Plasma Redox Balance in Advanced-Maternal-Age Pregnant Women and Effects of Plasma on Umbilical Cord Mesenchymal Stem Cells.

Pregnancy at advanced maternal age (AMA) is a condition of potential risk for the development of maternal-fetal complications with possible repercussions even in the long term. Here, we analyzed the changes in plasma redox balance and the effects of plasma on human umbilical cord mesenchymal cells (hUMSCs) in AMA pregnant women (patients) at various timings of pregnancy. One hundred patients and twenty pregnant women younger than 40 years (controls) were recruited and evaluated at various timings during pregnancy until after delivery. Plasma samples were used to measure the thiobarbituric acid reactive substances (TBARS), glutathione and nitric oxide (NO). In addition, plasma was used to stimulate the hUMSCs, which were tested for cell viability, reactive oxygen species (ROS) and NO release. The obtained results showed that, throughout pregnancy until after delivery in patients, the levels of plasma glutathione and NO were lower than those of controls, while those of TBARS were higher. Moreover, plasma of patients reduced cell viability and NO release, and increased ROS release in hUMSCs. Our results highlighted alterations in the redox balance and the presence of potentially harmful circulating factors in plasma of patients. They could have clinical relevance for the prevention of complications related to AMA pregnancy.

Vaginal metastasis of lung cancer: A case report.

Lung adenosquamous carcinoma (ASC) is a rare biphasic malignant tumor with squamous cell carcinoma (SCC) and adenocarcinoma (AC) components. ASC is reported to be aggressive; the most common metastatic sites are the regional lymph nodes and surrounding areas. A 46-year-old woman was referred to the emergency department with a persistent dry cough. She underwent fibro-bronchoscopy and was diagnosed with an adenosquamous lung carcinoma. Other than pulmonary and lymphatic findings, a total-body computed tomography (CT) examination highlighted a hypodense formation, of about 9 mm, with a cystic appearance, at the level of the vaginal region. A biopsy performed in the posterior vaginal wall highlighted a vaginal wall flap with subepithelial localization of neoplasia, compatible with the pulmonary ASC. Oncologists took charge of the case and the patient commenced medical therapy with entrectinib. Four months later, she developed dyspnea, and high-resolution CT highlighted an increase in the pathological tissue causing bronchial occlusion. The patient underwent endobronchial stent placement and thereafter restarted therapy with entrectinib, previously stopped because of the new symptoms, and was closely monitored. Apparently only one case of vaginal metastasis from pulmonary tumor has been previously reported, and this is the first report of vaginal metastasis from ASC. Although extremely rare, the presence of such metastasis should be considered in women with suspected vaginal neoformations.

Aggressive Pelvic Angiomyxoma in a Patient with Twin Pregnancy: Diagnosis, Treatment, and Clinical Complications in Light of the Literature.

(1) Background: Aggressive angiomyxoma is a mesenchymal cancer that is rare during pregnancy. It is a neoplasm that relapses and infiltrates the nearest structures. Our aim is to evaluate the management and outcomes of an observed case, in light of the current literature. (2) Methods: We observed this condition at the "Maggiore della Carità" Hospital in Novara (Italy) in a patient with an initial twin pregnancy and a suspected pelvic mass. The words "angiomyxoma" and "pregnancy" were searched on the main online scientific search sources (PubMed, Google Scholar, Scopus, WES, and Embase, etc.). (3) Results: The patient underwent surgery with a complicated follow-up, but recent negative controls. We analyzed the literature about the topic and found only 24 similar clinical cases. (4) Conclusions: Considering the current literature, it is useful to assess an aggressive angiomyxoma in the differential diagnosis of soft masses in pregnant women. The treatment of choice is surgical excision, and vaginal delivery is feasible. The therapeutic decision depends on each case.

Hysteroscopy in the new media: quality and reliability analysis of hysteroscopy procedures on YouTube™.

