Trends in Caesarean Section Rate According to Robson Group Classification among Pregnant Women with SARS-CoV-2 Infection: A Single-Center Large Cohort Study in Italy.

BACKGROUND: Since there is no available data on temporal trends of caesarean section (CS) rates in pregnant women with COVID-19 through the pandemic, we aimed to analyze the trends in caesarean section rate in a large cohort of pregnant women with COVID-19, according to the Robson Ten Group Classification System of deliveries. METHODS: We prospectively enrolled pregnant women with a diagnosis of COVID-19 who delivered in our center between March 2020 and November 2021. Deliveries were classified, according to the Robson group classification, and according to three time periods: (1) deliveries from March 2020 to December 2020; (2) deliveries from January 2021 to April 2021; (3) deliveries from May 2021 to November 2021. We compared pregnancy characteristics and incidence of caesarean section, according to the Robson category in the total population, and according to the three time periods. RESULTS: We included 457 patients matching the inclusion criteria in our analysis. We found that overall CS rate significantly decreased over time from period 1 to period 3 (152/222, 68.5% vs. 81/134, 60.4% vs. 58/101, 57.4%, χ2 = 4.261, p = 0.039). CS rate significantly decreased over time in Robson category 1 (48/80, 60% vs. 27/47,57.4% vs. 8/24, 33.3%, χ2 = 4.097, p = 0.043) and Robson category 3 (13/42, 31% vs. 6/33, 18.2% vs. 2/22, 9.1%, χ2 = 4.335, p = 0.037). We also found that the incidence of induction of labor significantly increased over time (8/222, 3.6% vs. 12/134, 9% vs. 11/101, 10.9%, χ2 = 7.245, p = 0.027). CONCLUSION: Our data provide an overview of the temporal changes in the management and obstetric outcome of COVID-19 pregnant women through the pandemic, confirming that standards of obstetrical assistance for pregnancies complicated by SARS-CoV-2 infection improved over time.

A case of 20-week abortion in a rare communicating rudimentary horn of a misinterpreted unicornuate uterus, incorrectly diagnosed as bicornuate: A serious hazard!

Female genital malformations, as the unicornuate uterus, are deviations from normal anatomy that could impair the reproductive potential of a woman or her health. We present a rare case of a 20-week spontaneous abortion in a 24 years old patient affected by a misunderstood unicornuate uterus with communicating rudimentary horn, previously diagnosed as bicornuate, and for this reason subjected to induction of abortive labor, using mifepristone and gemeprost. Following the ultrasound exam and MRI, performed due to the failure of the abortive procedure, revealed the diagnosis of unicornuate uterus with (not clear) communicating accessory horn pregnancy, then treated with laparotomy. 3D-ultrasonography, and above all MRI, should be performed in all those cases of suspected uterine anomalies, especially in presence of pregnancy or abortion, with the aim of avoiding wrong treatments, which leads to a high risk of uterine rupture. In this case, given the uncertainty of imaging exams performed in such an advanced second trimester of pregnancy, only the surgical approach was able to discover the real communication.

Breast metastasis two years after pelvic surgery and adjuvant chemotherapy for serous ovarian cancer.

Ovarian cancer is considered the leading cause of death among gynecologic neoplasias. Breast metastases from primary ovarian cancer have been reported in only 0.03-0.6% of all breast cancers. A 38-year-old female, multipara, affected by advanced ovarian cancer and undergone a total abdominal hysterectomy with bilateral salpingo-oophorectomy, omentectomy, and pelvic peritonectomy two years earlier, was discovered to have a breast metastasis. She underwent a quadrantectomy (QSI) with an open biopsy of nodularity attached to the pectoral muscle fascia: on definitive histological characterization the breast lesions showed a high-grade invasive carcinoma, with papillary serum differentiation, and the immunohistochemistry study of breast lesion showed positivity for cytokeratin 7 and an extensive positivity for Wilm's tumor (WT)-1 and paired box 8 (PAX8). These aspects are indicative of mammary metastasis from carcinoma of ovarian origin. Despite their rarity, metastases to breast from ovarian cancer should be considered possible because their recognition and differentiation compared to primary tumors are crucial for prognosis. Future clinical studies on MOCB should be performed to discover new specific markers for a more accurate histopathological diagnosis and to establish the real need of surgical treatment.

