Short-Term Outcome of Robotic versus Laparoscopic Hysterectomy for Endometrial Cancer in Women with Diabetes: Analysis of the US Nationwide Inpatient Sample.

This study investigated short-term outcomes of robotic versus laparoscopic hysterectomy for endometrial cancer (EC) in women with diabetes. We extracted the data of hospitalized females aged ≥18 years who were diagnosed with EC and diabetes and underwent robotic or laparoscopic hysterectomy from the US Nationwide Inpatient Sample (NIS) 2005-2018. Associations between study variables and in-hospital outcomes, including complications, unfavorable discharge, length of stay (LOS), and hospital costs, were examined using logistic regression. A total of 5745 women (representing 28,176 women in the US) were included. Multivariable analysis revealed that robotic surgery was significantly associated with a decreased risk of unfavorable discharge (adjusted odds ratio [aOR] = 0.63, 95% confidence interval [CI]: 0.46, 0.85) than pure laparoscopic surgery. Women who underwent robotic surgery had a significantly shorter LOS (0.46 fewer days, 95% CI: -0.57, -0.35) but higher total hospital costs (6129.93 greater USD; 95% CI: 4448.74, 7811.12). Compared with pure laparoscopic surgery, robotic hysterectomy was associated with less unfavorable discharge among women aged ≥60 years (aOR = 0.60, 95% CI: 0.44, 0.80). For US women with EC and diabetes, robotic hysterectomy is associated with shorter LOS, decreased risk of unfavorable discharge, especially among older patients, and higher total costs than laparoscopic surgery.

Improved symptoms and signs of refractory interstitial cystitis in women after intravesical Nanofat plus platelet-rich plasma grafting: A pilot study.

Interstitial cystitis/bladder pain syndrome (IC/BPS) is characterized by bladder pain accompanied by irritative urinary symptoms, and typical cystoscopic and histological features. In this pilot study, we assessed the impact of lesion-targeted bladder injection therapy using a biocellular regenerative medicine on patients with refractory IC/BPS. The medicine, which was an autologous emulsified fat (Nanofat) and platelet-rich plasma (PRP) combination, was prepared intraoperatively. Six patients (aged 40-54 years), who completed a standard protocol of four consecutive treatments at 3-month intervals, were followed up at 6 months postoperatively. All patients (100%) reported marked (+3; +3 ~ -3) improvement of their overall bladder conditions. Mean bladder pain (from 8.2 to 1.7; range: 0 ~ 10), IC-related symptoms (from 18.5 to 5.7; range: 0 ~ 20), and bother (from 14.8 to 3.8; range: 0 ~ 16) improved significantly (p < 0.01). The normalization of bladder mucosal morphology with treatments was remarkable under cystoscopic examination, and no significant adverse events were found. The cultured mesenchymal stem cells from Nanofat samples of the six patients were verified in vitro. Our preliminary results suggest novel intravesical therapy with autologous Nanofat plus PRP grafting is safe and effective for refractory IC/BPS. Surgical efficacy might be attributed to an in vivo tissue engineering process.

Verification of HPV16 as a good prognostic factor for cervical adeno-adenosquamous carcinoma via an international collaborative study.