BACKGROUND: Hysteroscopy plays a crucial role in diagnosing and managing various intrauterine pathologies. However, its execution can be influenced by patients' perception and understanding, which are often shaped by digital resources such as YouTubeTM. Given its popularity and accessibility, YouTubeTM has the potential to greatly influence patients' knowledge and expectations about this procedure, highlighting the need for accurate and reliable information. PURPOSE: This study aims to assess the reliability and quality of hysteroscopy information available to patients on YouTubeTM. Understanding the nature of information patients' access can help address their fears and potential misunderstandings about the procedure, consequently reducing the likelihood of suspension or postponement due to anxiety. METHODS: A comprehensive analysis of YouTubeTM was conducted, simulating the search process of a patient seeking information about hysteroscopy. The study evaluated the reliability and quality of 90 out of the first 100 hysteroscopy-related videos on YouTubeTM, scored by four gynecologists-two experienced hysteroscopists and two trainees. The videos were assessed for reliability and quality using the mDISCERN and Global Quality Scale (GQS) scores. RESULTS: The average mDISCERN and GQS scores for the evaluated videos were below the optimal three points, highlighting the lack of fluency, comprehensiveness, and reliability of the available information. Notably, while videos produced by experts, including doctors and professional channels, had higher scores, they still fell short of the minimum score of 3. These videos also were not considered more suitable for either patients or trainees. Videos that were assessed as reliable (mDISCERN ≥ 3) were observed to be longer and were more frequently produced by doctors. These videos were suggested more to trainees rather than patients. Similarly, videos deemed as fluent and comprehensive (GQS ≥ 3) were longer and were more often recommended to patients. CONCLUSIONS: While YouTubeTM is a widely used source of medical information, the quality and reliability of hysteroscopy videos on the platform are poor. The strategic use of selected, high-quality hysteroscopy videos can enhance procedure success and alleviate patient fears. However, the unsupervised discovery of information by patients could potentially lead to procedure failure or an elevated level of stress due to misleading or incorrect information.

"The Sword in the Stone": radical excision of deep infiltrating endometriosis with bowel shaving-a single-centre experience on 703 consecutive patients.

BACKGROUND: Laparoscopic segmental bowel resection, disc excision and rectal shaving are described as surgical options for the treatment of bowel endometriosis, but the gold standard has not yet established. The aim of the study is to investigate the efficacy of the laparoscopic bowel shaving technique in terms of pain symptomatology and to analyse early and late postoperative complications. METHODS: Retrospective cohort study of a series of 703 consecutive patients treated between January 2014 and December 2019 in a tertiary care referral centre. All patients underwent laparoscopic bowel shaving with concomitant radical excision of DIE. RESULTS: Bilateral posterolateral parametrectomy and ureterolysis were performed, respectively, in 314 (44.7%) and 318 cases (45.2%). A radical hysterectomy was performed in 107 cases (82.9%). Postoperative complications were infrequent: 17 patients required a reoperation (2.4%) and in this subgroup we registered 2 rectovaginal fistulas (0.3%), 4 patients received blood transfusion (0.6%), 12 patients (1.7%) experienced postoperative fever, 6 patients experienced impaired bladder voiding (0.9%) after 6 months. Median follow-up was 14 months. The study reported good clinical and surgical results, with a regression of symptoms (p < 0.0001) and an overall rate of recurrence of 6.5%. Clinical and instrumental criteria of bowel endometriosis relapse were exclusively detected in 5 patients (0.8%). Eleven patients (1.7%) with relapsed endometriosis were reoperated. CONCLUSIONS: Bowel shaving is a feasible and valuable surgical procedure. It is only the last step of a complex surgery which is aimed to minimize the residual quote of infiltrating nodule and requires a multidisciplinary team to achieve optimal treatment preoperatively, intraoperatively and postoperatively.

Preventing the human factor: organizational aspects linked to fetal asphyxia.

BACKGROUND: Perinatal asphyxia can cause cerebral palsy and hypoxic-ischemic encephalopathy. They are public health problems because they cause permanent disability. METHODS: This is a retrospective, analytical, observational study. Overall, 162 cases of mothers whose children experienced fetal asphyxia were compared to 361 controls where this condition did not occur. The variables analyzed were classified as: prepartum, intrapartum and organizational. RESULTS: Assisted reproductive technology obtained pregnancies, smoking, maternal body mass index, lack of one-to-one assistance during labor, birth on a day of high-volume activity increased the risk of fetal asphyxia, as well as other traditionally linked factors like shoulder dystocia or age over 35 years. CONCLUSIONS: Cerebral palsy cannot always be prevented because it is a syndrome with a multitude of potential causes. But a small number of cases is likely to be linked to acute intrapartum events that could be limited by changing organizational policies such as staff training and implementing teamwork and discussion. Our paper proposes strategies to try and modify organizational risk factors and therefore limit the incidence of fetal asphyxia.

