The Cavernous Nerve Injury Rat Model: A Pictorial Essay on Post-Radical Prostatectomy Erectile Dysfunction Research.

Understanding and addressing post-radical prostatectomy (RP) erectile dysfunction (ED) is of paramount importance for clinicians. Cavernous nerve (CN) injury rat model studies have provided consistently promising experimental data regarding regaining erectile function (EF) after nerve damage-induced ED. However, these findings have failed to translate efficiently into clinical practice, with post-RP ED therapeutic management remaining cumbersome and enigmatic. This disparity highlights the need for further standardization and optimization of the elaborate surgical preparation protocols and multifaceted reporting parameters involved in reliable CN injury rat model experimentation. Even so, despite its technical complexity, this animal model remains instrumental in exploring the functional implications of RP, i.e., surgical lesions of the neurovascular bundles (NVBs). Herein, besides cavernous nerve (CN) dissection, injury, and electrostimulation, multiple pressure measurements, i.e., mean arterial pressure (MAP) and intra-cavernosal pressure (ICP), must also be achieved. A transverse cervical incision allows for carotid artery cannulation and MAP measurements. Conversely, ICP measurements entail circumcising the penis, exposing the ischiocavernous muscle, and inserting a needle into the corporal body. Finally, using an abdominal incision, the prostate is revealed, and the major pelvic ganglia (MPG) and CNs are dissected bilaterally. Specific surgical techniques are used to induce CN injuries. Herein, we provide a narrative and illustrative overview regarding these complex experimental procedures and their particular requirements, reflecting on current evidence and future research perspectives.

Ultrasound Pretreatment Lymph Node Evaluation in Early-Stage Breast Cancer: Should We Biopsy High Suspicion Nodes?

BACKGROUND: With the growing incidence of breast cancer, efficient and correct staging is essential for further treatment decisions. Axillary ultrasound (US) remains the most common method for regional nodal involvement assessment. The aim of this study was to evaluate whether high-risk US features can accurately predict axillary lymph node metastasis. METHODS: A total of 150 early-stage breast cancer patients (T1 or T2) were prospectively included in the study. Based on axillary US, patients were classified as normal, low-risk, or high-risk, with all patients in the low-risk and high-risk groups undergoing fine-needle aspiration (FNAB) and core-needle biopsies. RESULTS: For the low-risk US group, a lower prediction rate of axillary nodal metastasis was achieved than for the group with high-risk features, recording a sensitivity of 66.6% vs. 89.2%, a specificity of 57.1% vs. 100%, a positive predictive value (PPV) of 26.6% vs. 100%, a negative predictive value (NPV) of 88% for both groups, and an accuracy of 58.9% vs. 94%, respectively. FNAB resulted in more false-negative results compared to core-needle biopsy in both low-risk and high-risk US groups. CONCLUSIONS: Our findings suggest that high-risk US features can predict axillary lymph node metastasis with high accuracy.

Laparoscopic Pectopexy versus Vaginal Sacrospinous Ligament Fixation in the Treatment of Apical Prolapse.

OBJECTIVES: To compare the follow-up results of a sacrospinous ligament fixation (SSLF) technique for laparoscopic bilateral fixation of the vagina to the iliopectineal ligament via a PVDF-mesh (laparoscopic pectopexy technique, LP) in terms of cure rate and postoperative complications rate. MATERIAL AND METHODS: This prospective study included 160 patients diagnosed with pelvic organ prolapse stage II-IV according to the POP-Q system. Eighty-two patients (51.25%) underwent vaginal sacrospinous ligament fixation and seventy-eight patients (48.75%) underwent the laparoscopic pectopexy procedure. RESULTS: The cure rate was high in both groups, 95.12% of the patients (78 out of 82) in the SSLF group and 93.59% of the patients (73 out of 78) in the LP group were cured post surgery, leading to an overall cure rate of 151 out of 160 patients. Pelvic pain was present in 5.00% of all patients, but was notably more frequent in the SSLF group (7, 8.54%) than in the LP group (1, 1.28%). Dyspareunia occurred in 4.37% of all patients, slightly more frequently in the SSLF group (6, 7.32%) than the LP group (1, 1.28%), but without significant difference. CONCLUSIONS: The laparoscopic pectopexy procedure has comparably positive follow-up results with the conventional sacrospinous ligament fixation procedure. Both SSLF and LP are effective in the treatment of pelvic organ prolapse, with favorable anatomical and subjective results, a high cure rate and low rates of serious postoperative complications.

