surgically confirmed adnexal torsion during pregnancy: Does the trimester make a difference?

AIM: To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters. METHODS: This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups. RESULTS: The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023). CONCLUSIONS: Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

Reproductive and obstetric outcomes following operative hysteroscopy for treatment of retained products of conception.

BACKGROUND: Retained products of conception following delivery or early pregnancy failure are often treated by operative hysteroscopy. We aimed to evaluate reproductive and obstetric outcomes following operative hysteroscopy for treatment of retained products of conception. We also investigated the effect of time interval between operative hysteroscopy and pregnancy on these outcomes. METHODS: A retrospective cohort study conducted at the gynecology department of a tertiary teaching hospital between January 2012 and December 2016. Included were women who underwent operative hysteroscopy for treatment of retained products of conception and became pregnant following the procedure. Reproductive and obstetric data were retrieved from electronic medical records and by telephone questionnaire. The effect of time interval between operative hysteroscopy and pregnancy on reproductive outcomes was also evaluated by comparing women who conceived 6 months or less and women who conceived more than 6 months following surgery. RESULTS: Seventy-nine women who underwent operative hysteroscopy for treatment of retained products of conception and who conceived later were included. Mean time from women's attempt to conceive to conception was 4.6 (SD=6.4) months. Conception rate was 84.8% at 6 months and reached 92.4% at 12 months postsurgery. Miscarriage rate for the consecutive pregnancy following hysteroscopy was 15.2% and delivery rate was 84.8%. Two cases of obstetric complications including one case of retained placenta and one case of post-partum hemorrhage were noted. Time interval between operative hysteroscopy and pregnancy did not affect reproductive or obstetric outcomes. CONCLUSIONS: Women treated by operative hysteroscopy for retained products of conception have no negative reproductive and obstetric outcomes. Time interval between the procedure and pregnancy has no effect on these outcomes.

Urinary dysfunction in women following total mesorectal excision versus partial mesorectal excision for treatment of rectal cancer.

BACKGROUND: Colorectal cancer is a condition which is associated with substantial morbidity and mortality. The aim of this study was to assess urinary dysfunction and its effect on quality of life in women who underwent total mesorectal excision compared to women treated by partial mesorectal excision for treatment of rectal cancer. METHODS: We performed a retrospective cohort study at a tertiary university hospital between January 2014 and December 2019. A comparison was performed between women who underwent total mesorectal excision as opposed to partial mesorectal excision for treatment of rectal cancer. Pre-operative, intra-operative and post-operative data were compared between groups. Data regarding radiation therapy was recorded and compared as well. Urinary dysfunction and its impact on quality of life were assessed using UDI-6 and USIQ questionnaires. Further univariate and multivariate analyses were performed in the attempt of assessing risk factors for urinary dysfunction. RESULTS: A total of 107 women were included in the study, 73 women underwent partial mesorectal excision as opposed to 34 women who were treated by total mesorectal excision. Twenty-five women in the TME group underwent radiation therapy prior to surgery as opposed to none in the PME group (p < 0.001). Urinary dysfunction following surgery as assessed using the UDI-6 questionnaire did not differ between groups. Similar findings were recorded with regard to the impact of urinary dysfunction on quality of life as assessed using the USIQ questionnaire. Following multivariate analysis longer hospital stay was associated with increased risk of some degree of urinary dysfunction. CONCLUSIONS: Women undergoing total mesorectal excision have comparable results to partial mesorectal excision with regard to urinary dysfunction.

Chemotherapy-based gonadotoxicity risk evaluation as a predictor of reproductive outcomes in post-pubertal patients following ovarian tissue cryopreservation.