Firefly® System and Organ Transillumination in Robotic Gynecologic Surgery.

BACKGROUND AND OBJECTIVES: Near-infrared fluorescence (NIRF) of the Firefly® system has become a useful and widespread technique for the visualization and detection of tumors, sentinel lymphnodes, and vascular/anatomical structures. METHODS: Between February 1, 2017 to September 30, 2019, a total of 25 patients affected by benign and malignant pathologies underwent robotic surgery by the use of organ transillumination with the concomitant Firefly®. We analyzed the pre-operative patients' characteristics (age and body mass index [BMI], previous abdominal surgeries and systemic disease); pre-operative diagnosis, surgical procedure and approach (multiport or single site), transilluminated organ, surgical outcomes (operating time, incidence of intraoperative complications, and incidence of conversion to other surgery); and postoperative outcome. The surgical procedures included: four bladder endometriosis nodules resections, one pelvic lymphadenectomy with ureterolysis, and 23 hysterectomies. RESULTS: The average operating time was 283.3 (+/- 76.9) minutes, there were no intra-operative complications or laparotomic conversions. The average recovery days were 5.9. There have been three grade 2 post-surgical complications, following the Memorial Sloan Kettering Cancer Center Surgical Secondary Events System classification. The combination of NIRF and transillumination allows a clear view of the anatomical landmarks and the resection margins. CONCLUSIONS: It's likely that improvement in the anatomical detail could confer a greater surgical safety with lower percentage of intra and post-surgical complications and sparing of safe tissue. To evaluate the validity of these techniques in a larger number of patients and compare these new surgical procedures with standard ones, further studies are needed.

The perception of Italian pregnant women and new mothers about their psychological wellbeing, lifestyle, delivery, and neonatal management experience during the COVID-19 pandemic lockdown: a web-based survey.

BACKGROUND: In response to the COVID-19 pandemic, drastic measures for social distancing have been introduced also in Italy, likely with a substantial impact in delicate conditions like pregnancy and puerperium. The study aimed to investigate the changes in lifestyle, access to health services, and mental wellbeing during the first Italian lockdown in a sample of Italian pregnant women and new mothers. METHODS: We carried out a web-based survey to evaluate how pregnant women and new mothers were coping with the lockdown. We collected data about healthy habits (physical exercise and dietary habits), access to health services (care access, delivery and obstetric care, neonatal care, and breastfeeding), and mental wellbeing (psychological well-being and emotive support). Descriptive analysis was performed for both groups of participants, whereas a Poisson analysis was used to measure the association between some structural variables (age, education, socio-economic data, partner support, contact, free time, previous children, and pregnancy trimester) and anxiety or depression, difficulties in healthy eating and reduction in physical activity after lockdown started. Chi2 and Adjusted Prevalence Ratios were estimated only for pregnant women. RESULTS: We included 739 respondents (response rate 85.8 %), 600 were pregnant (81.2 %), and 139 (18.8 %) had delivered during lockdown (new mothers). We found a high score for anxiety and depression in 62.8 % of pregnant women and 61.9 % of new mothers. During the lockdown, 61.8 % of pregnant women reduced their physical exercise, and 44.3 % reported eating in a healthier way. 94.0 % of new mothers reported to have breastfed their babies during the hospital stay. Regarding the perceived impact of restrictive measures on breastfeeding, no impact was reported by 56.1 % of new mothers, whereas a negative one by 36.7 %. CONCLUSIONS: The high prevalence of anxiety and depressive symptoms in pregnant women and new mothers should be a public health issue. Clinicians might also recommend and encourage "home" physical exercise. On the other hand, about half of the sample improved their approach towards healthy eating and a very high breastfeeding rate was reported soon after birth: these data are an interesting starting point to develop new strategies for public health.

