Uterine smooth muscle tumors: a multicenter, retrospective, comparative study of clinical and ultrasound features.

OBJECTIVE: To evaluate a wide range of clinical and ultrasound characteristics of different uterine smooth muscle tumors to identify features capable of discriminating between these types. METHODS: This was a retrospective, multicenter study that included 285 patients diagnosed with uterine smooth muscle tumors (50 leiomyosarcomas, 35 smooth muscle tumors of uncertain malignant potential, and 200 leiomyomas). The patients were divided into three groups based on the histological type of their tumors, and the groups were compared according to the variables collected. RESULTS: Leiomyosarcomas were more common in older and post-menopausal women. Compared with leiomyomas, smooth muscle tumors of uncertain malignant potential and leiomyosarcomas had similar ultrasound features such as absence of normal myometrium, multilocular appearance, hyper-echogenicity in case of uniform echogenicity, absence of posterior shadows, echogenic areas, and hyperechoic rim. Leiomyosarcomas were larger, had more cystic areas, and were associated with a higher prevalence of pelvic free fluid. Smooth muscle tumors of uncertain malignant potential were characterized by a higher frequency of International Federation of Gynecology and Obstetrics (FIGO) type 6-7, the absence of internal shadows, and, in the case of cystic area, the presence of a regular internal wall. Tumor outline varied among the three histological types. A color score of 1 was typical of leiomyoma, a color score 2 was mainly observed in leiomyomas and smooth muscle tumors of uncertain malignant potential, a color score 3 did not differ among the tumors, while a color of score 4 was related to leiomyosarcomas. When combining color scores 3 and 4, leiomyosarcomas and smooth muscle tumors of uncertain malignant potential showed a high percentage of both circumferential and intra-lesional vascularization. A cooked appearance was not statistically different among the tumors. CONCLUSIONS: Based on our findings, specific ultrasonographic features as well as age and menopausal status are associated with different uterine smooth muscle tumor types. Integration of these data can help the pre-operative assessment of these lesions for proper management.

Immune Checkpoints in Recurrent Pregnancy Loss: New Insights into a Detrimental and Elusive Disorder.

Recurrent pregnancy loss (RPL) refers to two or more miscarriages before 20 weeks gestation. Its prevalence is 1-2%; its pathogenesis remains unexplained in more than 50% of cases, in which the cause is thought to be abnormal immune activity during placentation leading to a lack of pregnancy-induced immune tolerance. It is unknown whether immune activity is deranged in the endometrium of women with RPL. We studied the gene expression and the quantitative tissue protein levels of three immune checkpoints (CD276, which enhances cytotoxic T-cell activity, cytotoxic T-lymphocyte-associated antigen-4 [CTL-4], which reduces Th1 cytokine production, and lymphocyte activation gene-3 [LAG-3], which shows suppressive activity on Tregs and CD4+ T-cells) in endometrial samples from 27 women with unexplained RPL and in 29 women with dysfunctional uterine bleeding and previous uneventful pregnancies as controls. RNA isolation, real-time PCR, protein isolation, and ELISA were performed. CD276 gene expression and protein tissue levels were significantly lower in the endometrium of the RPL group than in the controls, whereas both CTL-4 and LAG-3 were significantly higher. This difference suggests defective endometrial immune regulation and overactivation of immune response in women with a history of RPL, at least in relation to controls with dysfunctional uterine bleeding and previous normal reproductive history.

Conservation finance: What are we not doing? A review and research agenda.

Conservation finance embraces a series of innovative financing mechanisms aimed at raising and managing capital to be used for the conservation of biodiversity. The climate emergency and the pursuit of sustainable development underline the criticality of financial support for achieving this goal. Funding for the protection of biodiversity, in fact, has long been disbursed by governments in a residual form, only after they have dealt with social needs and political challenges. To date, the main challenge of conservation finance is to identify solutions that not only generate new revenue for biodiversity, but also effectively manage and allocate existing funding to provide a mix of social and community benefits as well. The paper, therefore, aims to act as a wake-up call, urging academics working in economics and finance to turn their attention to resolving the financial problems faced by conservation. Through a comparative bibliometric analysis, the study aims to outline the structure of scientific research on the topic of conservation finance, to understand the state of the art, and to identify open questions and new research trends. The results of the study show that the topic of conservation finance is currently a prerogative of scholars and journals of ecology, biology and environmental sciences. Finance scholars pay very little attention to the topic and yet there are many opportunities/needs for future research. The results are of interest to researchers in banking and finance, policy-makers and managers.