Evaluating Patient Preferences and Clinical Outcomes in Stress Urinary Incontinence Treatment: A Short-Term Follow-Up Study of the Transobturator Tape Procedure and Pubourethral Ligament Plication (a Minimally Invasive Technique).

OBJECTIVE: This study aims to provide an in-depth analysis of patient preferences and clinical outcomes associated with two surgical techniques for treating stress urinary incontinence (SUI): the transobturator suburethral sling (TOT) procedure and the pubourethral ligament plication (PUL) procedure. We evaluated the rates of postoperative complications, the duration of each procedure, hemoglobin loss, and days of hospitalization. MATERIALS AND METHODS: This prospective study included 80 patients who underwent surgery for SUI: 40 patients for the TOT procedure and 40 patients for the PUL procedure. Clinical data on patient characteristics, treatment efficacy, and post-surgical outcomes were analyzed to assess patient preferences and real-world clinical effectiveness. RESULTS: Regarding patient preferences, those who underwent TOT surgery were more likely to be older, had a higher average number of pregnancies, and were more often postmenopausal, in contrast to those who underwent PUL surgery (p < 0.001 for each comparison). TOT patients had a hospital stay on average of 1.02 days, while PUL patients benefited from ambulatory stays only. In addition, the TOT group had a significantly longer average operating time (16.80 min) compared to the PUL group (9.90 min, p < 0.001). The study revealed notable outcomes in both groups, with high cure rates for both TOT (N1 = 33, 82.5%) and PUL (N2 = 28, 70%) procedures. Specifically, 76.25% of the patients (61 out of 80) were cured after the procedures. Chronic pelvic pain was present in 3.75% of all patients and was notably only observed in the TOT group, with 3 (7.5%) cases being noted. Similarly, vaginal erosion was experienced by 5% of all patients, with 10% of patients in the TOT group and none in the PUL group being affected. Dyspareunia occurred in 2.5% of all patients, with there being two (5%) cases in the TOT group and none in the PUL group. CONCLUSIONS: This study highlights that while the PUL procedure achieves cure rates comparable to TOT, it offers a less invasive option with shorter operating times and no hospitalization required. These findings suggest that PUL could be a viable alternative for stress urinary incontinence (SUI) treatment, especially in contexts where avoiding mesh use is preferred. This adds significant value to patient-centered care in SUI management, offering tailored treatment options based on patient characteristics, preferences, and risk profiles.

Risk of More Advanced Lesions at Hysterectomy after Initial Diagnosis of Non-Atypical Endometrial Hyperplasia in Patients with Postmenopausal Bleeding and Oral Anticoagulant Treatment.

Background and Objectives: Endometrial hyperplasia (EH) is a precursor lesion to endometrial cancer (EC), and when cellular atypia is present, in 40% of cases, they are diagnosed with EC on hysterectomy. Usually, EH is clinically manifested by uterine bleeding. In patients with oral anticoagulant therapy (OAT), the uterus is the second most common source of bleeding. The aim of the study was to show that uterine bleeding in postmenopausal patients undergoing OAT may reveal precancerous endometrial lesions with atypia, or neoplastic lesions in patients with an initial diagnosis of endometrial hyperplasia without atypia (non-atypical endometrial hyperplasia, NAEH) on dilation and curettage (D&C). We will be able to estimate the risk of a postmenopausal female patient with uterine bleeding during an OAT to have a precancerous endometrial lesion. Materials and Methods: The subjects of the study were 173 female patients with uterine bleeding, who have had total hysterectomy with bilateral salpingoovarectomy, of whom 99 underwent an OAT. There were 101 female patients initially diagnosed with NAEH, of which 60 did not have anticoagulant treatment (mean age 57.36 ± 6.51) and 41 had anticoagulant treatment (mean age 60.39 ± 7.35) (p = 0.006). From the pathology diagnosis moment, the surgery was performed at 42.09 ± 14.54 days in patients without OAT and after 35.39 ± 11.29 days in those who received such treatment (p = 0.724). Results: Initial diagnosis of NAEH established at D&C was changed at the final diagnosis after hysterectomy in EH with cellular atypia (atypical endometrial hyperplasia AEH) or EC in 18.18% of patients without OAT, and in 40.54% of patients who received this treatment. Conclusions: Based on a logistic regression model, it is estimated that female patients with an initial histopathological diagnosis of NAEH and who underwent OAT have, on average, 4.85 times greater odds (OR = 4.85, 95% CI 1.79-14.06) than the others of being identified postoperatively with more advanced lesions.