Genistein and 17ß-Estradiol Protect Hepatocytes from Fatty Degeneration by Mechanisms Involving Mitochondria, Inflammasome and Kinases Activation.

BACKGROUND/AIMS: Oxidative stress and mitochondria dysfunction could be involved in the onset of non-alcoholic fatty liver disease (NAFLD) and in its progression to non-alcoholic steatohepatitis (NASH). Estrogens/phytoestrogens could counteract liver fat deposition with beneficial effects against NAFLD by unclear mechanisms. We aimed to analyze the protective effects elicited by genistein/estradiol in hepatocytes cultured in NAFLD-like medium on cell viability, triglycerides accumulation, mitochondrial function and oxidative stress and the role of NLRP3 inflammasome, toll like receptors 4 (TLR4), Akt and 5' AMP-activated protein kinase (AMPK)α1/2. METHODS: Human primary hepatocytes/hepatoma cell line (Huh7.5 cells) were incubated with a 2 mM mixture of oleate/palmitate in presence/absence of genistein/17ß-estradiol. In some experiments, Huh7.5 cells were exposed to various inhibitors of the above pathways and estrogenic receptors (ERs) and G protein-coupled estrogen receptor (GPER) blockers, before genistein/17ß-estradiol. Cell viability, mitochondrial membrane potential, reactive oxygen species and triglycerides content were examined by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl tetrazolium bromide (MTT), 5,51,6,61-tetrachloro-1,11,3,31 tetraethylbenzimidazolyl carbocyanine iodide (JC-1), 2,7-dichlorodihydrofluorescein diacetate (H2DCFDA) and the Triglyceride Colorimetric Assay. The expression/activation of kinases was analyzed by means of Western blot. RESULTS: Genistein/17ß-estradiol protected hepatocytes against NAFLD-like medium, by preventing the loss of cell viability and mitochondrial function, triglycerides accumulation and peroxidation. The blocking of kinases, ERs and GPER was able to reduce the above effects, which were potentiated by NLRP3 inflammasome. CONCLUSION: Our findings suggest novel mechanisms underlying the protective effects elicited by phytoestrogens/estrogens against NAFLD/NASH and open novel therapeutic perspectives in the management of NAFLD in postmenopausal women.

Evaluation of quality of life, body image and surgical outcomes of robotic total laparoscopic hysterectomy and sentinel lymph node mapping in low-risk endometrial cancer patients - A Robotic Gyne Club study.

INTRODUCTION: The aims of the study were to evaluate quality of life, cosmetic results and surgical outcomes of robotic single-site and robotic multiport total laparoscopic hysterectomy with sentinel lymph node mapping in women treated for low-risk endometrial cancer. MATERIAL AND METHODS: The study is a prospective, multicenter, case-control study conducted at Ospedale Santa Chiara in Trento and Novara and Pavia University Hospitals. Seventy-six consecutive patients with a biopsy-confirmed diagnosis of low-risk endometrial cancer or atypical endometrial hyperplasia who between January 2017 and January 2019 had undergone robotic total laparoscopic hysterectomy and sentinel lymph node mapping were included. Data on surgical outcomes, quality of life and cosmetic results were prospectively collected and analyzed based on the surgical approach with robotic single-site vs robotic multiport assistance. Patients' clinical characteristics, intra-operative parameters, sentinel lymph node mapping results and postoperative findings were prospectively recorded. Clinical follow up was performed 4 weeks and 6 and 12 months after surgery. Fifty-one patients underwent a robotic multiport procedure and 25 patients a robotic single-site surgery. RESULTS: There was one significant difference between the two groups in terms of patient characteristics: mean body mass index (BMI) in the multiport group was 29 kg/m2 vs 24.8 kg/m2 in the single-site group (P value <.001). After univariate and multivariate analysis on intraoperative and postoperative findings, a shorter surgical time was observed in the single-site cohort than in the multiport group (148.7 vs 158.2 minutes, P value .0182). BMI also had a significant effect on surgical time (P = .022). No differences were seen in terms of sentinel lymph node detection: the bilateral detection rate was 96.1% for multiport (66.7% bilateral, 29.4% monolateral) and 96% for single-site (76% bilateral, 20% monolateral) procedures. No differences between the two approaches were identified with regard to postoperative complications, pain, cosmetic results or quality of life comparisons. CONCLUSIONS: For the treatment of low-risk endometrial cancer and atypical endometrial hyperplasia with total hysterectomy and sentinel lymph node mapping, the robotic single-port approach is comparable to the multiport procedure in terms of intraoperative and postoperative findings, and has an advantage in terms of shorter surgical times. Further studies are required to identify possible differences in quality of life and cosmetic results.