Clinical and Histopathological Predictors of Recurrence in Uterine Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Multicenter Retrospective Cohort Study of Tertiary Centers.

BACKGROUND: The term uterine smooth muscle tumor of uncertain malignant potential (STUMP) indicates a rare, equivocal entity between benign leiomyomas and leiomyosarcomas. In the present study, we evaluated a comprehensive range of clinical, surgical, and pathological features in a large multicenter series of patients with STUMP to identify risk factors for recurrence. METHODS: This is a retrospective study performed by collecting consecutive cases diagnosed between January 2000 and December 2020 in five tertiary centers. Associations between STUMP recurrence and clinicopathological characteristics as well as surgical treatment modality were investigated. RESULTS: Eighty-seven patients affected by STUMP were considered. Of them, 18 cases (20.7%) recurred: 11 as leiomyosarcoma (LMS) and 7 as STUMP. The mean time to recurrence was 79 months. We found that fragmentation/morcellation, epithelioid features, high mitotic count, Ki-67 value > 20%, progesterone receptor (PR) < 83%, and p16 diffuse expression were associated with higher risk of recurrence and shorter recurrence-free survival (RFS). Furthermore, morcellation/fragmentation and mitotic count remained independent risk factors for recurrence and shorter RFS after multivariate analysis, while the presence of epithelioid features was an independent risk factor for recurrence only. CONCLUSIONS: Our results suggest that morcellation is associated with risk of recurrence and shorter RFS, thus it should be avoided if a STUMP is suspected preoperatively. Epithelioid features, high proliferation activity, low PR expression, and diffuse p16 expression are also unfavorable prognostic factors, so patients presenting these features should be closely followed up.

Obstetric and neonatal outcomes after SARS-CoV-2 infection in the first trimester of pregnancy: A prospective comparative study.

OBJECTIVE(S): This prospective observational cohort study aimed to evaluate whether women with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during the first trimester of pregnancy are at higher risk of adverse obstetric and neonatal outcomes compared to negative patients. STUDY DESIGN: Seromolecular testing for SARS-CoV-2 was performed at 12, 16, 21 weeks, and at delivery; the cohort was then subdivided into a first-trimester SARS-CoV-2-positive (case) group and a SARS-CoV-2-negative (control) group. The primary outcome was a composite adverse obstetric outcome, defined as the presence of either abortion, preterm delivery, preterm prelabor rupture of membranes, preeclampsia, intrauterine growth restriction, stillbirth; and a composite measure of adverse neonatal events, including either 1- and 5-min Apgar score ≤ 7, neonatal intensive care unit admission and congenital birth defects. Maternal symptoms and antibody titer were secondarily assessed. RESULTS: A total of 17 of 164 women tested positive for SARS-CoV-2 (10.3%) in the first trimester. One SARS-CoV-2-positive patient who gave birth at another hospital was excluded. Composite adverse obstetric outcome was observed in 6.2% (1/16) SARS-CoV-2-positive and 10.5% (11/105) SARS-CoV-2-negative women; composite adverse neonatal outcome in 12.5% (2/16) and 7.6% (8/105), respectively. In the newborns of women who had developed IgG antibodies, the same antibodies were detected in arterial cord blood and the nasopharyngeal swab tested negative for SARS-CoV-2. No maternal pneumonia or hospital admission due to coronavirus disease-19 were recorded. CONCLUSION: Asymptomatic or mildly symptomatic women during the first trimester of pregnancy did not experience significantly more adverse events than SARS-CoV-2-negative women.

Quinagolide Treatment Reduces Invasive and Angiogenic Properties of Endometrial Mesenchymal Stromal Cells.

