Primary flap closure of perineal defects to avoid empty pelvis syndrome after pelvic exenteration in gynecologic malignancies: An old question to explore a new answer.

Pelvic exenteration (PE) is a radical oncological surgical procedure proposed in patients with recurrent or persistent gynecological cancers. The radical alteration of pelvic anatomy and of pelvic floor integrity can cause major postoperative complications. Fortunately, PE can be combined with reconstructive procedures to decrease complications and functional and support problems of pelvic floor, reducing morbility and mortality and increasing quality of life. Many options for reconstructive surgery have been described, especially a wide spectrum of surgical flaps. Different selection criteria have been proposed to select patients for primary perineal defect flap closure without achieving any strict indication of the best option. The aim of this review is to focus on technical aspects and the advantages and disadvantages of each technique, providing an overview of those most frequently used for the treatment of pelvic floor defects after PE. Flaps based on the deep inferior epigastric artery, especially vertical rectus abdominis musculocutaneous (VRAM) flaps, and gracilis flaps, based on the gracilis muscle, are the most common reconstructive techniques used for pelvic floor and vaginal reconstruction. In our opinion, reconstructive surgery may be considered in case of total PE or type II/III PE and in patients submitted to prior pelvic irradiation. VRAM could be used to close extended defects at the time of PE, while gracilis flaps can be used in case of VRAM complications. Fortunately, numerous choices for reconstructive surgery have been devised. As these techniques continue to evolve, it is advisable to adopt an integrated, multi-disciplinary approach within a tertiary medical center.

Renal anomalies in newborns with vacterel association: case series and literature review.

Nocturnal enuresis (NE) was defined by the World Health Organization (ICD-10) and the American Psychiatric Association (DSM-5) as bed-wetting in children aged >5 years. In cases of mental retardation, the developmental age may be equivalent to 5 years. In this review, we focus on the current knowledge about the etiology of enuresis and the most recent therapeutical options. Both non-pharmacological and pharmacological therapies are included, although the relative effectiveness of each remains uncertain. To date, motivational, alarm and drug therapies are the mainstay of treatment. Alarm therapy remains the first-line treatment modality for NE, while desmopressin is the most commonly used medical treatment.

Different concentration of human cord blood HMGB1 according to delivery and labour: A pilot study.

OBJECTIVE: Oxidative stress is involved in several maternal conditions characterized both by an increase in free radicals synthesis and a parallel decrease in the antioxidant activity. Parturition induces considerable oxidative stress and many inflammatory mediators, among which HMGB1, are involved from the beginning of pregnancy to the birth of the infant. We evaluated serum cord blood HMGB1 levels in a population of neonates to investigate correlation with mode of delivery, as well as the influence of labour. SETTING AND PATIENTS: The study subjects were 325 neonates delivered at University Hospital "G. Martino" of Messina over an 18-month period. Following cord separation, venous blood sampling was performed on umbelical cords. RESULTS: In the cord venous blood, we found HMGB1 values significantly more elevated in spontaneous vaginal group when compared to elective or emergency caesarean section group. Regarding labour, umbilical cord venous blood HMGB1 levels were significantly higher in the spontaneous and induced labour group, compared to non-labouring women. CONCLUSION: These results could highlight a possible role of HMGB1 during birth time related to mode of delivery and labour.

Preterm birth: incidence, risk factors and second trimester cervical length in a single center population. A two-year retrospective study.

OBJECTIVE: To report the incidence and the major risk factors (RFs) associated with preterm birth (PTB), combining both maternal RFs and cervical length (CL), and to understand if cervical length measurement is really useful in all the patients. PATIENTS AND METHODS: The study population consisted of 2048 women admitted to the Department of Obstetrics and Gynecology, University Hospital of Messina, over a 2-year period. Preterm cases represented approximately 8.64% of our total population and, exactly, 65% were late preterm, 32% were preterm, and 3% were extremely preterm. RESULTS: An analysis of PTB sub-categories based on gestational age showed a stronger correlation between gestational age and CL among preterm and extremely preterm, while no correlation was found among late preterm. Between preterm cases and controls, there was a significant difference in pre-pregnancy weight and Body Mass Index (BMI). Moreover, a significant association between PTB and uterine anomalies, poli-oligodramnios and hypertension was found. CONCLUSIONS: We strongly suggest adding a transvaginal ultrasound CL universal screening to all pregnant women at the time of the second trimester ultrasound. We encourage further studies to identify new RFs of PTB and to define the mechanisms by which risk factors are related to PTB.

Association between maternal serum high mobility group box 1 levels and pregnancy complicated by gestational diabetes mellitus.