Laparoscopic management of a cornual pregnancy following failed methotrexate treatment: case report and review of literature.

To describe a rare case of a singleton 8-week cornual pregnancy (CP), treated by laparoscopic incision of the uterine wall, the ectopic pregnancy was removed and the uterine site was sutured with interrupted sutures. A 21-year-old woman was admitted for suspected singleton CP at week 8. Clinical examination, b-hCG increase, and transvaginal ultrasonography (TU) were used to monitor the suspected diagnosis of an ectopic pregnancy. Following failure of methotrexate administration, surgeons performed a laparoscopy. The CP removal was performed by laparoscopic incision, enucleating the corneal mass and suturing the uterine site of the ectopic pregnancy with interrupted sutures. Intraoperative and postoperative complications and uterine integrity preservation were studied. Postoperative recovery period was normal, without intraprocedural or postprocedural complications.Uterine integrity was preserved. No further therapeutic interventions were needed in follow-up. This study confirmed the feasibility, safety and efficacy of performing a safe, minimally invasive, laparoscopic treatment of an early unruptured CP, without intraoperative and postoperative complications, with a normal postoperative recovery period and preservation of uterine integrity.

Preeclampsia and intrauterine growth restriction: Role of human umbilical cord mesenchymal stem cells-trophoblast cross-talk.

BACKGROUND: Oxidative stress is involved in the pathogenesis and maintenance of pregnancy-related disorders, such as intrauterine growth restriction (IUGR) and preeclampsia (PE). Human umbilical cord mesenchymal stem cells (hUMSCs) have been suggested as a possible therapeutic tool for the treatment of pregnancy-related disorders in view of their paracrine actions on trophoblast cells. OBJECTIVES: To quantify the plasma markers of peroxidation in patients affected by PE and IUGR and to examine the role of oxidative stress in the pathophysiology of PE and IUGR in vitro by using hUMSCs from physiological and pathological pregnancies and a trophoblast cell line (HTR-8/SVneo). STUDY DESIGN: In pathological and physiological pregnancies the plasma markers of oxidative stress, arterial blood pressure, serum uric acid, 24h proteinuria, weight gain and body mass index (BMI) were examined. Furthermore, the pulsatility index (PI) of uterine and umbilical arteries, and of fetal middle cerebral artery was measured. In vitro, the different responses of hUMSCs, taken from physiological and pathological pregnancies, and of HTR-8/SVneo to pregnancy-related hormones in terms of viability and nitric oxide (NO) release were investigated. In some experiments, the above measurements were performed on co-cultures between HTR-8/SVneo and hUMSCs. RESULTS: The results obtained have shown that in pathological pregnancies, body mass index, serum acid uric, pulsatility index in uterine and umbilical arteries and markers of oxidative stress were higher than those found in physiological ones. Moreover, in PE and IUGR, a relation was observed between laboratory and clinical findings and the increased levels of oxidative stress. HTR-8/SVneo and hUMSCs showed reduced viability and increased NO production when stressed with H2O2. Finally, HTR-8/SVneo cultured in cross-talk with hUMSCs from pathological pregnancies showed a deterioration of cell viability and NO release when treated with pregnancy-related hormones. CONCLUSION: Our findings support that hUMSCs taken from patients affected by PE and IUGR have significant features in comparison with those from physiologic pregnancies. Moreover, the cross-talk between hUMSCs and trophoblast cells might be involved in the etiopathology of IUGR and PE secondary to oxidative stress.

Obstetric outcomes in patients who have undergone excisional treatment for high-grade cervical squamous intra-epithelial neoplasia.