Endometrial mesenchymal stromal cells (E-MSCs) extensively contribute to the establishment and progression of endometrial ectopic lesions through formation of the stromal vascular tissue, and support to its growth and vascularization. As E-MSCs lack oestrogen receptors, endometriosis eradication cannot be achieved by hormone-based pharmacological approaches. Quinagolide is a non-ergot-derived dopamine receptor 2 agonist reported to display therapeutic effects in in vivo models of endometriosis. In the present study, we isolated E-MSCs from eutopic endometrial tissue and from ovarian and peritoneal endometriotic lesions, and we tested the effect of quinagolide on their proliferation and matrix invasion ability. Moreover, the effect of quinagolide on E-MSC endothelial differentiation was assessed in an endothelial co-culture model of angiogenesis. E-MSC lines expressed dopamine receptor 2, with higher expression in ectopic than eutopic ones. Quinagolide inhibited the invasive properties of E-MSCs, but not their proliferation, and limited their endothelial differentiation. The abrogation of the observed effects by spiperone, a dopamine receptor antagonist, confirmed specific dopamine receptor activation. At variance, no involvement of VEGFR2 inhibition was observed. Moreover, dopamine receptor 2 activation led to downregulation of AKT and its phosphorylation. Of interest, several effects were more prominent on ectopic E-MSCs with respect to eutopic lines. Together with the reported effects on endometrial and endothelial cells, the observed inhibition of E-MSCs may increase the rationale for quinagolide in endometriosis treatment.

The "scar" of a pandemic: Cumulative incidence of COVID-19 during the first trimester of pregnancy.

Congenitally- or perinatally-acquired viral infections can be harmful to the fetus but data are limited about prevalence and outcomes of coronavirus disease 2019 (COVID-19) disease during the first trimester of pregnancy. We report epidemiologic data from a study investigating a cohort of women who became pregnant just before or during the COVID-19 pandemic. We recruited 138 consecutive pregnant women attending for first trimester screening (11-13 weeks of gestation) at Sant'Anna Hospital, Turin, Piedmont, Italy, during the plateau and the falling phase of the COVID-19 epidemic curve. Patients were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) immunoglobulin M/immunoglobulin G antibody levels and SARS-CoV-2 detection in sera and nasopharyngeal swab samples. COVID-19 cumulative incidence during the first trimester was of 10.1% with high prevalence of asymptomatic patients (42.8%). Similar to the course of the disease in non pregnant adults, 80% to 90% of infections were not severe.The prevalence of reported symptoms was four-fold higher in SARS-CoV-2 positive patients (57%) than in those negative (13%) (P < .001), suggesting that direct self-testing should open doors to confirmatory testing for COVID-19. Our findings support the need for COVID-19 screening in early pregnancy in epidemic areas to plan materno-fetal health surveillance programs.

Coronavirus disease 2019 and first-trimester spontaneous abortion: a case-control study of 225 pregnant patients.

BACKGROUND: The disease caused by the severe acute respiratory syndrome coronavirus 2 was named coronavirus disease 2019 and classified as a global public health emergency. The evidence related to the impact of coronavirus disease 2019 on pregnancy is limited to the second and third trimester of pregnancy, whereas data on the first trimester are scant. Many viral infections can be harmful to the fetus during the first trimester of pregnancy, and whether severe acute respiratory syndrome coronavirus 2 is one of them is still unknown. OBJECTIVE: With this study, we evaluated severe acute respiratory syndrome coronavirus 2 infection as a risk factor for early pregnancy loss in the first trimester of pregnancy. Furthermore, coronavirus disease 2019 course in the first trimester was assessed. STUDY DESIGN: Between February 22 and May 21, 2020, we conducted a case-control study at S. Anna Hospital, Turin, among pregnant women in their first trimester, paired for last menstruation. The cumulative incidence of coronavirus disease 2019 was compared between women with spontaneous abortion (case group, n=100) and those with ongoing pregnancy (control group, n=125). Current or past infection was determined by the detection of severe acute respiratory syndrome coronavirus 2 from nasopharyngeal swab and severe acute respiratory syndrome coronavirus 2 immunoglobulin G and immunoglobulin M antibodies in a blood sample. Patient demographics, coronavirus disease 2019-related symptoms, and the main risk factors for abortion were collected. RESULTS: Of 225 women, 23 (10.2%) had a positive test result for coronavirus disease 2019. There was no difference in the cumulative incidence of coronavirus disease 2019 between the cases (11/100, 11%) and the controls (12/125, 9.6%) (P=.73). Logistic regression analysis confirmed that coronavirus disease 2019 was not an independent predictor of early pregnancy loss (odds ratio, 1.28; confidence interval, 0.53-3.08). Coronavirus disease 2019-related symptoms in the first trimester were fever, anosmia, ageusia, cough, arthralgia, and diarrhea; no cases of pneumonia or hospital admission owing to coronavirus disease 2019-related symptoms were recorded. No difference in the incidence of symptoms was noted between the 2 groups. CONCLUSION: Severe acute respiratory syndrome coronavirus 2 infection during the first trimester of pregnancy does not seem to predispose to early pregnancy loss; its cumulative incidence did not differ between women with spontaneous abortion and women with ongoing pregnancy. Coronavirus disease 2019 appears to have a favorable maternal course at the beginning of pregnancy, consistent with what has been observed during the second and third trimesters.