OBJECTIVE: This study (Asian Gynecologic Oncology Group [AGOG]13-001/Taiwanese Gynecologic Oncology Group [TGOG]1006) was to validate human papillomavirus (HPV)16 as an independent good prognostic factor and investigate the impact of treatment modalities to cervical adenocarcinoma and adenosquamous carcinoma (AD/ASC). MATERIALS AND METHODS: Patients receiving primary treatment at AGOG and TGOG member hospitals for cervical AD/ASC were retrospectively (1993-2014) and prospectively (since 2014) enrolled. DNA extraction from paraffin-embedded tissue (FFPE) specimens was used for HPV genotyping. Those with suspected endometrial origin were excluded for analysis. RESULTS: A total of 354 patients with valid HPV results were enrolled, 287 (81.1%) of which had HPV-positive tumors. The top-3 types were HPV 18 (50.8%), HPV16 (22.9%) and HPV45 (4.0%). The HPV16-negativity rates varied widely across hospitals. 322 patients were eligible for prognostic analyses. By multivariate analysis, advanced stage (HR5.8, 95% confidence interval [CI] 2.1-15.8; HR5.8, 95% CI 1.6-20.5), lymph node metastasis (HR4.6, 95% CI 2.7-7.9; HR7.3, 95% CI 3.8-14.0), and HPV16-positivity (HR0.3, 95% CI 0.1-0.6; HR0.3, 95% CI 0.1-0.9) were independent prognostic factors for progression-free survival (PFS) and overall survival (OS). Stage I patients with primary surgery had better 5-year PFS (82.8% vs 50.0% p = 0.020) and OS (89.3% vs 57.1%, p = 0.017) than those with non-primary surgery, while the propensity scores distribution were similar among the treatment groups. CONCLUSION: This study confirmed that HPV16-positivity was a good prognostic factor for PFS and OS in AD/ASC, and patients seemed to have better outcome with primary surgery than non-primary surgery.

Repurposing gestrinone for tumor suppressor through P21 reduction regulated by JNK in gynecological cancer.

Endometriosis has been shown to increase the risk of gynecological cancers. However, the effect of gestrinone, a clinical endometriosis drug, on gynecological cancers remains unclear. This study aimed to understand the effect of gestrinone on gynecological cancers. A retrospective study was conducted using the Longitudinal Health Insurance Database 2000 of the Taiwan National Health Insurance Research Database (NHIRD) to observe the risk of gynecological cancers. Medication records from the Department of Obstetrics and Gynecology, Chung Shan Medical University Hospital CSMUH and cancer records from the Taiwan Cancer Registry were collected to analyze the correlation between gestrinone use and gynecological cancers. Subsequently, human cell lines were used to investigate the effect of gestrinone on gynecological cancers. A total of 8330 endometriosis patients were enrolled, and analyses revealed that endometriosis patients had a higher risk of developing ovarian and endometrial cancer. However, the rate of cervical cancer was not statistically different (P = 0.249). Analyses of both the NHIRD and CSMUH databases revealed that gestrinone may reduce the risk of gynecological cancer. Cellular experiments verified the anticancer effects of gestrinone, which effectively and specifically inhibited the growth of HeLa cervical cancer cells, decreased P21 expression via JNK phosphorylation, and induced apoptosis. Combining the results of clinical database analysis and cell experiments, our findings prove that gestrinone has the potential to protect against cancer through regulation of the JNK-P21 axis. Repurposing the anticancer efficacy of gestrinone may be a strategy for targeted therapy in the future.

Postpartum HPV Vaccination Rate and Differences in Background Characteristics Between HPV Vaccinated and Unvaccinated Postpartum Women: Strict Monitoring and Follow-Up of Postpartum HPV Vaccination Program.

There is a need to increase the vaccine completion rates in women who have already received human papillomavirus (HPV) vaccines. With vaccines requiring multiple doses, designing a vaccination control program and increasing the proportion of women who complete vaccination are critical and remain as huge challenges. Currently, there are no published reports on the differences in the background characteristics between postpartum women who are vaccinated or unvaccinated against HPV. This study aimed to determine the vaccination rates of the second and third doses of HPV vaccination utilizing an achievable HPV vaccination program in postpartum women. In this retrospective study, 243 postpartum women attending Chiayi Chang Gung Memorial Hospital between March and September 2014 were enrolled. These women were classified into two groups: one group received the HPV vaccine under a practical, controlled postpartum HPV vaccination program, and the other group did not. The rates for the second and third rounds of HPV vaccination in postpartum women were calculated. The differences in the background characteristics between the two groups were determined using the Student's t test, chi-square test or Fisher's exact test, and the multiple logistic models, as appropriate. Under the controlled postpartum HPV vaccination program, the completion rate for the three doses of postpartum HPV vaccination was 97.2%. Significant differences were observed according to maternal age, gender of the newborn, and postpartum Pap smear results between the two groups in our study. In conclusion, the controlled postpartum HPV vaccination program is a reasonable method for achieving an excellent completion rate for the three doses of postpartum HPV vaccination and may be a good model for any multiple-dose vaccination protocol.