OBJECTIVE: To evaluate the relationships between excisional treatment for high-grade cervical intra-epithelial neoplasia (CIN2+) and obstetric outcomes in terms of preterm delivery risk, premature rupture of membrane (PROM) and type of delivery, and between pre-term delivery and the type of excisional technique (radio frequency excision, laser conization). METHODS: This was a retrospective study of the obstetric outcomes of 2316 women aged 25-45 years who underwent excisional treatment for CIN2+ at the Obstetric and Gynecological Clinic of Ospedale Maggiore della Carità in Novara and at the Obstetric and Gynecological Department of Ospedale Sant'Anna in Torino in the period 2005-2014 and were evaluated until April 2016, and 57,937 untreated women of the same age, from the same centers. RESULTS: After treatment, 320 women had at least one pregnancy leading to delivery after a mean of 3.35 years. Treatment significantly increased the risk of preterm delivery. Compared with no treatment, the risk of preterm birth was higher in women who had undergone treatment (33.13% vs. 6.60%). Techniques removing or ablating more tissue, such as large loop excision of the transformation zone, were associated with worse outcomes (OR 2.96, 95% IC 1.72-5.10). Smoking habits significantly increase the risk of preterm delivery in the treated women (OR 2.82, 95% IC 1.61-4.9). The risk of premature rupture of the membranes (PROM) (40% vs. 23.22%), the risk of preterm PROM (pPROM) (13.13% vs. 2.71%) and dystocic births (18.75% vs 4.48%) were also significantly increased after treatment. Caesarean sections were less frequent among the treated women (15.94% vs. 32.41%). CONCLUSIONS: Our findings reveal a relationship between cervical excisional treatment and pre-term delivery, PROM, and the method of delivery. In order to minimise risk and guarantee the best obstetric outcome, patient treatment and follow-up should be personalised.

Pregnancy-related decidualization of subcutaneous endometriosis occurring in a post-caesarean section scar: Case study and review of the literature.

Endometriosis of surgical scars is a rare complication of caesarean sections (incidence: 0.03-0.4%) and other surgical procedures. As endometriosis could be responsive to hormonal stimulation, decidualization and other secondary changes may occur during pregnancy or progestin therapy, sometimes causing a clinically-evident increase in the size of the endometriotic nodules, which could be mistaken for malignant tumors. To our knowledge, we report the 8th subcutaneous case of a pregnancy-related decidualization occurring in a post-caesarean section scar endometriosis. A 33-year-old woman showed a painless, firm, subcutaneous nodule (size: 1 cm) located near the scar of a caesarean section performed 3 years before. Ultrasound examination revealed a well-delimited, hypoechogenic nodule showing perilesional inflammatory reaction without vascular signals. The nodule was considered a post-surgical granuloma: its size did not increase during 4 years of follow-up. Finally, the nodule was totally excised during a second caesarean section performed at 39 weeks of gestation. Histological examination showed nodules of decidualized stromal cells surrounding rare, small, atrophic endometrial glands. Nuclear atypia and mitoses were absent. On immunohistochemical examination, the epithelial cells were pan-CK(AE1/AE3)+/ER+/PR+/S100-/Calretinin-/Vimentin-, while the stromal cells were pan-CK(AE1/AE3)-/Vimentin+/ER+/PR+/CD10+/S100-/Calretinin-. We reviewed the literature, discussing the main clinic-pathological diagnostic pitfalls and the possible differential diagnoses.

Modulation of Oxidative Stress by 17 ß-Estradiol and Genistein in Human Hepatic Cell Lines In Vitro.