A Fascial Reinterpretation of the Classical Female Pelvic Surgical Anatomy: Seeing Things from a Different Angle.

STUDY OBJECTIVE: The classical surgical anatomy of the female pelvis was born with radical hysterectomy [1] and focused on the pivotal role of the lateral parametrium, a conceptually complex structure, an artifact of surgical anatomy [2] without which the whole classical model would collapse. Here, using natural planes, we tried to simplify the puzzle of the virtual spaces surrounding this structure [3,4]. With the aim of better conceptualizing the classical model of the female pelvic surgical anatomy, we broadened its perspective, which had been narrowly focused on the historic gynecologic setting, by developing a comprehensive model of pelvic retroperitoneal compartmentalization. This dissection was based on the invariable anatomic (fasciae) rather than the surgical-anatomic (parametrium) structures and aimed at providing a holistic, more user-friendly approach intended for surgical and educational purposes [5]. Because each compartment has its own surgical function (hence the name), the excavation of a single compartment may be used as a rational guide to tailor surgery to the site of the pathologic condition to be treated or the type of procedure required, whereas the compartments' sequential development may be useful in planning surgical strategies. Redefining the classical model according to the anatomic fascial planes of dissection potentially allows for an intrinsic surgical reproducibility, minimizing dissective bias. A reinterpretation of the known anatomy is required to enhance education. The breaking down of such a complex system (the pelvis) into smaller parts (compartments) will hopefully provide a useful guide for conceptualization and navigation; surgical navigation requires a holistic mental map and a few invariable anatomic reference points or landmarks. DESIGN: A step-by-step laparoscopic demonstration of the fascial model, developed on a fresh frozen female pelvis, and its correlation with the classical female retroperitoneal surgical anatomy. SETTING: Cadaver Laboratory, Department of Legal Medicine, University of Turin. INTERVENTIONS: The first part of the video shows the progressive development of the 3 hemicompartments in the right hemipelvis and of the fourth median compartment after the identification of 3 invariable anatomic reference points: the obliterated umbilical artery, the ureter, and the sacrouterine ligament as superficial landmarks of 3 deeper fascial-ligamentous structures: the umbilicovesical fascia, the urogenital-hypogastric fascia, and the sacropubic ligament, respectively (Figure 1). The areas delimited by the aforementioned deep fascial ligamentous structures have been designated as compartments: • the right parietal hemicompartment, so called because it is bordered by the sidewall of the pelvis, lateral to the umbilicovesical fascia • the right vascular hemicompartment, so called because of the presence of the internal iliac vessel's visceral branches between the umbilicovesical fascia and the urogenital-hypogastric fascia • the visceral compartment, so called because it contains the pelvic organs between the sacropubic ligaments • the right neural hemicompartment, so called because of the presence of the organ-specific vegetative bundles, medial to the urogenital-hypogastric fascia. The second part of the video describes the retrorectal, presacral, and retropubic connection areas between the neural, vascular, and parietal hemicompartments of each hemipelvis, justifying their overall crescent shape. Finally, the spaces of classical surgical anatomy included in each hemicompartment are listed not only according to their anatomic criterion, but also according to their functional criterion. In fact, the parietal compartment should be developed for the evaluation of the pelvic lymph node status or during exenterative and urogynecologic procedures. The vascular compartment must be prepared when sectioning of the vascular visceral pedicles at their origin is required. Development of the neural compartment is required whenever visceral neural components are to be spared. The visceral compartment has to be developed for complete organ mobilization and exposure. CONCLUSION: Taken as a whole, our 4-compartment model of pelvic anatomic surgery is intended for use in planning and optimizing surgical strategies. Moreover, it is potentially able to simplify surgical teaching and training, allowing the fitting together of puzzle-like pieces of disjointed organ-specific retroperitoneal spaces according to their function (Figure 2). The correlation of this approach to clinical outcomes is still being determined.