Long Non-Coding RNA Expression in Laser Micro-Dissected Luminal A and Triple Negative Breast Cancer Tissue Samples-A Pilot Study.

Background and Objectives: Breast cancer (BC) remains one of the major causes of cancer death in women worldwide. The difficulties in assessing the deep molecular mechanisms involved in this pathology arise from its high complexity and diverse tissue subtypes. Long non-coding RNAs (lncRNAs) were shown to have great tissue specificity, being differentially expressed within the BC tissue subtypes. Materials and Methods: Herein, we performed lncRNA profiling by PCR array in triple negative breast cancer (TNBC) and luminal A tissue samples from 18 BC patients (nine TNBC and nine luminal A), followed by individual validation in BC tissue and cell lines. Tissue samples were previously archived in formalin-fixed paraffin-embedded (FFPE) samples, and the areas of interest were dissected using laser capture microdissection (LCM) technology. Results: Two lncRNAs (OTX2-AS1 and SOX2OT) were differentially expressed in the profiling analysis (fold change of 205.22 and 0.02, respectively, p < 0.05 in both cases); however, they did not reach statistical significance in the individual validation measurement (p > 0.05) when analyzed with specific individual assays. In addition, GAS5 and NEAT1 lncRNAs were individually assessed as they were previously described in the literature as being associated with BC. GAS5 was significantly downregulated in both TNBC tissues and cell lines compared to luminal A samples, while NEAT1 was significantly downregulated only in TNBC cells vs. luminal A. Conclusions: Therefore, we identified GAS5 lncRNA as having a differential expression in TNBC tissues and cells compared to luminal A, with possible implications in the molecular mechanisms of the TNBC subtype. This proof of principle study also suggests that LCM could be a useful technique for limiting the sample heterogeneity for lncRNA gene expression analysis in BC FFPE tissues. Future studies of larger cohort sizes are needed in order to assess the biomarker potential of lncRNA GAS5 in BC.

Survival Analysis of Patients with Inflammatory Breast Cancer in Relation to Clinical and Histopathological Characteristics.

PURPOSE: To evaluate the survival of patients with inflammatory breast cancer (IBC) and to correlate these survival rates with the histopathological parameters found in the resection specimen of the tumor. PATIENTS AND METHODS: This retrospective study was based on 27 patients that had been diagnosed and had undergone surgery in the 2nd General and Oncological Surgery Clinic of the County Emergency Hospital in Timisoara, Romania. Data about the patient group were collected from archived patient files over a period of eight years starting from January 2008. The collected data regarded age, tumor size and histopathological type and immunohistochemistry (IHC), presence or absence of tumor embolus in lymphatic or blood vessels and the presence or absence of distant metastases at the time of diagnosis. We evaluated the impact of tumor characteristics on the patients' outcome. RESULTS: The 12-month survival rates postsurgery were significantly increased if tumors were <5 cm compared to those >5 cm (p=0.046), if nodal status was N0 vs N1-2 (p=0.039), as well as in cases where distant metastases were absent, compared to patients with distant metastases (p=0.001, α=0.001) and positive-hormone receptors (p=0.043). Survival was influenced neither by histopathological type (p=0.357) nor by the presence of tumor embolus in the resection specimen (p=0.250) and HER2 status (p=0.763). Survival at 12 months after surgery was equal between those with stage IIIB noninflammatory breast cancer (NIBC) and IBC. At 24 months after surgery, IBC cases presented a significantly lower probability of survival. CONCLUSION: The prognosis of patients with IBC is reserved compared to NIBC, increased tumor size, positive lymph node, hormone receptors negative cases and distant metastases drastically decreasing survival rates.

Laparoscopic Pectopexy with Burch Colposuspension for Pelvic Prolapse Associated with Stress Urinary Incontinence.