An exceptional uterine inversion in a virgo patient affected by submucosal leiomyoma: Case report and review of the literature.

Inversion of the uterus is quite a rare obstetric (puerperal) or gynecological (non-puerperal) condition. Non-puerperal type may be benign or malign mass induced or idiopathic. To the best of our knowledge, this is the first case with a large review of literature of uterine inversion in a patient without sexual experience. We report the case of a 52-year-old, unmarried virgo woman, affected by schizophrenia, was referred to our emergency room for evidence of a mass outside of the vaginal introitus, combined with vaginal bleeding and abdominal pain. The patient underwent vaginal myoma resection and abdominal hysterectomy with bilateral adnexectomy. The diagnosis of uterine inversion was confirmed during operation. Diagnosis of uterine inversion is often not easy and imaging studies might be helpful. Despite the rarity, uterine non-puerperal inversion is possible: for this reason, it is necessary to perform appropriate, conservative treatment, especially in women affected by benign myomas and with a desire for pregnancy.

Efficacy and safety of the trans-obturator TVT-Abbrevo device in normal weight compared to overweight patients affected by stress urinary incontinence.

OBJECTIVE: To investigate if TVT-Abbrevo has similar outcomes in normal weight and overweight patients. STUDY DESIGN: Retrospective evaluation of 205 (105 normal weight women and 100 overweight women with BMI ≥ 25 kg/m(2)) undergone TVT-Abbrevo positioning with 12 month follow-up. Primary outcomes were objective cure rate (defined as no leakage during CST) and subjective cure rate ("very much improved"/"much improved" at PGI-I), secondary outcomes were intra-operative and post-operative complications. RESULTS: Objective cure rates in the normal and overweight groups were 96.2% and 94%, respectively (p=.47). Subjective cure rates in the normal and overweight groups were 90.5% and 88%, respectively (p=.57). ICIQ-SF, I-QoL and PGI-S scores significantly improved in both groups with no differences between the two groups. No serious intra- or post-operative complications were observed. No differences were observed in pain VAS scores and number of analgesic vials administered. CONCLUSIONS: TVT-Abbrevo seems to have similar efficacy and safety in normal weight and overweight women. More studies are needed to assess the efficacy of this device in frankly obese women and long-term outcomes.

Medium-term and long-term outcomes following placement of midurethral slings for stress urinary incontinence: a systematic review and metaanalysis.

INTRODUCTION AND HYPOTHESIS: Questions regarding the long-term efficacy and safety of midurethral slings (MUS) are still unresolved, notwithstanding the widespread use of these procedures. The objective of this review was to evaluate the long-term outcomes of retropubic MUS (RP-MUS) procedures and the medium-term outcomes of transobturator MUS (TO-MUS) procedures. METHODS: MEDLINE, EMBASE, NLH, ClinicalTrials.gov, and Google Scholar databases were searched up to June 2014 with restriction to English language and using the search terms: "stress urinary incontinence", "midurethral sling", "tension-free tape", "transobturator tape", and "follow-up". Studies with a follow-up of 36 months for TO-MUS and 60 months for RP-MUS were searched. Only studies comparing a RP-MUS or TO-MUS with another synthetic sling were included. Data from 49 studies were included. Data were expressed as odds ratios (OR) with 95 % confidence intervals (CI) and combined using the Mantel-Haenszel fixed effects model. Differences in the proportions were evaluated using the chi-squared test. RESULTS: RP-MUS had similar objective cure rates (OR 1.15, 95 % CI 0.75 - 1.76) but higher subjective cure rates than TO-MUS (OR 1.76, 95 % CI 1.08 - 2.86). No differences were observed between outside-in (TOT) and inside-out (TVT-O) and between TO-MUS and minisling. Bladder injuries were more frequent (OR 7.01, 95 % CI 2.94 - 17.90) and vaginal erosions were less frequent for RP-MUS (OR 0.24, 95 % CI 0.07 - 0.84). Vaginal injuries were more common with TOT than with TVT-O (OR 7.96, 95 % CI 1.15 - 157.9). Pain-related complications were more common with TO-MUS than with minimally invasive tapes (OR 8.75; 95 % CI 9.02 - 57.90). CONCLUSIONS: MUS have similar objective cure rates in the long term and medium term. TO-MUS is associated with a lower subjective cure rate than RP-MUS.

