Surgical morbidity of total laparoscopic hysterectomy for benign disease: Predictors of major postoperative complications.

OBJECTIVE: To estimate rate of perioperative complications and to define risk factors of 30-day major (Clavien-Dindo ≥ 2) postoperative complications of total laparoscopic hysterectomy (TLH) for benign disease. STUDY DESIGN: An uncontrolled single-center single-arm retrospective study. Data of consecutive patients who have undergone TLH for pathologically confirmed benign disease between January 2000 and December 2019 have been analyzed. Perioperative surgical outcomes, occurrence of postoperative complications, readmissions, and reoperations within 30 days from surgery were registered. Univariate and multivariable analyses were performed to determine the factors associated with major (Clavien-Dindo ≥ 2) postoperative complications. RESULTS: Over the study period 3090 patients were included in the study. Conversion to open surgery occurred in 54 (1.7%) cases. Mean operative time for TLH was 87.7 (±1.7) minutes while mean estimated blood loss was 119.5 (+7.4) mL. Overall, postoperative complications were registered in 430 (13.9%) patients, and major events were observed in 208 (6.7%) of the cases. Same-hospital readmissions and reoperations within 30-day from surgery occurred in 78 (2.5%) and 28 (0.9%) patients, respectively. At multivariable analysis, endometriosis (odds ratio: 3.51, 95%CI:1.54-8.30, p = 0.02), the need for conversion to open surgery (odds ratio: 1.26, 98%CI:1.03-12.64, p < 0.001), and the occurrence of any intraoperative complication (odds ratio: 3.10, 95%CI: 1.45-21.61, p < 0.001) were found as independent risk factors for major postoperative complications. CONCLUSIONS: Total hysterectomy performed via laparoscopy is associated with acceptable major postoperative complications rate. A huge effort should be made to minimize the occurrence of intraoperative complications and the need for conversion to open surgery. Patients undergoing TLH for endometriosis should be counselled about the increased risk of major postoperative events.

[The use of RCGO triggers in the obstetric - gynecological procedures: the impact on the reduction of adeverse events. The experience of the Lombardia Region]. / L'utilizzo dei RCOG trigger in area ostetrica - ginecologica e la riduzione degli eventi avversi. L'esperienza della regione Lombardia.

The last few weeks of pregnancy are critical to a baby's health because important organs, including the brain and lungs, are not completely developed until the end of pregnancy. The adverse events during labor and childbirth can have very serious physical, psychological and financial consequences for the child, the family, health professionals and the whole community. These events can be reduced through interventions aimed at improving the safety and quality of care, based on evidence-based knowledge, guidelines and practices that must be widely and effectively applied. This work reports the experience of the Lombardy Region on improvement actions in the obstetric and gynecological procedures for the reduction of adverse events and sentinel events through the monitoring and management of the RCGS trigger tool.

Predictors of recurrence following laparoscopic radical hysterectomy for early-stage cervical cancer: A multi-institutional study.

OBJECTIVE: To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC). METHODS: This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored. RESULTS: 428 patients were included in the analysis. With a median follow-up of 56 months (1-162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01-1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34-20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11-0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01-1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58-24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12-0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13-0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39-17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS. CONCLUSIONS: In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role.

Transvaginal contained tissue extraction after laparoscopic myomectomy: a cohort study.