STUDY OBJECTIVE: To present a case of pelvic organ prolapse associated with stress urinary incontinence treated by laparoscopic pectopexy followed by Burch colposuspension. DESIGN: Case report. SETTING: University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Romania. PATIENTS: We present the case of a 41-year-old woman, gravida 1 para 1, with no notable medical or surgical history, with a body mass index of 40 kg/m2, who presented in our service with heavy menstrual bleeding, dysmenorrhea, pelvic pressure, dyspareunia, stress urinary incontinence, and voiding difficulties. Local examination revealed a cervix descended 2 cm below the hymenal ring, cystocele, urethrocele, and a positive cough stress test. The pelvic prolapse was classified as pelvic organ prolapse quantification stage 3. Ultrasound exam revealed a uterus with diffuse adenomyosis of the posterior uterine wall and normal adnexa. Because of the patient's obesity, the treatment plan was laparoscopic supracervical hysterectomy for the treatment of adenomyosis, laparoscopic pectopexy for the correction of the apical defect, and Burch colposuspension for the cure of stress incontinence. INTERVENTIONS: The patient was placed in the standard dorsal lithotomy position with the hips in extension and the knees flexed and the table in 45° Trendelenburg position. One 10-mm umbilical optical trocar and three 5-mm trocars were used-2 inserted 2 cm above and medial to the anterior superior iliac crests, and the third, 5 cm below the umbilical trocar. The dissection started on the left side of the pelvis. The peritoneum was incised in the center of a V-shaped area bordered by the left round ligament and the obliterated umbilical artery (the medial umbilical ligament). The soft tissue was dissected, and the left iliopectineal ligament (also known as the inguinal ligament of Cooper) was identified right under the external iliac vein and prepared. The same steps were repeated on the right side of the pelvis. The procedure continued with the dissection of the vesicovaginal space. The anterior vaginal wall was exposed with the help of a retractor placed inside the vagina and held by an assistant. A supracervical hysterectomy was performed. An 8 × 15-cm polypropylene mesh, cut in a T shape, was introduced in the abdomen. First, the short arm of the T was fixed on the anterior vaginal wall using multiple absorbable tacks (AbsorbaTack fixation device; Medtronic, Dublin, Ireland). To use a type of nonabsorbable fixation, we decided to also fix the mesh to the cervix stump with 3 isolated stitches (Silk Suture 2-0; Ethicon, Somerville, NJ). Second, with the purpose of ensuring a permanent fixation, the lateral arms of the mesh were attached to the iliopectineal ligaments with multiple nonabsorbable tacks on both sides (ProTack fixation device; Medtronic, Dublin, Ireland). The procedure continued with the complete closure of the peritoneum with VICRYL 2-0 sutures (Ethicon). Because the patient also had stress urinary incontinence, a Burch colposuspension was performed. To expose its limits, the urinary bladder was filled with 200 mL of saline. After the incision of the peritoneum, the avascular space of Retzius was opened. The dissection continued until the Cooper's ligaments were exposed bilaterally. The proper suture placement points on the vaginal wall were facilitated by an assistant's intravaginal finger. Two isolated nonabsorbable silk stitches (Silk Suture 2-0) were placed through the Cooper's ligament and through the anterior vaginal wall on each side. The knots were tied just enough to properly lift the vaginal wall in the normal position, assessed by the assistant by vaginal route, but not too tight to avoid urethral obstruction. MEASUREMENTS AND MAIN RESULTS: The duration of the surgery was 95 minutes, with minimal blood loss of about 60 mL. The patient recovered well, with the Foley catheter being removed after 12 hours. The patient was discharged after 48 hours. The 6-month follow-up examination revealed a correct anatomical position of the anterior vaginal wall and of the cervix at 6 cm above the hymenal ring and no urinary incontinence. CONCLUSION: Laparoscopic pectopexy represents a new option for the treatment of pelvic organ prolapse. In the case we reported, no intraoperative or postoperative complications were present, and the follow-up assessment revealed an effective correction of the prolapse. Further studies are needed to conclude the efficiency and safety of this new procedure.

Surgically Induced Menopause-A Practical Review of Literature.

Menopause can occur spontaneously (natural menopause) or it can be surgically induced by oophorectomy. The symptoms and complications related to menopause differ from one patient to another. We aimed to review the similarities and differences between natural and surgically induced menopause by analyzing the available data in literature regarding surgically induced menopause and the current guidelines and recommendations, the advantages of bilateral salpingo-oophorectomy in low and high risk patients, the effects of surgically induced menopause and to analyze the factors involved in decision making.