Effect of modified laparoscopic hysterectomy on pelvic floor function: A retrospective observational study.

Hysterectomy is a potential risk factor for subsequent surgery for pelvic organ prolapse, especially when the prolapse exists before hysterectomy. Women without prolapse before hysterectomy may also experience prolapse after hysterectomy. This study aimed to describe a surgical modification of laparoscopic colposuspension with round ligaments after hysterectomy in women without preexisting genital prolapse and to evaluate the initial surgical results in these patients.We reviewed data of 54 patients who underwent laparoscopic hysterectomy with colposuspension with unilateral or bilateral round ligaments after hysterectomy at Chia-Yi Chang Gung Memorial Hospital from July 2012 to March 2015. Vaginal length was measured before and after colposuspension after complete hysterectomy. Preoperative characteristics of the patients, perioperative quality, postoperative outcomes, and vaginal length differences were analyzed.Vaginal length increased by a mean of 2.59 cm after colposuspension. The mean extra-operative time needed for laparoscopic colposuspension was about 10 minutes. No severe complications were reported in our patients, and we did not find any cystocele after completing vaginal cuff suspension to the round ligament.The vaginal apex level was maintained in our modified laparoscopic hysterectomy. Therefore, laparoscopic colposuspension with round ligaments is a promising option as a routine, first-line standard procedure in younger women without genital prolapse to maintain an acceptable vaginal length after laparoscopic hysterectomy.

Integration of data mining classification techniques and ensemble learning to identify risk factors and diagnose ovarian cancer recurrence.

Ovarian cancer is the second leading cause of deaths among gynecologic cancers in the world. Approximately 90% of women with ovarian cancer reported having symptoms long before a diagnosis was made. Literature shows that recurrence should be predicted with regard to their personal risk factors and the clinical symptoms of this devastating cancer. In this study, ensemble learning and five data mining approaches, including support vector machine (SVM), C5.0, extreme learning machine (ELM), multivariate adaptive regression splines (MARS), and random forest (RF), were integrated to rank the importance of risk factors and diagnose the recurrence of ovarian cancer. The medical records and pathologic status were extracted from the Chung Shan Medical University Hospital Tumor Registry. Experimental results illustrated that the integrated C5.0 model is a superior approach in predicting the recurrence of ovarian cancer. Moreover, the classification accuracies of C5.0, ELM, MARS, RF, and SVM indeed increased after using the selected important risk factors as predictors. Our findings suggest that The International Federation of Gynecology and Obstetrics (FIGO), Pathologic M, Age, and Pathologic T were the four most critical risk factors for ovarian cancer recurrence. In summary, the above information can support the important influence of personality and clinical symptom representations on all phases of guide interventions, with the complexities of multiple symptoms associated with ovarian cancer in all phases of the recurrent trajectory.

Intravenous leiomyomatosis of the uterus: A clinicopathological analysis of nine cases and literature review.