BACKGROUND/AIMS: estrogens and phytoestrogens exert hepatoprotection through mechanisms not clearly examined yet. Here, we investigated the protective effects exerted by 17ß-estradiol and genistein against oxidative stress in hepatocytes and hepatic stellate cells (HSCs) and the involvement of specific receptors and the intracellular signalling. METHODS: Huh7.5 and LX-2, alone or in co-culture with Huh7.5, were treated with 17ß-estradiol and genistein alone or in the presence of menadione and of estrogen receptors (ERs) and G protein-coupled-estrogenic-receptors (GPER) blockers. Cell viability, mitochondrial membrane potential and oxidant/antioxidant system were measured by specific kits. Western Blot was used for the analysis of Akt and p38-mitogen-activated-protein kinases (MAPK) activation and α-smooth-muscle actin expression. RESULTS: In Huh7.5, 17ß-estradiol and genistein prevented the effects of peroxidation by modulating Akt and p38MAPK activation. Similar antioxidant and protective findings were obtained in LX-2 of co-culture experiments, only. ERs and GPER blockers were able to prevent the effects of 17ß-estradiol and genistein. CONCLUSION: In Huh7.5 and LX-2, 17ß-estradiol and genistein counteract the effects of peroxidation through the involvement of ERs and GPER and by an intracellular signalling related to Akt and p38MAPK. As concerning LX-2, paracrine factors released by Huh7.5 play a key role in protection against oxidative stress.

Laparoscopic Nerve-Preserving Sacropexy.

STUDY OBJECTIVE: To demonstrate our developed nerve-preserving technique during laparoscopic sacropexy (LSP) for multicompartment pelvic organ prolapse. DESIGN: A step-by-step demonstration of our surgical procedure on video (Canadian Task Force classification II-2). Informed consent was obtained from the subject, and the applicable Institutional Review Board provided approval. SETTING: Although sacropexy does remain the 'gold standard' procedure for apical prolapse [1], the subjective outcome of the procedure has been reported to be not so satisfactory as its anatomic outcome [2]. New onset bowel symptoms have been observed with voiding and sexual dysfunctions [3]. Published data revealed a correlation between iatrogenic denervation during LSP and postoperative dysfunctions [4-6]. We adopted a nerve-preserving approach with the aim of reducing the iatrogenic morbidity. INTERVENTIONS: Our surgical nerve-preserving LSP technique from the promontory down to the right uterosacral ligament and the rectovaginal space proceeds in 3 steps: Step 1: Opening the peritoneum. The peritoneum is opened just medial to the right common iliac artery, approximately 20 to 30 mm above the sacral promontory, allowing a safe approach in an area far from nerves and vascular structures. Peritoneal incision is extended toward the promontory. The underlying presacral fascia containing the right hypogastric nerve (rHN) is identified and incised longitudinally. The presacral fascia and the rHN are then pushed medially to expose the longitudinal anterior vertebral ligament; the finding of the middle sacral veins represents the limit of any further medial dissection. Opening and displacement of the prevertebral fascia are not mandatory. Step 2: Opening the peritoneum of the right pelvic sidewall, respecting the integrity of the presacral fascia and of the rHN contained within it. An inverted L-shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament is completed, with care taken to preserve the rHN identified previously. In proximity to the uterus, the dissection line crosses the upper edge of the right uterosacral ligament at its proximal third and extends medially. The rectovaginal space is opened and joined to the peritoneal tunnel with a section of the superficial layer of the right uterosacral ligament, preserving its deep nervous portion. Step 3: Dissection of the rectovaginal space, respecting the integrity of the rectal fascia. The rectovaginal space is fully dissected, and at its caudal edge the dissection is carried out laterally to the rectum upward to identify the pelvic parietal fascia covering the levator ani muscle, in the middle to the cranial edge of the perineal body. Preservation of the rectal fascia prevents possible injury to the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which runs close to the pelvic floor. The complete dissection of the rectovaginal space appears in an inverted V-shaped space covering approximately two-thirds of the posterior vaginal wall, with the apex at the convergence of the uterosacral ligaments. The procedure is completed with dissection of the vesicovaginal space through the creation of an avascular triangular-shaped space with the apex at the dorsal end of the bladder trigone and laterally limited by the superficial vascular layer of the vesicouterine ligaments. The bladder branches of the inferior hypogastric plexus run far from the surgical field in the deep portion of the vesicouterine ligaments. CONCLUSION: A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps, which allow the surgeon to visualize all of the nerve pathways and potentially dangerous anatomic structures.

Robotic-Assisted Conservative Excision of Retrocervical-Rectal Deep Infiltrating Endometriosis: A Case Series.