MicroRNA Expression in Laser Micro-dissected Breast Cancer Tissue Samples - a Pilot Study.

Breast cancer continues to represent a significant public health burden despite outstanding research advances regarding the molecular mechanisms of cancer biology, biomarkers for diagnostics and prognostic and therapeutic management of this disease. The studies of micro RNAs in breast cancer have underlined their potential as biomarkers and therapeutic targets; however most of these studies are still done on largely heterogeneous whole breast tissue samples. In this pilot study we have investigated the expression of four micro RNAs (miR-21, 145, 155, 92) known to be involved in breast cancer, in homogenous cell populations collected by laser capture microdissection from breast tissue section slides. Micro RNA expression was assessed by real time PCR, and associations with clinical and pathological characteristics were also explored. Our results have confirmed previous associations of miR-21 expression with poor prognosis characteristics of breast cancers such as high stage, large and highly proliferative tumors. No statistically significant associations were found with the other micro RNAs investigated, possibly due to the small sample size of our study. Our results also suggest that miR-484 could be a suitable endogenous control for data normalization in breast tissues, these results needing further confirmation by future studies. In summary, our pilot study showed the feasibility of detecting micro RNAs expression in homogenous laser captured microdissected invasive breast cancer samples, and confirmed some of the previously reported associations with poor prognostic characteristics of breast tumors.

Laparoscopic Resection of Cesarean Scar Ectopic Pregnancy after Unsuccessful Systemic Methotrexate Treatment.

STUDY OBJECTIVE: To present a case of a cesarean scar ectopic pregnancy treated by laparoscopic resection followed by isthmocele repair. DESIGN: A case report. SETTINGS: The University Gynecology Clinic of the Emergency Clinical City Hospital Timișoara, Timișoara, România. BACKGROUND: Cesarean scar pregnancy is a rare form of ectopic pregnancy. In recent years, its prevalence has risen because of the increasing number of cesarean sections. An early diagnosis can lead to early management, decreasing the risk of life-threatening complications such as uterine rupture and massive hemorrhage. Many therapeutic options are available, medical and surgical, but the current literature suggests that the laparoscopic approach with ectopic pregnancy resection is the best option. CASE REPORT: We present the case of a 30-year-old woman with a previous cesarean section in 2012 who was diagnosed by transvaginal ultrasound with a 6-week live pregnancy implanted at the level of the cesarean scar. The initial management was the administration of a 2-dose methotrexate protocol, but after 72 hours the transvaginal ultrasound showed an embryo with cardiac activity still present associated with an increased beta human chorionic gonadotropin level. We decided on laparoscopic surgical treatment, aiming to extract the pregnancy and repair the scar defect. A similar case was presented by Mahgoub et al [1], but their case had a different evolution, with decreasing levels of hCG. INTERVENTIONS: In order to reduce the blood loss, the anterior trunks of the hypogastric arteries were clipped. The side wall peritoneum was cut bilaterally, and the ureters and the hypogastric arteries were dissected. Next, we performed the dissection of the vesicouterine space. Because of the previous cesarean section, the identification of the correct dissection plane was difficult. A uterine manipulator was used to facilitate the dissection. The exact location of the gestational sac was demonstrated using intraoperative transvaginal ultrasound. To reduce the bleeding, Glypressin (Ferring GmbH, Saint Prex, Switzerland) was injected at the level of the uterine scar. The cesarean scar was cut using a monopolar knife. The gestation sac was reached easily and then extracted from the abdominal cavity with the use of an endobag. In order to obtain proper healing, the margins of the scar were resected using cold scissors. The hysterotomy was closed using a double-layered suture with 2.0 Vicryl (Ethicon Inc., Cincinnati, OH). We used methylene blue to verify the tightness of the suture. The final step was the removal of the clips. MEASUREMENTS AND MAIN RESULTS: The operative time was 85 minutes with minimal blood loss of about 20 mL. The patient recovered well and was discharged 2 days after the procedure. A transvaginal ultrasound was performed 1 month after the surgery showing good healing of the anterior uterine wall. CONCLUSION: The laparoscopic approach with excision and repair of the uterine wall represents a safe and efficient therapeutic option for the treatment of the cesarean scar ectopic pregnancy.

p16/Ki-67 dual staining has a better accuracy than human papillomavirus (HPV) testing in women with abnormal cytology under 30 years old.