BACKGROUND AND AIMS: Gestational diabetes mellitus (GDM), is characterized by chronic, low-grade subclinical inflammation with altered production of cytokines and mediators. Recently, a new protein acting as a "danger signal", high mobility group box 1 (HMGB1), that migrates quickly during electrophoresis, has been identified. The aim of our study was to analyze serum levels of HMGB1 in pregnant women, with or without GDM, in the third trimester of pregnancy to evaluate correlation with insulin resistance and other risk factors for GDM. METHODS AND RESULTS: Seventy five pregnant women positive to the 75 g oral glucose tolerance test (OGTT) were included in the study group and 48 pregnant women who were negative to the screening test, were randomly selected using a computer-generated randomisation table. A significant positive univariate correlation was observed between serum HMGB1 levels, HOMA-IR index, glycaemia values at OGTT and pre-pregnancy BMI. Moreover, logistic regression analysis showed that serum HMGB1 was independent linked to GDM. CONCLUSION: Our study demonstrated that HMGB1, a marker of chronic inflammation, is associated to GDM and insulin resistance level, in the third trimester of pregnancy.

Cytogenetic analysis of epithelial ovarian cancer's stem cells: an overview on new diagnostic and therapeutic perspectives.

Ovarian cancer is one of the most frequent solid tumor that shows clearly biphasic behaviour in response to chemotherapy, with the majority of patients who achieved complete remission after the first cycle of chemotherapy, and subsequently present a relapse which, in most cases, leads to death. Epithelial ovarian cancer (EOC) arises as a consequence of genetic alterations that affect the cells of the ovarian surface, which leads to changes that occur through the activation of oncogenes and inactivation of tumor suppressor genes. The progression of EOC is characterized by a series of combined epigenetic aberrations, including the most important of those determined by the loss of methylation of certain regions of DNA encoding genes such as Ras-association domain-containing family 1 [(RASSF1A) tumor suppressor], death-associated protein kinase [(DAPK) protein kinase associated with the regulation of apoptosis], human sulfa- tase-I [(hSulf-1) sulfatase, which plays a key role in the regulation of apoptosis], breast cancer 1 gene [(BRCA1) tumor suppressor gene, involved in the processes of DNA repair], and HOXAI0 (gene required to promote many transcription factors). To date, accumulating evidence suggests that the initial clinical response is due primarily to the therapeutic efficacy of chemotherapy against differentiated can- cer cells that constitute the bulk of the tumor, whereas the high rate of recurrence is thought to be due to remaining drug-resistant cells, biologically distinct, identified as cancer stem cells (CSC). Current efforts are focusing on genetic and cytological definition of CSC, to guide the development of new diagnostic, and therapeutic perspectives.

Management of the second phase of labour: perineum protection techniques.

The obstetric experience alongside scientific evidences in literature indicate several management techniques during the expulsive period of labour to minimize obstetric complications. Among the various methods that can be used for the protection of the perineum during the expulsive phase, some are performed prepartum (perineum massage), while most are used during childbirth. Among the second group, progressively increasing importance is assumed by the manual techniques to protect the perineum (using the "hands-on" and "hands-off") and by episiotomy. These techniques, when used in accordance to the guidelines, may favour the reduction of adverse outcomes for both the mother and the newborn, both immediately after birth and after a longer time. The midwife should be aware of the evidences in literature so that a critical analysis of the available techniques can be made and put in action during the expulsive phase in order to protect the mother and the foetus from any unfavourable outcomes. Currently, clinical evidence in literature is directing obstetric and medical staff towards a careful analysis of the maternal-foetal parameters, in order to achieve a precise assessment of the risks factors of intrapartum and postpartum outcomes. Increasingly, there is the need for close collaboration between the midwife and medical staff to ensure proper personalized assistance based on the peculiar characteristics of the woman and the fetus.

Analysis of the Influence of Lunar Cycle on the Frequency of Spontaneous Deliveries: A Single-centre Retrospective Study.

BACKGROUND: Man, since ancient times, has been convinced of, and has researched scientific evidence that the barometric and gravitational forces play an important role in structural and biological variation of the planets, influencing the various forms of life. In particular, the synergistic relationships between variations in atmospheric pressure and gravitational forces on human gestation period have been the subject of rigorous observations and statistical calculations, which have not led to a universal conclusion in literature. OBJECTIVES: The aim of our work was to check whether there is a higher incidence of spontaneous deliveries, during the periods of full Moon than during the other phases of the Moon. METHODS: We performed a retrospective analysis of 327 non-induced vaginal deliveries in a year, divided by month. We subsequently analyzed the incidence of these deliveries during periods of full Moon Vs other lunar phases. RESULTS: We evidenced a statistically significant difference between the annual total spontaneous deliveries happened in full Moon periods Vs all other Moon phases (T= 2,3948; p=0,0256). However, we reported a discordant trend of deliveries in full Moon period, depending on each considered month. CONCLUSION: Since these differences were found both in increase and decrease, it is unacceptable the assumption of a linear correlation between periods of full Moon and increased frequency of spontaneous deliveries. For this reason, our data allow us to conclude that there is no need to increase the number of doctors and midwives in obstetric units during these periods.