BACKGROUND: The sterilizing effect of cancer treatment depends mostly on the chemotherapy regimen and extent of radiotherapy. Prediction of long-term reproductive outcomes among cancer survivors according to chemo-radiotherapy regimen may improve pre-treatment fertility preservation counseling and future reproductive outcomes. METHODS: The aim of this study was to evaluate long term reproductive outcomes in cancer survivors according to gonadotoxicity risk estimation of the chemo-radiotherapy regimens utilized. This retrospective cohort study was comprised of post-pubertal female patients referred for fertility preservation during 1997 and 2017 was performed. Eligible adult patients were addressed and asked to complete a clinical survey regarding their ovarian function, menstruation, reproductive experience and ovarian tissue auto-transplantation procedures. Results were stratified according to the gonadotoxic potential of chemotherapy and radiotherapy they received-low, moderate and high-risk, defined by the regimen used, the cumulative dose of chemotherapy administered and radiation therapy extent. RESULTS: A total of 120 patients were eligible for the survey. Of those, 92 patients agreed to answer the questionnaire. Data regarding chemotherapy regimen were available for 77 of the 92 patients who answered the questionnaire. Menopause symptoms were much more prevalent in patients undergoing high vs moderate and low-risk chemotherapy protocol. (51.4% vs. 27.3% and 16.7%, respectively; p < 0.05). Spontaneous pregnancy rates were also significantly lower in the high-risk compared with the low-risk gonadotoxicity regimen group (32.0% vs. 58.3% and 87.5%, respectively; p < 0.05). CONCLUSION: Patients scheduled for aggressive cancer treatment have significantly higher rates of menopause symptoms and more than double the risk of struggling to conceive spontaneously. Improving prediction of future reproductive outcomes according to treatment protocol and counseling in early stages of cancer diagnosis and treatment may contribute to a tailored fertility related consultation among cancer survivors.

Vaginal Colposuspension Using the Uphold Lite Mesh System versus Transvaginal Hysterectomy with Uterosacral Ligament Suspension for Treatment of Apical Prolapse: A Comparative Study.

STUDY OBJECTIVE: To compare clinical and anatomic outcomes as well as patient satisfaction in women undergoing vaginal colposuspension using the Uphold Lite system (Boston Scientific Corporation, Marlborough, MA) and transvaginal hysterectomy with uterosacral ligament suspension (VUSLS) for the treatment of apical prolapse. DESIGN: Retrospective cohort study. SETTING: Female pelvic medicine and reconstructive surgery unit at a university-affiliated tertiary medical center. PATIENTS: Women with apical prolapse who underwent either vaginal colposuspension using the Uphold Lite system (uterine-preserving as well as after previous hysterectomy) or VUSLS from 2010 to 2019. Excluded were women with 1 month or less of follow-up. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A total of 164 women were included in the study: 112 women underwent VUSLS, and 52 underwent colposuspension using the Uphold Lite mesh system. Age, body mass index, maximal birth weight, comorbidity rates, and pelvic organ prolapse severity were similar between the groups. The clinical cure rate was similarly high in both groups, with 91.1% in the women who underwent VUSLS and 88.5% in those in the Uphold Lite group (p = .60). No differences were noted between the groups with regard to anatomic cure rate or composite outcome success rate (73.9% vs 76.0%, p = .77 and 70.3% vs 74.0%, p = .63, in the VUSLS and Uphold Lite groups, respectively). An advantage was noted in the VUSLS group with regard to patient satisfaction with 98.1% of the women stating that their condition was very much better (Patient Global Impression of Improvement questionnaire: A) or much better (Patient Global Impression of Improvement questionnaire: B) compared with 83.9% of the women in the Uphold Lite group (p = .023). In an attempt to assess the association between different variables and the composite outcome, a multivariate analysis was performed in which increased body mass index, menopausal status, and increased preoperative genital hiatus were found to decrease composite outcome success. CONCLUSION: Vaginal colposuspension using the Uphold Lite system and VUSLS for the treatment of apical prolapse have comparable results with high clinical success rates.

Recurrent Tubal Ectopic Pregnancy Management and the Risk of a Third Ectopic Pregnancy.