Due to a high rate of transient human papillomavirus (HPV) infection, HPV genotyping has a low specificity for high-grade cervical lesions, especially in young women. p16/Ki-67 dual immunocytochemical staining can also be used for the detection of oncogenic changes in cervical cells. Our aim was to compare the performance of p16/Ki-67 dual staining and HPV genotyping in the detection of high-grade cervical lesions in patients with atypical squamous cells of undetermined significance (ASCUS)/low-grade squamous intraepithelial lesion (LSIL) on Pap smear. We retrospectively analyzed 310 patients with ASCUS/LSIL on Pap smear, who underwent colposcopy. Among these, 161 patients with suspected lesions detected by colposcopy were referred for biopsy. HPV genotyping by LINEAR ARRAY HPV Genotyping Test (CE-IVD) and p16/Ki-67 dual staining by CINtec PLUS Cytology kit was performed prior to cervical biopsy. The overall sensitivity and specificity of HPV genotyping for the detection of cervical intraepithelial neoplasia (CIN) 2-3 was 79% and 72%, respectively in patients with ASCUS, and 85% and 64%, respectively in patients with LSIL. For p16/Ki-67 test, sensitivity and specificity rate was 66% and 93%, respectively in ASCUS and 59% and 79%, respectively in LSIL group. The specificity of p16/Ki-67 staining was significantly higher in both groups in patients aged <30 years compared to patients >30 years old (p < 0.001). Our results showed that p16/Ki-67 dual staining has a higher specificity compared to HPV genotyping, especially in patients under 30 years old. This indicates the usefulness of p16/Ki-67 testing in the triage of patients with ASCUS/LSIL and <30 years old, prior to referral for colposcopy and biopsy.

HPV genotyping and p16÷Ki-67 dual staining in the detection of high-grade cervical lesion in patients with LSIL on Pap smear.

p16÷Ki-67 dual-stained cytology, either alone or combined with human papillomavirus (HPV) 16÷18 genotyping, could be a useful tool for triage for colposcopy of HPV-positive patients. Based on this background, we aimed at comparing the diagnostic performance of the p16÷Ki-67 dual staining test, and high-risk HPV test for the detection of high-risk cervical intraepithelial neoplasia (CIN2÷3) in patients diagnosed with low-grade squamous intraepithelial lesion (LSIL) on Pap smear. We performed a retrospective study including 184 patients with LSIL cytology on Pap smear, of which 64 were referred for biopsy after colposcopy. Prior biopsy HPV genotyping and dual staining test were performed on all 64 patients. The mean age of the patients selected for conization was 36 years and seven months. The pathological exam showed that 28.13% (18÷64) from the patients LSIL on cytology were actually having CIN2÷3: 12 cases with CIN2, five cases with CIN3 and one case of in situ cervical carcinoma. HPV positive were 56.25% (36÷64) of the patients with LSIL. The p16÷Ki-67 dual staining test was positive in 29.69% (19÷64) of the patients with LSIL. Among women with LSIL cytology, the sensitivity and specificity of the HPV genotyping test for predicting CIN2÷CIN3 were 94.44% (17÷18) and 58.7% (27÷46), respectively. The sensitivity and specificity of the p16÷Ki-67 dual staining test were 66.67% (12÷18) and 84.78% (39÷46), respectively. Our results agree with other data available in literature and suggest that the p16÷Ki-67 dual staining test could be included in the management protocol of patients with modified cytology as a triage test before referring those patients for colposcopy.

Laparoscopic Promontohysteropexy During Pregnancy.