Genistein aglycone: a dual mode of action anti-osteoporotic soy isoflavone rebalancing bone turnover towards bone formation.

Osteoporosis is characterized by reduced bone mass and structural deterioration of bone tissue leading to enhanced bone fragility and a consequent increase in fracture risk. Bone loss further increases in postmenopausal women when the ovaries stop making estrogens. Women undergoing treatment for osteoporosis require long-term dosing therapeutic regimens, that offer no symptomatic relief, and may cause side effects. To avoid this problem, many therapeutic alternatives have been proposed. Epidemiological data support a robust relationship between soy isoflavones, fracture incidence and bone mineral density in osteoporotic, postmenopausal women. These suggest that a high isoflavone intake, restores the metabolic balance of bone formation and resorption. However, this matter is still controversial and several reports show negative results, probably because different doses and/or isoflavones have been used. Although it is difficult to identify the specific isoflavone most involved in preventing or restoring bone loss, a review of current literature based on new encouraging preclinical and clinical data, indicates that aglycone genistein appears to be the most effective isoflavone in preserving bone health. Genistein aglycone, through a peculiar anti-osteoporotic dual mode of action, can positively regulate bone cell metabolism rebalancing bone turnover towards bone formation. Genistein in fact stimulates osteoblast and inhibits osteoclast function, mainly through the osteoprotegerin-sRANKL system. The positive results achieved by genistein aglycone intake, in terms of efficacy and safety, have stimulated the development of specially formulated medical food products for the clinical management of postmenopausal bone loss.

Laparoscopic sacrocolpopexy in the treatment of vaginal vault prolapse: 8 years experience.

OBJECTIVE: The aim of this study was to evaluate the long-term results of a laparoscopic sacrocolpopexy for the treatment of vaginal vault prolapse. STUDY DESIGN: Between January 1999 and January 2007, 165 laparoscopic sacrocolpopexy procedures, using a polypropylene mesh, were performed on women affected by vaginal vault prolapse. Intraoperative complications included: 5 bladder injuries and 3 sigmoid perforations. Postoperative complications included: 10 cases of fever, 5 cases of lumbosciatica, 15 cases of detrusor overactivity, 2 cases of vaginal haematoma, and 5 cases of minimal dispareunia. At 1, 6 and 12 months after surgery, a clinical evaluation was carried out for all patients. After this period, we contacted the women annually. RESULTS: We treated 165 women, with an average age of 67 (range 58-76 years; S.D. 19.22), average parity of 3 (range 2-5), and average body mass index of 28 (range 24-30). In many of them, more than one additional procedure was performed. At a median follow-up of 43 months (range 6-96 months), out of a total of 138 patients (27 were lost at follow-up), we obtained successful treatment in 131 women (success rate of 94.9%), with a high rate of satisfaction from the procedure. Recurrent vaginal vault prolapse was registered in seven women (5.07%): in 3, the vaginal vault collapsed after a period ranging from 7 to 20 days, caused by the use of a Vyprol mesh (hence use of same was suspended), and in a further three women the mesh detached after less than 1 month. Finally, in one case, we reported an erosion between the first and the second follow-up and the mesh was visualized in the vagina. CONCLUSIONS: Our study shows that laparoscopic sacrocolpopexy, in the hands of an expert surgeon, can be considered a safe, effective procedure for the treatment of vaginal vault prolapse, allowing long-term anatomical restoration (94.9% success rate).

Effects of genistein aglycone in osteoporotic, ovariectomized rats: a comparison with alendronate, raloxifene and oestradiol.