Tension-free vaginal tape-obturator and tension-free vaginal tape-Secur for the treatment of stress urinary incontinence: a 5-year follow-up randomized study.

OBJECTIVE: Single-incision slings were developed to overcome the complications related to retropubic and trans-obturator tapes. TVT-Secur was the first of this kind of devices to be marketed and yielded contrasting results. Aim of this non-inferiority study is to report the 5-year follow-up of a randomized, single-blind, controlled trial comparing TVT-O to TVT-Secur. STUDY DESIGN: Randomized, single blind, controlled study conducted in two tertiary urogynecological centers. 154 patients were allocated to either TVT-O or TVT-Secur and were contacted 5 years after the procedure to undergo urogynecological examination (POP-Q staging, challenge stress test and post-void residual urine evaluation), to complete I-QOL and PGI-I questionnaires, and to score their satisfaction on a 5-point Likert scale. Patients who were not objectively evaluated were interviewed over the telephone. Primary outcome was subjective success defined as being "very much improved" or "much improved" on the PGI-I. RESULTS: 120 patients were evaluated only subjectively (TVT-O: 62; TVT-Secur: 58) and 84 objectively and subjectively (TVT-O: 46; TVT-Secur: 38). Subjective success (79% vs. 63.8%) and objective cure rates (82.6% vs. 68.4%) 5 years after the procedure were lower for TVT-Secur, but not significantly. Recurrent UTIs were reported by 17.8% of women (TVT-O 9, TVT-Secur 6) and two de novo urgency cases (one per group) were observed. Re-operation rate for stress urinary incontinence (SUI) was 20%. CONCLUSIONS: TVT-Secur did not show an inferior subjective success rate in comparison with TVT-O five year after the original procedure, even though displaying a clear trend toward a lower efficacy. Considering that the long-term safety profile is similar between the two procedures, there are no advantages in using TVT-Secur.

Effect of local infiltration analgesia on post-operative pain following TVT-O: a double-blind, placebo-controlled randomized study.

PURPOSE: To evaluate the effect of a protocol of local anesthesia and epinephrine associated with sedo-analgesia on post-TVT-O pain in comparison with infiltration of saline and epinephrine. METHODS: Forty-two patients undergoing TVT-O were randomized into two groups to receive periurethral infiltration with epinephrine only (group A, n = 21) or with epinephrine plus 1 % lidocaine hydrochloride (group B, n = 21). Post-operative pain was assessed using a visual analog scale (VAS) from 0 (absence of pain) to 10 (maximum pain possible), 1, 6, 12 and 24 h after the procedure. The total amount of analgesia was recorded and the proportion of women reporting a pain VAS score ≥4, 1 h after the procedure was calculated. ANOVA for repeated measures and Bonferroni correction, the Student's t test for independent samples, the Mann-Whitney U test, the Fisher exact test, or the χ (2) test for parametric was used. RESULTS: Pain level was significantly lower in group B 1 (p = 0.01) and 6 h (p = 0.05) after surgery, but not 12 and 24 h after the procedure. No significant difference was observed in the proportion of women requesting analgesia and in the total dosage of analgesics between the two groups. A significant higher proportion of women in group A reported a pain VAS score higher than four 1 h after surgery in comparison with patients in group B. CONCLUSIONS: This randomized study seems to indicate that systematic infiltration before TVT-O positioning with local anesthetic may reduce immediate post-operative pain.