Knowledge of Vulvar Anatomy and Self-examination in a Sample of Italian Women.

OBJECTIVE: The aim of the study was to investigate the knowledge of vulvar anatomy and vulvar self-examination (VSE) in a sample of Italian women attending a gynecology clinic. METHODS: For this original research from May to July 2019, 512 women attending the Lower Genital Tract Clinic at the Department of Surgical Sciences of the University of Torino were invited to participate in a 29-question survey about vulvar anatomy, VSE, and sociodemographic details. Data were analyzed using descriptive statistics. RESULTS: Of 512 patients, 500 completed the questionnaire (98% response rate). The mean age of respondents was 41 years (range = 17-77 years). Education level was evenly distributed between elementary, high school, and university graduates. Only 15% of interviewed women were able correctly sketching vulvar anatomy. Seventy-six percent of the women had not heard about VSE, and 61% of the women approach their genitalia with feelings of shame and embarrassment. Only 23% of the women would seek medical advice after identification of possible abnormalities during VSE. A majority (69%) of the women would like to have more information about VSE and vulvar health through educational videos and social media. CONCLUSIONS: Education about VSE may lead to earlier diagnosis of vulvar cancers and other pathologies. Further efforts are needed to disperse information about normal external female genital anatomy and VSE to achieve self-confidence among women.

Risk of HPV-related extra-cervical cancers in women treated for cervical intraepithelial neoplasia.

BACKGROUND: The aim was to estimate the risk of subsequent extra-cervical Human Papillomavirus (HPV) related cancer in patients surgically treated for high grade cervical intraepithelial neoplasia (CIN 2-3). This is the first study in Italy investigating the occurrence of extra-cervical tumors in this cohort of patients. METHODS: 3184 patients surgically treated for CIN2-3 since 1992 at the Department of Surgical Sciences of University of Torino were considered. The risk of HPV-related cancer was calculated as Standardized Incidence Ratio (SIR), using as expected values tumour age specific incidence of resident population. RESULTS: 173 second primary cancer (SCPs) were identified. SIR to develop cancer after treatment for CIN2-3 was 2.2 (CI 95% 1.89-2.50). Among these occurrences, 10 are in HPV related sites: 1 anus (SIR = 1.8; 0.04-10.0), 3 vagina (SIR = 12.4; 2.56-36.3), 1 vulva (SIR = 1.7; 0.04-9.59), 5 oropharynx (SIR = 8.5; 2.76-19.8). Significant risk has been also recorded for pulmonary (SIR = 3.1; 0.70-5.27) and bladder (SIR = 4.05; 1.10-10.56), with smoking as possible cofactor. We also found increased risk for breast (SIR = 2.4; 2.07-2.84) and ovarian cancers (SIR = 2.1; 1.13-3.49), probably due to an higher adherence to spontaneous and programmed screening programs. CONCLUSIONS: Our study supports the hypothesis of an increased risk of HPV-related tumours for CIN treated patients, mostly for CIN3. It is conceivable the need of early diagnosis for these cancers in this higher-risk populations.

Psychosocial factors associated with postpartum psychological distress during the Covid-19 pandemic: a cross-sectional study.