OBJECTIVE: Intravenous/intravascular leiomyomatosis is characterized by intravenous proliferation of a histologically benign smooth muscle cell tumor mass that is non-tissue-invasive. Although benign, intravenous leiomyomatosis may cause remarkable systematic complications, presents significant diagnostic difficulties, and also is characterized by a relatively increased possibility of recurrence. We determine patients' characteristics, and recurrence and treatment of intravenous leiomyomatosis. MATERIALS AND METHODS: Prognostic factors are analyzed with univariate analysis. Differences in categorical data are evaluated by the X2 test. A P value below 0.05 is regarded as indicating a significant difference. RESULTS: The data results accord with the widely held view that complete excision of intravenous leiomyomata achieves favorable prognoses regarding remission. The efficacy of using Gonadotropin releasing hormone agonists to prevent growth or recurrence of tumors in unresected or incompletely resected intravenous leiomyomatosis foci. CONCLUSION: If complete surgical resection is not possible, partial resection followed by hormone therapy using gonadotropin-releasing hormone agonists is recommended, which in this study achieved the same favorable prognosis with regard to remission.

Vesicovaginorectal fistula on a FDG PET/CT of a patient with recurrent cervical cancer and end-stage renal disease.

A 59-year-old woman with recurrent cervical cancer and end-stage renal disease was referred for FDG PET/CT for restaging. The patient had hemodialysis for 4 years and radiotherapy 3 years ago and 1 year ago. The PET/CT scan showed recurrent cervical cancer and intense FDG radioactivity in the urinary bladder, with a small air bubble in both the urinary bladder and the vagina. After supine positioning without voiding, the delayed images showed more air bubbles with less FDG activity in the urinary bladder. The vesicovaginorectal fistula was confirmed by surgery.

A prospective study of nerve-sparing radical hysterectomy for uterine cervical carcinoma in Taiwan.

OBJECTIVE: Surgical therapy for cervical carcinoma carries a significant risk of functional impairment to the bladder. This study evaluates the feasibility and complications of nerve-sparing radical hysterectomy (NRH) in Taiwan. METHODS: Between March 2010 and March 2011, consecutive patients diagnosed with early stage cervical cancer (FIGO stage Ia2 to Ib1) and tumor size < 3 cm were recruited prospectively to undergo NRH or conventional radical hysterectomy (RH). Patients with histories of urinary stress incontinence or bladder dysfunction disease were excluded. A modified Tokyo nerve-sparing radical hysterectomy was performed. RESULTS: A total of 30 patients were enrolled. Among these, 18 patients underwent NRH with successful bilaterally nerve-sparing procedures in 15 cases (83%), unilaterally nerve-sparing procedures in 2 cases (11%), and a failure in 1 case (6%). The indwelling catheter was removed on postoperative day 6. The mean±SD duration from operation to spontaneous voiding was 6.8 ± 1.5 days for women who underwent NRH; the corresponding duration for women who underwent RH or failed NRH was 20.6 ± 3 days. None of the patients who underwent NRH required intermittent catheterization. All 12 patients who underwent RH needed self-catheterization after discharge. There was a significant reduction in the incidence of postoperative self-catheterization (p<0.01) and bladder dysfunction (p<0.006). Average satisfaction score analyzed by the Likert-scale questionnaire was 4.5 for the NRH group and 1.9 for RH group (p<0.0001). CONCLUSIONS: We concluded that the new technique of NRH can reduce postoperative bladder dysfunctions.

Association of p53 and CDKN1A genotypes with endometriosis.

BACKGROUND: The tumor suppressor p53 protein plays a critical role in different cellular processes in response to DNA damage and it is responsible for transcriptional induction of the p21 (CDKN1A/WAF1/CIP1) gene. Both p53 and p21 are thought to play major roles in the development of human malignancy. Polymorphic variants of p53 at codon 72, and CDKN1A at codon 31, have been found to be associated with cancer susceptibility, but few studies have investigated their effect on endometriosis risk. MATERIALS AND METHODS: In this hospital-based case-control study, we investigated the association of p53 codon 72 and CDKN1A codon 31 polymorphisms with endometriosis susceptibility in a Taiwanese population. In total, 180 patients with endometriosis, and 330 age-matched controls in Central Taiwan were recruited and genotyped. RESULTS: We found a significant difference in the distribution of the p53 genotype, but not the CDKN1A genotype, between the endometriosis and control groups. Individuals with the C (Pro) allele at p53 codon 72 had a 1.6-fold increased odds ratio of endometriosis, and those with Arg/Pro and Pro/Pro genotypes for p53 codon 72 had a 1.84- and 2.74-fold (95% confidence interval=1.17-2.92 and 1.58-4.74) increased risk of endometriosis compared to those with Arg/Arg, respectively. The distribution of haplotype combinations of p53 codon 72 and CDKN1A codon 31 was statistically different in the endometriosis and control groups. The percentages of the three subgroups with p53 CC homozygote were all higher in the endometriosis group than in the control group. CONCLUSION: Our findings suggest that the C (Pro) allele of p53 codon 72 may be associated with the development of endometriosis, and could serve as a potential biomarker for early prediction of this disease.