STUDY OBJECTIVE: To evaluate the rate of a third ectopic pregnancy according to the modality of treatment of the second ectopic pregnancy. DESIGN: Retrospective cohort study. SETTING: University-affiliated tertiary medical center. PATIENTS: One hundred eleven women who had 2 ectopic pregnancies and a third consecutive pregnancy between 2003 and 2018. INTERVENTIONS: Surgery or medical treatment as required. MEASUREMENTS AND MAIN RESULTS: With regard to the modality of treatment of the second ectopic pregnancy, the patients were divided into 3 groups: expectant management, medical treatment with methotrexate, and laparoscopic salpingectomy. Univariate and multivariate analyses were conducted to assess the association of various parameters of the second ectopic pregnancy with the occurrence of a third ectopic pregnancy in the consecutive pregnancy. Twenty women (18.0%) were managed expectantly, 55 (49.6%) were treated with methotrexate, and 36 (32.4%) underwent surgery. Expectant management resulted in significantly higher rates of a third ectopic pregnancy compared with treatment with methotrexate or surgical intervention (50.0% vs 18.2% and 13.8%, respectively; p = .005). In the cases of 2 ipsilateral ectopic pregnancies, the interventional approach (medical or surgical treatment) resulted in lower recurrence rates compared with expectant management (25.7% vs 60.0%, respectively; p = .043). CONCLUSION: The risk of a third episode of an ectopic pregnancy after expectant management of a second ectopic pregnancy is extremely high. An interventional approach by treatment with methotrexate or salpingectomy is therefore preferred for recurrent ectopic pregnancy management, especially in ipsilateral recurrences.

TORC2-a new player in genome stability.

The inhibition of the central growth regulatory kinase TOR, which participates in two complexes, TORC1 and TORC2, has been a focus of metabolic and cancer studies for many years. Most studies have dealt with TORC1, the canonical target of rapamycin, and the role of this complex in autophagy, protein synthesis, and cell growth control. Recent work on TORC2 in budding and fission yeast species points to a conserved role of this lesser-known TOR complex in the survival of DNA damage. In budding yeast, TORC2 controls lipid biosynthesis and actin cytoskeleton through downstream AGC kinases, which are now, surprisingly, implicated in the survival of oxidative DNA damage. Preliminary data from mTORC2 modulation in cancer cells suggest that an extension to human chemotherapy is worth exploring.

Glucose activates TORC2-Gad8 protein via positive regulation of the cAMP/cAMP-dependent protein kinase A (PKA) pathway and negative regulation of the Pmk1 protein-mitogen-activated protein kinase pathway.

The target of rapamycin (TOR) kinase belongs to the highly conserved eukaryotic family of phosphatidylinositol 3-kinase-related kinases. TOR proteins are found at the core of two evolutionary conserved complexes, known as TORC1 and TORC2. In fission yeast, TORC2 is dispensable for proliferation under optimal growth conditions but is required for starvation and stress responses. TORC2 has been implicated in a wide variety of functions; however, the signals that regulate TORC2 activity have so far remained obscure. TORC2 has one known direct substrate, the AGC kinase Gad8, which is related to AKT in human cells. Gad8 is phosphorylated by TORC2 at Ser-546 (equivalent to AKT Ser-473), leading to its activation. Here, we show that glucose is necessary and sufficient to induce Gad8 Ser-546 phosphorylation in vivo and Gad8 kinase activity in vitro. The glucose signal that activates TORC2-Gad8 is mediated via the cAMP/PKA pathway, a major glucose-sensing pathway. By contrast, Pmk1, similar to human extracellular signal-regulated kinases and a major stress-induced mitogen activated protein kinase (MAPK) in fission yeast, inhibits TORC2-dependent Gad8 phosphorylation and activation. Inhibition of TORC2-Gad8 also occurs in response to ionic or osmotic stress, in a manner dependent on the cAMP/PKA and Pmk1-MAPK signaling pathways. Our findings highlight the significance of glucose availability in regulation of TORC2-Gad8 and indicate a novel link between the cAMP/PKA, Pmk1/MAPK, and TORC2-Gad8 signaling.