Deep infiltrating endometriosis (DIE) is a complex disease that impairs the quality of life and the fertility of women. Colorectal DIE accounts for 70% to 93% of all the intestinal endometriotic sites and frequently needs a surgical approach. However, the indications for the surgical management of this condition are still controversial. From March 2010 to June 2014, we scheduled 33 consecutive patients presenting with retrocervical-rectal DIE of any diameter not involving the mucosa nor producing rectal stenosis >50% for laparoscopic robotic-assisted nerve-sparing rectal nodulectomy (LRN). All patients were examined preoperatively, at 3 months and 6 months postoperatively, and yearly thereafter. Dysmenorrhea, dyschezia, dyspareunia, and dysuria were evaluated on a 10-point visual analog scale. Among the 33 enrolled patients, 31 (93.9%) fulfilled the selection criteria and were submitted to LRN. In 1 out of 31 available patients (3.2%), a segmental bowel resection was considered necessary for prudential purpose at the end of the nodulectomy procedure. No laparotomic conversion was performed in any case. A wide variety of associated surgical procedures were performed in 25 of 30 patients (83.3%). No intraoperative complications were observed. One grade 3b and 2 grade 1 postoperative complications were recorded. The mean larger axis of the excised nodules measured on the formalin-fixed specimen was 26.4 mm. We found significant improvements in patient symptoms at a 3-month follow-up which persisted over the time. We observed 2 (6.7%) recurrences of intestinal endometriosis and 1 (3.3%) recurrence of chronic pelvic pain without clinical and/or radiologic evidence of endometriotic lesions. The mean follow-up time was 27.6 months. We believe that LRN is feasible and safe and shows promising results in terms of radicality, anatomic recurrence rate, and pain recurrence rate for treating isolated retrocervical-rectal DIE not involving the mucosa, without limiting this procedure to nodules smaller than 3 cm.

Intraoperative radiotherapy in gynaecological and genito-urinary malignancies: focus on endometrial, cervical, renal, bladder and prostate cancers.

Intraoperative radiotherapy (IORT) refers to the delivery of a single radiation dose to a limited volume of tissue during a surgical procedure. A literature review was performed to analyze the role of IORT in gynaecological and genito-urinary cancer including endometrial, cervical, renal, bladder and prostate cancers.Literature search was performed by Pubmed and Scopus, using the words "intraoperative radiotherapy/IORT", "gynaecological cancer", "uterine/endometrial cancer", "cervical/cervix cancer", "renal/kidney cancer", "bladder cancer" and "prostate cancer". Forty-seven articles were selected from the search databases, analyzed and briefly described.Literature data show that IORT has been used to optimize local control rate in genito-urinary tumours mainly in retrospective studies. The results suggest that IORT could be advantageous in the setting of locally advanced and recurrent disease although further prospective trials are needed to confirm this findings.

Beyond sentinel node algorithm. Toward a more tailored surgery for cervical cancer patients.

Nowadays cervical cancer is frequently diagnosed at early stage. For these patients lymph node metastasis (LNM) is considered the most important prognostic factor. During the last decade many efforts have been made to reduce rate of complications associated with lymphadenectomy (LND). A great interest has arisen in sentinel lymph node (SLN) biopsy as a technique able to decrease number of LND performed and, at the same time, to assess lymph nodal status. High diagnostic performances have been reached thanks to SLN surgical algorithm. However, despite the efforts, about 25% of these patients undergo at least unilateral LND to meet NCCN recommendations. Data of women with International Federation of Gynecology and Obstetrics stage IA1-IB1/IIA1 cervical carcinoma were retrospectively collected by six Italian institutions. All patients underwent complete preoperative staging workup and were primarily treated by radical hysterectomy and pelvic bilateral LND. A total of 368 patients with early-stage cervical cancer were identified. Among them 333 (90.5%) showed no suspicious enlarged nodes at the preoperative magnetic resonance imaging (MRI). In this subset, tumor diameter ≥20 mm was the only independent predictor of LN status (P = 0.003). None of the 106 patients with negative MRI nodal assessment, with squamous and adenosquamous histotype and a tumor diameter less than 2 cm had LNM. Based on these results we propose a new modified SLN surgical algorithm that could safely reduce LND performed in patients with very low-risk early-stage cervical cancer.