The role of lipocalin 2 and its concernment with human nonmetastatic clone 23 type 1 and p53 in carcinogenesis of uterine cervix.

To investigate the novel role of lipocalin 2 and its concernment with human nonmetastatic clone 23 type 1 (nm23-H1) and p53 in cervical carcinogenesis, SiHa cervical cancer cells were knocked down for nm23-H and lipocalin 2 or overexpressed by lipocalin 2 genes. We found that the overexpression of lipocalin 2 or knockdown of nm23-H1 genes increased the proliferation of SiHa cancer cells, while knocking down of lipocalin 2 decreased the proliferation of SiHa. Furthermore, knockdown of nm23-H1 or overexpression of lipocalin 2 was associated with reduced expression of p53 and its downstream gene p21. Using tissue microarrays, lipocalin 2 immunoreactivity was significantly elevated in cancer tissues as compared with it in high- or low-grade dysplasia or normal tissues. Serum secreted form lipocalin 2 from patients with cervical cancer increased in comparison with normal controls. Conclusively, secreted form lipocalin 2 reflects its implication in cervical cancer tissues and may be utilized as an adjuvant biomarker.

Transvaginal sonographic criteria for the diagnosis of adenomyosis based on histopathologic correlation.

OBJECTIVE: To evaluate the accuracy of different transvaginal sonographic criteria in the diagnosis of adenomyosis, and to determine the most useful sonographic feature by comparison with histopathologic results. MATERIALS AND METHODS: A total of 213 consecutive patients scheduled for hysterectomy underwent preoperative transvaginal sonography in this retrospective study. The diagnosis of adenomyosis was made if one or more of the following sonographic findings were present: (1) a globular uterine configuration; (2) poor definition of the endometrial-myometrial interface; (3) sub-endometrial echogenic linear striations; (4) myometrial anterior-posterior asymmetry; (5) myometrial cysts; and (6) a heterogeneous myometrial echotexture. These sonographic findings were then compared with the histopathologic findings. RESULTS: The prevalence of adenomyosis was 39.9%. The sensitivity, specificity, positive and negative predictive values, and accuracy of transvaginal ultrasound for the diagnosis of adenomyosis were 87.1, 60.1, 59.2, 87.5 and 70.9%, respectively. We found that subendometrial echogenic linear striations, a heterogeneous myometrial echotexture, and myometrial anterior-posterior asymmetry showed greater accuracy for the diagnosis of adenomyosis. Further evaluation of these findings showed that subendometrial echogenic linear striations had the best sensitivity, and positive and negative predictive values for the diagnosis of uterine adenomyosis (91.8, 67.8 and 92.9%, respectively). The presence of a globular uterine configuration was the most specific sonographic feature (78.1%), but showed poor specificity (50.6%). CONCLUSION: The presence of subendometrial echogenic linear striations, a heterogeneous myometrial echotexture, and myometrial anterior-posterior asymmetry on transvaginal ultrasonography supports the diagnosis of adenomyosis. Among the transvaginal ultrasonographic findings consistent with the diagnosis of adenomyosis, subendometrial linear striations had the highest diagnostic accuracy.