OBJECTIVE: To describe the technique and report perioperative outcomes of transvaginal contained extraction of surgical specimens at laparoscopic myomectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Two Italian referral centres for gynaecological minimally invasive surgery. POPULATION: Consecutive patients who underwent laparoscopic myomectomy. METHODS: Tissue extraction was accomplished following laparoscopic myomectomy in a specimen retrieval bag via a posterior colpotomy incision. If morcellation was necessary, this was performed extracorporeally, using a scalpel within the specimen retrieval pouch, whose edges were exteriorised through the vaginal introitus. MAIN OUTCOME MEASURES: Intra- and postoperative complications. RESULTS: A total of 316 women underwent transvaginal specimen retrieval with enclosed manual morcellation. The mean myomectomy specimen weight was 154 ± 128 g, and the mean operative time was 79 ± 26 minutes. No intraoperative complications occurred related to the specimen extraction or morcellation technique, or from rupture of the retrieval bag. Two (0.6%) women had a haemoperitoneum that spontaneously resolved and 16 (5.1%) had fever postoperatively. The final pathological diagnosis was benign in all cases. At the 30-day follow-up, no pelvic infection, vaginal dehiscence, or complaints of dyspareunia were recorded. CONCLUSIONS: Contained transvaginal extraction of fibroid specimens can be performed safely and efficiently in most women undergoing laparoscopic myomectomy. This technique represents a valuable minimally invasive alternative to intracorporeal morcellation. TWEETABLE ABSTRACT: Transvaginal contained morcellation at laparoscopic myomectomy is a valuable alternative to intracorporeal morcellation.

Endometrial cancer cells can express fibrinogen: Immunohistochemistry and RT-PCR analysis.

We investigated whether endometrial cancer (EC) cells can express fibrinogen. Consecutive patients treated for EC were enrolled (cases). A control group of women who had hysterectomy for benign conditions was identified in a case:control ratio of 4:1. Immunohistochemistry and reverse transcription polymerase chain reaction (RT-PCR) were performed to identify the presence of fibrinogen and the mRNA of its three chains (α, ß, γ) in the tissue specimens from both cases and controls. Sixteen EC cases and 4 benign controls were included. Immunohistochemistry failed in one case of EC. In 12/15 (80%) cases versus 0 controls, a moderate-to-intense positivity for fibrinogen was observed (p = 0.09; OR: 32.1; 95%CI: 1.4-752.9). Six (37.5%) women among the cases versus 0 controls expressed RNA for at least one chain of fibrinogen (p = 0.25). All the cases (6/6, 100%) with positive RT-PCR had moderate-to-intense positive immunohistochemistry. Molecular and immunohistochemistry show that some cases of EC have the capability to express fibrinogen and the mRNA of at least one of its chains.

Minilaparoscopic radical hysterectomy for cervical cancer: multi-institutional experience in comparison with conventional laparoscopy.

OBJECTIVE: To analyze the preliminary experience of three gynecologic oncology services with minilaparoscopic radical hysterectomy (mLRH) for the treatment of cervical cancer and to compare perioperative outcomes with those of conventional laparoscopic surgery (LRH). METHODS: Prospectively collected data on consecutive cervical cancer patients undergoing radical hysterectomy with a laparoscopic approach were analyzed retrospectively. Perioperative outcomes of women undergoing mLRH were compared to data from control patients who had undergone LRH with 5-mm instruments. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching. RESULTS: The study cohort consisted of 257 patients, 35 undergoing mLRH and 222 undergoing LRH. The two groups were comparable in terms of demographic and tumor characteristics. No significant differences were observed between groups in terms of operative time, blood loss, lymph node yield, amount of parametrial or vaginal cuff tissue removed, and percentage of intra- or postoperative complications, both in the entire cohort and in the PS matched group. No conversions were needed from mLRH to standard laparoscopy or from minilaparoscopy to open surgery. Conversion from standard laparoscopy to open surgery was necessary in 2 patients. A shorter hospital stay was observed among women who had mLRH than in those undergoing LRH [2 (1-10) vs 4 (1-14) days, p = 0.005]. This difference remained significant after PS matching. CONCLUSION: Our preliminary study suggests that in experienced hands minilaparoscopy is a feasible and safe technique for radical hysterectomy and yields results that are equivalent to those of LRH.

Infectious morbidity after total laparoscopic hysterectomy: does concomitant salpingectomy make a difference?

