Exploring Epithelial-Mesenchymal Transition Signals in Endometriosis Diagnosis and In Vitro Fertilization Outcomes.

Endometriosis (EMS) pathogenesis has been related to the release of inflammatory mediators in peritoneal fluid, creating an altered microenvironment that leads to low-grade oocyte/embryos and to the reduction of implantation rates. The Epithelial-Mesenchymal Transition (EMT), an inflammation-related process, can be a further contributing factor to EMS. This study aimed to investigate, among various cytokines and EMT markers (Cadherins, TGF-ß, HIF-1α), diagnostic markers of EMS and prognostic factors of in vitro fertilization (IVF) outcomes. Herein, EMS patients manifested higher serum levels of the inflammatory molecules IL-6, IL-8, and IL-12 and a decrease in the concentrations of the anti-inflammatory IL-10. Moreover, biochemical markers associated with the EMT process were more elevated in serum and follicular fluid (FF) of EMS patients than in controls. At the end, the number of good-quality embryos was inversely related to serum IL-6 and EMT markers. Interestingly, serum IL-6 and FF IL-10 concentrations differentiated EMS patients from controls. Finally, serum IL-8 and E-Cadherin levels, as well as FF IL-10, predicted positive IVF outcome with great accuracy. Our data confirm the pivotal role of inflammatory mediators (i.e., IL-6 and IL-10) in EMS pathogenesis and suggest that EMT-related markers are elevated in EMS patients and can be predictive of IVF outcome.

Clinical Use of Indocyanine Green in Bowel Endometriosis Surgery.

STUDY OBJECTIVE: To show feasibility of using indocyanine green (ICG) in endometriosis surgery, especially bowel endometriosis shaving, and to discuss its potential benefits. DESIGN: Stepwise demonstration of this technique with narrated video footage. SETTING: Endometriosis is a common benign chronic disorder, characterized by the presence of endometrial tissue outside the uterus. Deep infiltrating endometriosis (DIE) represents the most aggressive presentation. Robot-assisted laparoscopy represents an important innovation and has opened new perspectives for the treatment of endometriosis, offering numerous advantages especially in the most complex procedures, particularly when extragenital endometriosis diffusely involves pelvic structures including the bowel and the urinary tract [1]. Endometriosis affects the bowel in 30% of DIE cases, and it is usually associated with ovarian and ureteral involvement; therefore, a multidisciplinary team with both general and gynecologic surgeons is required. The goal of endometriosis surgery in these cases is to obtain long-term outcomes without compromising intestinal function. One possible treatment is laparoscopic shave excision, which consists of dissection, keeping it as superficial as possible to avoid compromising bowel integrity [2]. Recent studies have shown that ICG can be useful to evaluate the size and depth of penetration of lesions during endometriosis surgery to understand shaving excision and to prevent a major iatrogenic intestinal complication [3-7]. INTERVENTIONS: Total robot-assisted laparoscopic approach to a DIE case with adnexal, uterine, and intestinal endometriosis, with the presence of a nodular rectal lesion. The excision consisted of several key strategies to minimize iatrogenic rectal injury: CONCLUSION: The approach to DIE, particularly rectal endometriotic lesions, could be more accurate with ICG evaluation of vascular pertinence, in attempt to evaluate shaving feasibility of lesions in endometriosis laparoscopic robotic surgery.

Comparison of perioperative outcomes and technical features using da Vinci Si and Xi robotic platforms for early stages of endometrial cancer.

We directly compared perioperative outcomes and technical features between previous da Vinci Si and the newer Xi robotic platform during total hysterectomy plus salpingo-oophorectomy with or without lymphadenectomy for early-stage endometrial cancer. We retrospectively analyzed147 patients with histological confirmation of endometrial carcinoma stage IA: grade 1-2, 3 and stage IB: grade 1-2 who underwent surgery with da Vinci Si or Xi system between January 2016 and December 2018. Perioperative data, technical features and postoperative complications were considered. 91 patients underwent surgery with the Si system and 56 with the Xi system. Docking time using the Xi system was significantly shorter (p < 0.002), while overall operating time was similar. There were no significant differences in the number of harvested lymph nodes, conversion rate, mean hospital stay, complications, and technical aspects between the two groups. Our study detected similar perioperative outcomes and the trend toward shorter docking and operating time for Xi over Si robot.

COH outcomes in breast cancer patients for fertility preservation: a comparison with the expected response by age.