STUDY OBJECTIVE: To present a case of uterine prolapse in a pregnant patient at 10 weeks of gestation who was successfully treated by laparoscopic promontohysteropexy. To our knowledge, this is the first case of laparoscopic promontopexy during pregnancy to be reported in the literature. DESIGN: Step-by-step description of the surgery using videos (Canadian Task Force classification 3). SETTING: Uterine prolapse is a rare condition in young patients and is extremely rare in pregnant women. The reported incidence of uterine prolapse during pregnancy is 1/10,000 to 15,000 deliveries [1]. To date, only a few cases of prolapse during pregnancy have reported in the literature, most of which were treated with pessary insertion. A case involving laparoscopic surgery for uterine prolapse during pregnancy was reported by Matsumoto et al 1999 [2], but the authors did not perform the promontohysteropexy technique. INTERVENTION: A 27-year-old patient with uterine prolapse at 10 weeks of gestation was referred to our clinic for severe pelvic pain. Conservative treatment with pessary insertion was attempted but failed. Consequently, the patient was scheduled for laparoscopic promontohysteropexy. The surgery was made difficult by the increased size and softness of the uterus. To create an adequate surgical field, the sigmoid colon and right adnexa were suspended at the abdominal wall. The peritoneum above the promontorium was incised, and the longitudinal ligament was dissected. The paravesical spaces were opened, and the vesicovaginal space was dissected. A polypropylene mesh in the shape of an inverted "T" was introduced. The small arm was sutured to the anterior vaginal wall, and the posterior arms were passed through the posterior leaves of the broad ligament and fixed to the cervix at the level of the uterosacral ligaments. Both posterior arms were fixed at the level of the promontory using the Protack device (Medtronic, Minneapolis, MN). The mesh was completely covered with peritoneum. The patient was discharged 3 days after surgery, with no pain and with normal pelvic floor status. The pregnancy proceeded uneventfully, and she delivered a 3500-g healthy baby by scheduled cesarean section at 39 weeks of gestation. During surgery, the position of the mesh around the uterus was assessed. The mesh was completely covered with peritoneum, and there were no adhesions due to mesh insertion. At 6 months after delivery, pelvic floor status was reassessed and found to be normal. Written informed consent for reporting this case was obtained from the patient before the procedure. The procedure was performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. The Institutional Review Board and Ethical Committee of Victor Babes University of Medicine and Pharmacy ruled that approval was not required for this study. CONCLUSION: Laparoscopic promontohysteropxy can be performed during pregnancy if conservative treatment, such as pessary insertion, fails to restore the normal pelvic floor status.

The importance of immunocytochemistry in the detection of high-grade cervical lesions.

Despite the implementation of various screening programs in many countries, cervical cancer continues to be a major health problem. Cervical cytology is the most used screening method, but human papillomavirus (HPV) genotyping, alone or in combination with cytology, has gained ground during the last years. Still, one of the major limitations of HPV-genotyping is the low specificity of HPV as a screening method in young women that are HPV-positive, but with no potential for future disease. Obviously, there is a need for a better screening algorithm. The ideal screening test for cervical high-grade lesions should detect the effect of high-risk (HR)-HPV infection after cell transformation, but not before, and should accurately identify the cases that are more likely to experience disease progression to neoplasia. Solid data regarding the benefit of immunocytochemistry in the evaluation of the patients with modified cervical cytology have been published recently. The use of the dual staining with p16INK4a and Ki-67 could increase specificity of the method for the detection of atypical cells and may perform better in predicting the risk of high-grade dysplasia in the near future.

Age and HPV type as risk factors for HPV persistence after loop excision in patients with high grade cervical lesions: an observational study.

BACKGROUND: Persistent infections with high risk human papillomaviruses (HR-HPV) cause virtually all cervical cancers. METHODS: An observational study was conducted aiming to estimate the rate of HPV infection persistence after LEEP in patients with high grade squamous intraepithelial lesions (HSIL). Moreover, the study investigated if persistence is age related. For this reason a total of 110 patients were included between January 2010 and June 2015. RESULTS: At 6 months after LEEP the overall HPV infection persistence rate was 40.9 %, at 12 months 20 % and at 18 months 11.8 %. Type 16 showed the highest persistence rate: 27.3 % at 6 months, 12.7 % at 12 months and 10 % at 18 months after LEEP. The persistence for HPV type 16 at 6 months after LEEP was significantly higher in the group > =36.5 years old compared to the persistence rate in the group <36.5 years old (p = 0.0027, RR = 2.75, 95 %ϵ(1.34; 5.64)) (see Table 3). CONCLUSIONS: LEEP does not completely eradicate HPV infection. HPV persistence rate after LEEP is higher in infections with type 16 and in women older than 36.5 years.

Human Papilloma Virus Persistence after Cone Excision in Women with Cervical High Grade Squamous Intraepithelial Lesion: A Prospective Study.