The study was aimed to test the hypothesis that preservation of the fallopian tubes at the time of total laparoscopic hysterectomy (TLH) increases the risk for postoperative infection. The study group consisted of 137 consecutive women undergoing TLH with conservation of the ovaries, who had concomitant bilateral total salpingectomy at the time of TLH. The control group included 145 women who had had TLH without salpingo-oophorectomy before the study period. Women undergoing bilateral total salpingectomy at the time of TLH had a lower rate of infectious morbidity compared with those who had TLH alone (3/137 versus 14/145, P = 0.01). Multivariable analysis showed that bilateral total salpingectomy at the time of TLH and blood loss are independent predictors of infectious morbidity.

Transumbilical surgical specimen retrieval: a viable refinement of laparoscopic surgery for pelvic masses.

The purpose of this study was to evaluate the feasibility and surgical outcome of a policy of routine specimen retrieval through the umbilical port, avoiding the enlargement of ancillary port-site incisions. A total of 1116 women underwent laparoscopic surgery for the treatment of a pelvic mass with extraction of the specimen through the umbilical port site (a total of 1453 retrieval procedures). All retrieval procedures were successfully carried out with this technique. Neither intraoperative complication related to the retrieval procedure nor accidental rupture of the endoscopic bag occurred. There was an injury to the epigastric artery. Neither trocar-site hernias (both umbilical trocar insertion sites and extraumbilical sites) nor port-site metastases occurred.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses.

OBJECTIVE: To evaluate the feasibility and safety of laparoscopic management of adnexal masses > or = 10 cm in size. DESIGN: Prospective cohort study. SETTING: Two Gynecology Departments of University Hospitals. POPULATION: All women presenting with an adnexal mass > or = 10 cm in diameter were candidates for laparoscopic management. Women were excluded from laparoscopic approach if there was evidence of ascites or gross metastatic disease. Neither the sonographic features of the cyst nor elevated serum CA125 level was used to exclude women from having a laparoscopic approach. METHODS: A single operative protocol was followed for all women. All removed specimens were sent for immediate pathological evaluation. MAIN OUTCOME MEASURES: Rate of conversion to laparotomy, incidence of cancer encountered, and operative complications. RESULTS: One hundred and eighty-six women underwent laparoscopic evaluation for an adnexal mass of 10 cm or larger in size. The average preoperative mass size was 12.1 +/- 4.9 cm. A benign pathological condition was found in 86.6% (161/186) of the women, primary ovarian cancer in 16 (8.6%) women, a metastatic tumour of gastrointestinal origin in 1 (0.5%) woman, and a low malignant potential ovarian tumour in 8 (4.3%) women. Laparoscopic management was successful for 174 (93.5%) women. Reasons for conversion to laparotomy included anticipated technical difficulty (n = 7) and malignancy (n = 5). No intraoperative complications occurred in the entire study group. CONCLUSIONS: The vast majority of large adnexal masses can be safely resected laparoscopically, provided that there is expertise in laparoscopic surgery, immediate access to frozen section diagnosis, and preparation of patient to receive an adequate cancer surgery where indicated.

Laparoscopic colorectal resections with transvaginal specimen extraction for severe endometriosis.

INTRODUCTION: Bowel resection is now considered the "gold standard" treatment for severe endometriosis infiltrating the bowel. Laparoscopic colorectal resection can be considered a safe option in order to reduce surgical trauma and complications as well as to improve cosmetics. Transvaginal approach, used for several years to remove large specimens, can be an interesting approach also in case of colorectal resections. AIM OF THE STUDY: To present our experience on laparoscopic colorectal resection and transvaginal specimen extraction as treatment of severe endometriosis. RESULTS: Eleven patients (mean age 45+/-12 years) have been operated by a combined team of gynecologist and colorectal surgeons. There were no intra- or post-operative complications. In all cases, the transvaginal route was used to remove the specimen and prepare the bowel for anastomosis. Patients were allowed to free light diet on post-operative day 3+/-1 and discharged on day 5+/-2. The mean follow-up was 4+/-2 months and all patients are well with normal bowel function and symptoms free. CONCLUSIONS: Our preliminary experience demonstrates such approach is safe and feasible with excellent results in term of post-operative course.