A new quantitative method to evaluate adnexal tumors.

OBJECTIVE: The purpose of this study was to assess endometriomas and follicular cysts using a new quantitative method provided by the picture archiving and communication system. MATERIALS AND METHODS: We reviewed our computer ultrasound database of endometriomas and follicular cysts between November 2003 and July 2007. A total of 123 consecutive women diagnosed with an endometrioma or follicular cyst on two-dimensional sonography were re-evaluated using new parameters with the picture archiving and communication system. We chose quantitative tumor density and standard deviation on sonographic images as the new diagnostic parameters. Analysis of variance and Scheffé post hoc test were analyzed to compare the mean tumor density of the endometriomas and follicular cysts. The receiver operating characteristic curve was plotted to choose the cutoff value of the endometrioma tumor density with the best sensitivity and specificity. RESULTS: There was a significant difference when the tumor density of the follicular cyst and endometrioma groups was compared using the vaginal, abdominal or endovaginal approach (p < 0.001). Based on the results of the receiver operating characteristic curve, endovaginal ultrasonography is an excellent diagnostic tool with which to evaluate endometriomas. With endovaginal ultrasonography examination, the best cutoff value of tumor density is 28 and the sensitivity and specificity are 64% and 100%, respectively. CONCLUSION: The use of quantitative tumor density and standard deviation on sonographic images is a potential new diagnostic tool in the assessment of endometriomas and follicular cysts.

Age and prevalence of cervical carcinoma in subsequent hysterectomy following a conization procedure.

OBJECTIVE: To determine the prevalence and age of patients with cervical carcinoma missed by a loop electrosurgical excision procedure. MATERIALS AND METHODS: A total of 253 women with cervical dysplasia who underwent conization and 248 women who later underwent hysterectomy were retrospectively reviewed. The age and prevalence of those with cervical carcinoma diagnosed and missed by conization were determined. RESULTS: Of the 248 patients, 11 cases (4.4%) of cervical carcinoma were missed by cervical conization. The age of those with cervical carcinoma missed by conization was significantly greater than those whose diagnosis was not missed (p < 0.05). CONCLUSION: Women with severe cervical dysplasia who no longer wish to preserve fertility should be advised to undergo hysterectomy if the conization margins are not free of disease. Older women with incomplete resection margins tend to have undiagnosed hidden cervical carcinoma after cervical conization.

Adjuvant concurrent chemoradiotherapy with intensity-modulated pelvic radiotherapy after surgery for high-risk, early stage cervical cancer patients.

PURPOSE: This study was undertaken to assess local control and toxicity with adjuvant intensity-modulated radiotherapy (IMRT) and concurrent chemotherapy (CCRT) for early stage cervical cancer. PATIENTS AND METHODS: Between June 2004 and February 2007, 54 patients with early stage cervical cancer (stage IB-IIA) with high-risk factors for treatment failure after surgery were treated with adjuvant pelvic IMRT and CCRT. Adjuvant chemotherapy consisted of cisplatin (50 mg/m2) weekly for 4 to 6 courses. All the patients received 50.4 Gy of external beam radiotherapy with IMRT in 28 fractions and 6 Gy of high-dose rate vaginal cuff brachytherapy in 3 insertions. RESULTS: Adjuvant CCRT with IMRT provided good local tumor control in posthysterectomy cervical cancer patients with high-risk pathologic features. The 3-year locoregional control and disease-free survival were 93% and 78%, respectively. Histology and lymph node metastasis were indicators for disease-free survival. Low acute and chronic treatment-related toxicities were noted with IMRT. All the patients completed the radiotherapy treatment without any major toxicity. In terms of chronic toxicity, only 1 patient had grade 3 genitourinary toxicity and none had grade 3 gastrointestinal toxicity. CONCLUSION: Our results indicate that adjuvant CCRT with IMRT technique for adjuvant treatment of early stage cervical cancer is associated with excellent local control and low toxicity.