Tension-free vaginal tape-O and -Secur for the treatment of stress urinary incontinence: a thirty-six-month follow-up single-blind, double-arm, randomized study.

OBJECTIVE: To compare the efficacy of the inside-out tension-free vaginal tape-obturator (TVT-O) device versus the single-incision TVT-Secur device 36 months after the procedure. METHODS: A single-blind, randomized, parallel-group study on 154 patients with stress urinary incontinence (77 treated with TVT-O and 77 with the TVT-Secur hammock approach). The primary endpoint was the objective cure rate 36 months after the procedure evaluated with the challenge stress test. Secondary endpoints were subjective cure rate (evaluated with bladder diary, quality-of-life questionnaires, and patient-reported outcome tools) and intraoperative and postoperative complications. The primary endpoint was evaluated with a noninferiority study design. RESULTS: Sixty-six patients in the TVT-O group and 64 in the TVT-Secur group concluded the study. Thirty-six months after the procedure, 57/66 patients (86.4%) in the TVT-O and 50/64 (78.1%) in the TVT-Secur groups were objectively cured (noninferiority unilateral u test: p < .05). No differences were observed in the subjective cure and complication rates. CONCLUSIONS: TVT-Secur seems not to be inferior to TVT-O in the surgical treatment of stress urinary incontinence and causes less postoperative pain. The possibility of severe blood loss cannot be ruled out when TVT-Secur is used.

Vaginal delivery following single incision sling (TVT-Secur) for female stress urinary incontinence.

In recent years, surgical treatment of stress urinary incontinence has become minimally invasive owing to the introduction of the transobturator route first and then single incision devices for positioning of mid-urethral slings. Although a number of case reports in the literature describe pregnancies successfully terminated both by vaginal delivery and cesarean section following mid-urethral sling positioning, there is still no definitive consensus on which is the preferred mode of delivery in these patients. We report a case of spontaneous vaginal delivery at term in a 41-year-old multiparous woman two years after the positioning of a single incision sling (TVT-Secur). The patient remained continent throughout the gestation and in the following 24 months. This case seems to further support the concept that sling procedures for stress urinary incontinence do not represent an absolute contraindication to spontaneous vaginal delivery, although the preferred mode of delivery must be assessed on an individual basis.

Efficacy of a modified technique for TVT-O positioning: a twelve-month, randomized, single-blind, multicenter, non-inferiority study.

OBJECTIVE: To evaluate the impact of a more limited paraurethral dissection, avoidance of perforating the obturator membrane with scissors or guide, and a more medial trajectory of the trocar in positioning the TVT-O device on stress urinary incontinence cure rates. STUDY DESIGN: One hundred and ten patients were recruited for this randomized, single blind, multicenter, non-inferiority study, with a 1:1 ratio to undergo the traditional (n=55) or the modified (n=55) technique. Preoperatively, patients underwent POP-Q staging, Q-tip test, challenge stress test and urodynamics, and completed the I-QoL, PISQ-12, and PGI-S questionnaires. During the post-operative period, patients attributed a pain VAS score 1, 3, 6, 12 and 24h after the procedure and were followed up at 12 months, undergoing the same baseline evaluations. The primary outcome was the cure rate (absence of urine leaks at the challenge stress test or urodynamic testing) one year after the procedure. The primary outcome was evaluated using a non-inferiority test. RESULTS: No differences were observed in cure rates (traditional technique 92.3% vs. modified technique 88.8% and non-inferiority P<0.05) and in questionnaire scores between the two groups. Post-operative pain was significantly lower in the modified technique group at each time point assessed, with the exception of 12h post-operatively. No differences between the two groups were observed in the number of analgesic vials administered. CONCLUSIONS: The modified technique does not seem to reduce the efficacy of TVT-O, but induces a reduction of post-operative pain.

TVT-Secur for the treatment of female stress urinary incontinence: a 24-month follow-up retrospective study.