PURPOSE: Breast cancer is the most common cancer diagnosed during childbearing age, and fertility preservation is becoming increasingly more essential. However, recent studies indicate a possible poorer response to controlled ovarian hyperstimulation (COH) in cancer patients than in non-cancer controls and a negative impact of BRCA mutations on female fertility. This study aims to evaluate ovarian response and the number of mature oocytes (MII) vitrified in women with breast cancer, with or without BRCA mutation, comparing them to the expected response according to an age-related nomogram. METHODS: This is a retrospective observational study involving sixty-one breast cancer patients who underwent COH for oocyte cryopreservation. The age-specific nomogram was built using 3871 patients who underwent COH due to oocyte donation, fertility preservation for non-medical reasons, or FIVET for male factor exclusively. RESULTS: The mean number of oocytes retrieved was 13.03, whereas the mean number of MII oocytes was 10.00. After the application of the z-score, no statistically significant differences were found compared with the expected response in the general population, neither by dividing patients according to the presence or absence of BRCA mutation nor according to the phase in which they initiated stimulation. CONCLUSION: The results obtained do not support the notion of a negative impact of the BRCA mutation on the ovarian response of women with breast cancer. Women with breast cancer undergoing COH for fertility preservation can expect the ovarian response predicted for their age.

Effect of d-chiro-inositol and alpha-lipoic acid combination on COH outcomes in overweight/obese PCOS women.

Insulin resistance (IR) plays a central role in the onset of polycystic ovary syndrome (PCOS). Insulin so insulin-sensitizing like inositols have been proposed as first line therapy. Among them d-chiro-inositol (DCI) seems to improve glucose metabolism and to increase ovulation frequency. Other studies have demonstrated that alpha-lipoic acid (ALA), with its antioxidant role, can also improve endocrine and metabolic profile of PCOS patients especially with familial diabetes. This a retrospective observational study with the aim to evaluate possible advantages of an integrative preparation combining DCI 500 mg and ALA 300 mg in overweight/obese PCOS patients with or without diabetic relatives who underwent IVF. Twenty PCOS patients who were taking the integrative preparation underwent controlled ovarian hyperstimulation in our center. The group with diabetic relatives tended to have a lower dose of gonadotropin, shorter stimulation days, higher number of MII oocytes, and higher number of fertilized oocytes. A combined regimen of DCI and ALA could be an interesting strategy in overweight PCOS patients with familial diabetes underwent ART.

Simulation as tool for evaluating and improving technical skills in laparoscopic gynecological surgery.

BACKGROUND: Simulation in laparoscopic surgery is nowadays recognized as a valid instrument for learning and training surgeons in different procedures. However, its role as evaluation test and self-assessment tool to verify basic surgical skills is still under discussion. METHODS: Thirty-three residents in obstetrics and gynecology at University of Pisa, Italy were recruited, and they received a simulation program consisting of 5 tasks. They had to perform basic laparoscopic surgery maneuvers as creating pneumoperitoneum, positioning trocars under vision, demonstrating the appropriate use of dominant and non-dominant hand and making single stitch and knot. They were evaluated with a modified OSATs scale. RESULTS: Senior trainees had better score than junior trainees (p value< 0,005) and after different sessions of simulation scores of both groups significantly improved (p < 0,001), especially for the junior group. All the trainees reported self-assessments that matched with the evaluation of external observers demonstrating the importance of simulation also as auto-evaluation test. CONCLUSIONS: In this study, we demonstrated the role of simulation as powerful tool to evaluate and to self-assess surgical technical skills and to improve own capacities, with the use of a modified OSATs scale adapted to specific exercises.

Role of robotic surgery on pelvic floor reconstruction.

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.

Robotic Approach to Ureteral Endometriosis: Surgical Features and Perioperative Outcomes.

Introduction: Surgical treatment of ureteral endometriosis is necessary to relieve urinary symptoms of obstruction and to preserve renal function. Which surgical approach to ureteral endometriosis should be considered the most appropriate is debated, due to the lack of scientific evidence. The aim of the present study is to assess the feasibility and to describe the perioperative outcomes of minimally invasive treatment of deep ureteral endometriosis using robotic assistance, highlighting the technical benefits and the limits of this approach. Method: A case-series including 31 consecutive patients affected by high-stage endometriosis including ureteral endometriosis using robotic assistance in our Department between November 2011 and September 2017. Results: All procedures were successfully completed by robotic technique, resulting in full excision of the parametrial nodules involving the ureter. Mean operating time was 184.8 ± 81 min. Mean hospital stay was 4.02 ± 3 days. Perioperative complications occurred in five patients and 4 out of 5 involved the urinary tract. Conclusions: Robotic surgery for deep infiltrating endometriosis of the ureter was feasible and allowed complete resection of ureteral nodules in all cases. No intraoperative complications arose, but a non-negligible rate of urinary tract complications was detected. This calls for a careful assessment of the benefits and specific risks associated with the use of robotic surgery for the treatment of deep infiltrating endometriosis of the ureter.