BACKGROUND: Trauma, natural and man-made catastrophic events can be predictors of postpartum psychological distress. In a public health response due to coronavirus disease 2019 outbreak, the Italian government imposed a lockdown from March 9 to May 3. This extraordinary situation may have been challenging for maternal psychological health. The aim of this study was to investigate the prevalence of depressive and post-traumatic stress symptoms in women giving birth during the Covid-19 pandemic and its associations with quarantine measures, obstetrical factors, and relational attachment style. METHODS: Women who gave birth in a high-volume obstetric/gynaecological medical centre located in an epidemic area during the Covid-19 pandemic (March 8 to June 15) were asked to complete an online survey about their childbirth experience and the perceived effect of the pandemic. The Edinburgh Postnatal Depression Scale (EPDS), the Impact of Event Scale-Revised (IES-R), and the Relationship Questionnaire (RQ) were administered to assess levels of postpartum depressive and post-traumatic stress symptoms (PTSS) and relational style of attachment, respectively. Multivariate analysis was applied to identify associations between quarantine measures, childbirth experience, attachment style, and EPDS and IES-R scores. RESULTS: The survey was completed by 163 women (response rate 60.8%). The prevalence of depressive symptoms was 44.2% (EPDS cut-off score ≥ 11) and the PTSS rate was 42.9% (IES-R cut-off score ≥ 24). Dismissive and fearful avoidant attachment styles were significantly associated with the risk of depression and PTSS, respectively. Perceived pain during birth was a risk factor for postpartum depression. Perceived support provided by healthcare staff was a protective factor against depression and PTSS. Another protective factor against PTSS was quiet on the ward due to the absence of hospital visitors. CONCLUSION: This study reports a high prevalence of postpartum depressive and PTSS in women who gave birth during the Covid-19 pandemic. Postnatal psychological distress seemed to be associated more with the prenatal experience and other individual factors than with the pandemic hospital restrictions. Early detection during pregnancy of an insecure attachment style is fundamental to provide targeted preventive and therapeutic psychological interventions.

Controlled ovarian stimulation and progesterone supplementation affect vaginal and endometrial microbiota in IVF cycles: a pilot study.

PURPOSE: Does controlled ovarian stimulation (COS) and progesterone (P) luteal supplementation modify the vaginal and endometrial microbiota of women undergoing in vitro fertilization? METHODS: Fifteen women underwent microbiota analysis at two time points: during a mock transfer performed in the luteal phase of the cycle preceding COS, and at the time of fresh embryo transfer (ET). A vaginal swab and the distal extremity of the ET catheter tip were analyzed using next-generation 16SrRNA gene sequencing. Heterogeneity of the bacterial microbiota was assessed according to both the Bray-Curtis similarity index and the Shannon diversity index. RESULTS: Lactobacillus was the most prevalent genus in the vaginal samples, although its relative proportion was reduced by COS plus P supplementation (71.5 ± 40.6% vs. 61.1 ± 44.2%). In the vagina, an increase in pathogenic species was observed, involving Prevotella (3.5 ± 8.9% vs. 12.0 ± 19.4%), and Escherichia coli-Shigella spp. (1.4 ± 5.6% vs. 2.0 ± 7.8%). In the endometrium, the proportion of Lactobacilli slightly decreased (27.4 ± 34.5% vs. 25.0 ± 29.9%); differently, both Prevotella and Atopobium increased (3.4 ± 9.5% vs. 4.7 ± 7.4% and 0.7 ± 1.5% vs. 5.8 ± 12.0%). In both sites, biodiversity was greater after COS (p < 0.05), particularly in the endometrial microbiota, as confirmed by Bray-Curtis analysis of the phylogenetic distance among bacteria genera. Bray-Curtis analysis confirmed significant differences also for the paired endometrium-vagina samples at each time point. CONCLUSIONS: Our findings suggest that COS and P supplementation significantly change the composition of vaginal and endometrial microbiota. The greater instability could affect both endometrial receptivity and placentation. If our findings are confirmed, they may provide a further reason to encourage the freeze-all strategy.

Is There a Place for Immune Checkpoint Inhibitors in Vulvar Neoplasms? A State of the Art Review.