Background. Persistent human papillomavirus (HPV) infection is a necessary event in cervical cancer tumorigenesis. Our objectives were to estimate the rate of HPV infection persistence after large loop excision of the transformation zone (LEEP) in patients with high grade squamous intraepithelial lesions (HSIL) and to investigate if HPV persistence is type related. Methods. We conducted a prospective study on 89 patients with HSIL treated with LEEP. DNA HPV was performed before surgery and at 6, 12, and 18 months after LEEP. Results. Four patients were excluded from the study. The HPV persistence in the remaining 85 patients was 32.95% (6 months), 14.12% (12 months), and 10.59% (18 months). Type 16 had the highest persistence rate, 23.5% (6 months), 11.8% (12 months), and 8.2% (18 months). Coinfection was found to be 54.12% before LEEP and 18.8% (6 months), 4.7% (12 months), and 3.5% (18 months) after LEEP. The rate of coinfections including type 16 was 46.83% of all coinfections. Coinfection including type 16 was not correlated with higher persistence rate compared to infection with type 16 only. Conclusions. HPV infection is not completely eradicated by LEEP in patients with HSIL lesion on PAP smear. HPV persistence after LEEP is influenced by HPV type. HPV type 16 has the highest persistence rate.

Transversal incision of the vagina favors the remaining of the tape in the middle-third urethra compared to longitudinal incision during transobturator sling procedures for stress urinary incontinence.

BACKGROUND: To describe a new type of incision of the vagina during transobturator sling procedure and to evaluate by ultrasound the tape position at 3, 6 and 12 months after surgery. We conducted a prospective study including 51 patients with urinary stress incontinence who underwent sling procedure using the transversal vaginal incision. Tape position was evaluated by ultrasound at 3, 6 and 12 months after surgery and expressed as a percentage of the urethral length (the proximal third of the urethral length 0-39 %, the middle third 40-60 %, and the distal third 60-100 %). Informed consent was obtained from all patients prior to their inclusion in the study. All procedures have been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments and were approved by the Institutional Review Board and Ethical Committee of "Victor Babes" University of Medicine and Pharmacy Timisoara before the beginning of the study (no 7/17.04.2012). RESULTS: At 3 months after surgery, 3.92 % of the slings were located in the proximal third of the urethra, 88.23 % in the middle third of the urethra and 7.84 % in the distal third. At 6 and 12 months after surgery we obtained similar results: 9.81 % of the slings were located in the proximal third of the urethra, 82.35 % in the middle third and 7.84 % in the distal third of the urethra. CONCLUSION: The transversal incision of the vagina offers a minimal dissection along the long axis of the urethra favoring the remaining of the tape in the middle third of the urethra.

ADAM12 and ADAM17 gene expression in laser-capture microdissected and non-microdissected breast tumors.

ADAM (a disintegrin and metalloprotease)12 and ADAM17 are multidomain transmembrane proteins involved in ectodomain shedding of cytokines, growth factors and adhesion molecules, with pivotal activities in the tumor microenvironment. The aim of this study was to confirm the up-regulation of ADAM17 and ADAM12 gene splicing variants in breast tumors and to delineate their expression between laser-capture microdissected (LCM) and non-microdissected breast tumors. The gene expression was analyzed by quantitative-reverse transcription-PCR in a total sample of 109 breast tumors paired with corresponding non-neoplastic breast tissues. ADAM12 and 17 proteins expression for corresponding tissue samples was confirmed by immunohistochemistry. ADAM12S, 12L and 17 genes were significantly up-regulated in either malign or benign LCM samples when compared to non-tumor controls. For non-LCM samples, it was obtained also an increased expression for ADAM12 and 17 genes in cancers, while in benign tumors only ADAM12 variants were significantly up-regulated compared to controls. When benign versus malignant tumors were compared, in LCM samples all investigated genes displayed a higher expression in cancers, whereas in non-LCM, ADAM12 variants were overexpressed in benign samples. The increased expression of ADAM12 protein in the tumor cells and stroma of benign breast diseases was immunohistochemically confirmed. These differences between LCM and non-LCM samples were explained by the contribution of the stroma to the expression of this marker. This study underlines the accuracy conferred by homogenous LCM samples on gene expression profiles and confers further evidence regarding the role of ADAM12 and 17 in the breast tumorigenesis and progression.