Two-trocar adnexal surgery: a "quasi" scarless operation.

BACKGROUND: This study aimed to explore the feasibility and safety of two-port abdominal cavity entry for adnexal surgery. METHODS: A series of patients undergoing laparoscopy for benign adnexal diseases requiring adnexectomy, ovariectomy, or salpingectomy were enrolled in the study. A 10-mm 0 degree umbilical operative laparoscope and one 3- or 5-mm suprapubic trocar were used. A grasping forceps was inserted through the ancillary trocar to displace medially and cranially the adnexa or the salpinx. The operation then was performed through the operative channel of the operative laparoscope. RESULTS: A total of 53 patients were enrolled. Bilateral salpingo-oophorectomy was performed in 10 cases. The median operative time was 39 min (range, 21-85 min). The median blood loss was 50 ml (range, 0-300 ml). The median size of the adnexal mass was 6 cm (range, 3-12 cm). No intraoperative complication occurred. At the 3-month follow-up visit, no extraumbilical abdominal scar was visible. CONCLUSIONS: The use of a two-trocar technique is safe and highly appreciated by the patients it leaves no visible abdominal scars.

Single and multiple umbilical cord cysts in early gestation: two different entities.

OBJECTIVE: To investigate the prevalence of single and multiple umbilical cord cysts in the first trimester and to assess whether there is a difference in the pregnancy outcome between them. METHODS: A targeted sonographic morphological and morphometric evaluation of the umbilical cord was performed in consecutive patients between 7 and 14 weeks of gestation. Crown-rump length and umbilical cord diameter were measured in all cases. Nuchal translucency thickness was measured between 11 and 14 weeks' gestation. In pregnancies at very early gestational ages (7-10 weeks) an additional scan was performed between 11 and 14 weeks. RESULTS: A total of 1159 patients was screened. The prevalence of umbilical cord cysts was 2.1% (24/1159). The cysts were single and multiple in 18 and six cases, respectively. The median (range) largest umbilical cord cyst diameter was no different between multiple and single umbilical cord cysts (3.8 (2.1-18) mm vs. 3.05 (2.0-7.8) mm; P = 0.386). All women with a single umbilical cord cyst delivered an infant without structural abnormalities and without features suggestive of chromosomal abnormalities. Among the women with multiple umbilical cord cysts, four had a missed miscarriage and one had a fetus with obstructive uropathy. CONCLUSION: Single and multiple umbilical cord cysts in the first trimester of gestation represent two different entities. While single cysts in the first trimester are associated with a favorable pregnancy outcome, the presence of multiple umbilical cord cysts is associated with an increased risk of miscarriage and aneuploidy.

[The use of hormonal contraception in perimenopause is still a hazard?]. / L'impiego della contraccezione ormonale in perimenopausa è ancora un azzardo?

The need for contraception in a period of life characterized by irregular menstrual cycles as the perimenopause represents a social and biological event for each woman and a challenge for the gynecologist. The use of oral contraceptives in perimenopause has been vastly discussed in the last decade. Several investigators have focused their attention on the risks related to hormonal administration to older women neglecting all the advantages. The introduction of new lower-dose formulations and progestin-only preparations as implants or intra-uterine system has deeply changed the indications for hormonal contraception allowing their use in patients in whom it was previously contraindicated. Cumulative evidence has demonstrated that the use of hormonal contraception during the perimenopausal period does not offer only advantages in term of cycle control but also gives an important protection against the development of gynecological malignancies. However, in clinical practice the use of hormonal contraceptives in older women has not been accepted by a large number of physicians who continue to consider hormonal contraception in women over forties a tabù. The aim of this review is to discuss lights and shadows of the use of hormonal contraception in perimenopause.