Vulvar cancer (VC) is a rare neoplasm, usually arising in postmenopausal women, although human papilloma virus (HPV)-associated VC usually develop in younger women. Incidences of VCs are rising in many countries. Surgery is the cornerstone of early-stage VC management, whereas therapies for advanced VC are multimodal and not standardized, combining chemotherapy and radiotherapy to avoid exenterative surgery. Randomized controlled trials (RCTs) are scarce due to the rarity of the disease and prognosis has not improved. Hence, new therapies are needed to improve the outcomes of these patients. In recent years, improved knowledge regarding the crosstalk between neoplastic and tumor cells has allowed researchers to develop a novel therapeutic approach exploiting these molecular interactions. Both the innate and adaptive immune systems play a key role in anti-tumor immunesurveillance. Immune checkpoint inhibitors (ICIs) have demonstrated efficacy in multiple tumor types, improving survival rates and disease outcomes. In some gynecologic cancers (e.g., cervical cancer), many studies are showing promising results and a growing interest is emerging about the potential use of ICIs in VC. The aim of this manuscript is to summarize the latest developments in the field of VC immunoncology, to present the role of state-of-the-art ICIs in VC management and to discuss new potential immunotherapeutic approaches.

Osteomyelitis of the pubic symphysis caused by methicillin-resistant Staphylococcus aureus after vaginal delivery: a case report and literature review.

BACKGROUND: Osteomyelitis of the pubic symphysis is a rare cause of pelvic pain after delivery, mainly caused by Staphylococcus aureus and Pseudomonas aeruginosa. The clinical context is the same as the more common diastasis of the pubic bone, but the presence of intense local pain in association with fever should prompt further clinical work-up based on blood chemistry, microbiology and diagnostic imaging. We report the first case of methicillin-resistant Staphylococcus aureus osteomyelitis of the pubic symphysis occuring after the delivery. CASE PRESENTATION: A 39-year-old woman developed pain over the pubic bone 12 h after the delivery. After 72 h fever rose and laboratory examination showed elevation of C-reactive protein and procalcitonin levels. Pelvic x-rays and magnetic resonance showed pubic diastasis, joint effusion, tiny irregularities of articular surfaces and, severe bone edema. The patient was started on broad spectrum intravenous (IV) antibiotics (piperacillin-tazobactam) and then replaced to IV vancomycin and oral levofloxacin based on antibiogram result. She was then discharged with oral antibiotic therapy and fully recovered. CONCLUSIONS: Due to the rarity of this disease, we compared our experience with the other cases of osteomyelitis of pubic symphysis occurring in peri-postpartum reported in the literature. The course of osteomyelitis was favourable in all patients, and only in one case an additional orthopedic procedure for symphysis fixation was necessary. Knowledge of this rare condition is important to enable prompt diagnosis and treatment.

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.

Feasibility and Acceptability of Office-Based Polypectomy With a 16F Mini-Resectoscope: A Multicenter Clinical Study.

STUDY OBJECTIVE: To investigate the feasibility and acceptability of office hysteroscopic polypectomy using a novel continuous-flow operative 16F mini-resectoscope. DESIGN: Multicenter prospective case series (Canadian Task Force classification III). SETTING: "SS Antonio e Biagio" Hospital, Alessandria, and University "Federico II" of Naples. PATIENTS: One hundred eighty-two patients with endometrial polyps. INTERVENTIONS: Hysteroscopic polypectomy performed with 16F mini-resectoscope in an office setting, without analgesia and/or anesthesia. MEASUREMENTS AND MAIN RESULTS: Polypectomy was successfully performed in 175 patients in a single surgical step (96.15%), with only 1 patient (.54%) requiring a second office surgical step to complete the surgery. Seven patients (3.84%) were excluded from the analysis of operative parameters because of severe pelvic pain during the office procedure, which required a second inpatient surgical step. No major complications were recorded. CONCLUSION: Our findings demonstrate that removal of endometrial polyps using the 16F mini-resectoscope in an office setting is a feasible and safe surgical option. Outpatient see-and-treat polypectomy is an acceptable and effective alternative to inpatient resectoscopic polypectomy.