PURPOSE: To evaluate the mid-term efficacy and safety of the TVT-Secur device in the treatment of stress urinary incontinence. STUDY DESIGN: Retrospective study evaluating 68 women affected by stress urinary incontinence treated with TVT-Secur procedure with hammock approach who attended the 24-month follow-up visit. Stress test, urodynamics, patient functional and quality of life questionnaires, visual analog scale pain score, and post-operative complications were evaluated. Data distribution was evaluated using the Shapiro-Wilk's test. Data were analyzed by the Student's t test for parametric variables, the Wilcoxon test for non-parametric variables, and the Chi-squared test for categorized variables. RESULTS: Objective cure rate 24 months after surgery was 80.8 %. Incontinence-quality of life and patient global impression of severity scores showed significant improvement. The only intra-operative complications were a vaginal wall tear and a case of severe bleeding, while post-operative complications were de novo urgency in five cases (7.3 %), one acute urinary retention (1.4 %), and one tape exposure (1.4 %). The study is limited by the retrospective design and the heterogeneity of patients. CONCLUSIONS: TVT-Secur seems to be an effective and safe procedure for stress urinary incontinence.

Effects of a modified technique for TVT-O positioning on postoperative pain: single-blind randomized study.

INTRODUCTION AND HYPOTHESIS: One of the most frequent and distressing complications of the tension-free vaginal tape obturator (TVT-O) procedure for stress urinary incontinence (SUI) is groin pain, which may be related to the surgical technique or to the tape. The aim of this study was to evaluate the impact of a more limited dissection and a more medial trocar trajectory in TVT-O positioning on postoperative pain. METHODS: Seventy-two SUI patients were randomized to undergo TVT-O either with the traditional technique (group A) or a modified procedure (reduced paraurethral dissection and a more medial trocar trajectory) (group B). Visual analog scale pain scores 12 h, 24 h, and 1 month after the procedure, number of analgesic vials, objective cure rate, and patient functional and quality of life scores 6 months after the procedure were evaluated. Data were analyzed by the Student's t test for parametric variables, the Mann-Whitney U and Wilcoxon tests for nonparametric variables, and Fisher's exact test for categorical variables. RESULTS: Pain scores were significantly lower in group B compared with group A 24 h after surgery (P = 0.01). Pain scores significantly decreased from 12-24 h postoperatively to 1 month follow-up in both groups (P < 0.001). No significant differences were observed in the number of analgesic vials administered, cure rates, and questionnaire scores between the two groups. CONCLUSIONS: More limited dissection and a more medial trocar trajectory of TVT-O seem to reduce postoperative groin pain at 24 h after the procedure, but not the analgesic requirement.

Plasma leptin and adiponectin levels in hormone replacement therapy and contraception: effects of different progestogens.

OBJECTIVE: To evaluate the impact of hormone replacement therapy and oral contraceptives containing different progestogens on adiponectin and leptin serum levels. DESIGN: Prospective, longitudinal, semi-randomized study. SETTING: General gynecology clinic of a university hospital. PATIENT(S): Forty-five healthy postmenopausal and 45 healthy premenopausal women. INTERVENTION(S): Thirty postmenopausal women were randomized to receive either drospirenone (DRSP) 2 mg + E(2) 1 mg (n = 15) or norethisterone acetate (NETA) 0.5 mg + E(2) 1 mg (n = 15). Thirty premenopausal women were randomized to receive either ethinilestradiol (EE) 0.020 mg + DRSP 3 mg (n = 15) or EE 0.020 mg + desogestrel 0.15 mg (n = 15). Furthermore, 15 postmenopausal and 15 premenopausal untreated women served as controls. MAIN OUTCOME MEASURE(S): Adiponectin and leptin serum levels before and after 6 months of hormonal therapy. RESULT(S): No significant differences in leptin levels were detected in any group after 6 months. Adiponectin levels were significantly reduced in the NETA + E(2) group and increased in the EE + DRSP group, while remaining unmodified in all other groups. CONCLUSION(S): Hormone replacement therapy with NETA, but not with DRSP, decreases serum adiponectin levels. Oral contraceptives containing DRSP increase serum adiponectin levels.