BACKGROUND AND PURPOSE: Genistein aglycone positively affects bone loss in postmenopausal women, but bone quality data are still lacking. To clarify this, we investigated the effects of genistein compared with alendronate, raloxifene and oestradiol in an animal model of established osteoporosis. EXPERIMENTAL APPROACH: Six months after ovariectomy, 96 ovariectomized (OVX) rats were divided into 8 equal groups, randomized to treatments (genistein aglycone (1 and 10 mg kg(-1) s.c.); alendronate (0.003 and 0.03 mg kg(-1) s.c.); raloxifene hydrochloride (0.05 and 0.5 mg kg(-1) s.c.); 17-alpha-ethinyl oestradiol (0.003 and 0.03 mg kg(-1) s.c.)) for 12 weeks. Untreated OVX (n=12) and sham OVX (n=12) were used as controls. At the beginning and end of treatment, bone mineral density (BMD) and bone mineral content (BMC) were assessed. At the end of the experiment, calcium, phosphorus, bone-alkaline phosphatase (b-ALP), collagen C-telopeptide (CTX), osteoprotegerin (OPG) and soluble receptor activator of nuclear factor-kappaB ligand (sRANKL) were assayed. Femurs were removed and tested for breaking strength and histology. KEY RESULTS: Genistein (10 mg kg(-1)) showed a greater increase in both BMD (P<0.0001 vs OVX) and BMC than all the other treatments. Moreover, genistein significantly increased breaking strength, bone quality, b-ALP (P<0.0001 vs OVX) and OPG, and reduced CTX and sRANKL compared with the other treatments at all dose levels. CONCLUSIONS AND IMPLICATIONS: The results strongly suggest that the genistein aglycone might be a new therapy for the management of postmenopausal osteoporosis in humans.

Bladder endometriosis: laparoscopic treatment and follow-up.

OBJECTIVES: This study aims to show the treatment outcome in women affected by isolated bladder endometriosis who underwent laparoscopic surgery in our units. Only women with deep nodules located in the bladder were selected, thus excluding women with deep lesions located in other sites. STUDY DESIGN: Between March 2005 and 2007, women with deep vesical endometriosis, referring to the Departments of Obstetrics and Gynaecology of University Hospitals "G. Martino"of Messina, "Paolo Giaccone"of Palermo and "San Paolo"of Milano, were respectively recruited. A preoperative assessment of the pathology was performed. Women who were concomitantly diagnosed deep nodules of the rectovaginal septum and/or endometriotic ovarian cysts were excluded. A medical therapy with oral contraceptive and/or GnRH analogues was first proposed to the patients affected. If medical treatment failed, a laparoscopic treatment was suggested. We performed a segmental resection of the involved wall or an extramucosal dissection of the bladder according to the cases. A clinical and an instrumental evaluation by ultrasound was performed every 6 months after surgery for the first year and subsequently every 12 months. At the time of referral, patients were also questioned about any recurrence of symptoms. RESULTS: Eight women, with a mean age of 33.8 (range 30-37 years; S.D.=2.5) and a mean parity of 1 (range 0-2) were recruited. Medical therapy failed in all cases and the women underwent laparoscopic treatment. Surgery was complete in all cases without a need for ureteral cannulation. No intraoperative complications occurred. The mean estimated blood loss was 98 ml (range 40-200 ml). All patients underwent at least the first follow-up assessment. In none of the women, recurrence of bladder endometriotic nodules was documented. In contrast, urinary symptoms were reported in three cases. Nevertheless, all the patients reported improvement of symptoms and declared to be satisfied. CONCLUSIONS: We recommend surgical eradication of bladder lesions. Laparoscopic treatment, in the hands of an expert surgeon, is the management of choice. It offers the best approach to the diagnosis allowing good long-term results, with a less invasive approach. Large multicentric studies are however required prior to drawing definite conclusions.

[Urinary incontinence in pregnancy and in puerperium: 3 months follow-up after delivery]. / Incontinenza urinaria in gravidanza e nel puerperio: follow-up a 3 mesi dal parto.

AIM: The aim of this clinic prospective study was to point out the predisposing risk factors for the development of urinary incontinence during pregnancy and postpartum and to understand how to prevent the symptomatology. METHODS: Sixty seven primipara women at 32 weeks of pregnancy and 3 months after the delivery, were studied through an urogynecological work-up and a questionnaire on the main urinary symptoms. RESULTS: At 32 weeks of pregnancy, 27 patients (40.29%) were affected by stress urinary incontinence (SUI) of type I and 22 (32.83%) by urge incontinence. Three months after delivery, it was observed SUI of type I in 8 patients (15.68%), SUI of type II in 9 patients (17.64%), SUI of type II and II degree cystouretrocele in 3 patients (5.8%) and urge incontinence in 14 patients (27.45%). The most frequent risk factors that were tracked down were: a vaginal delivery, with a prolonged labour, and the episiotomy. We didn't find either substantial changes in the weight between patients continent and incontinent or correlations with the patients' age or with the weight of the foetus and the symptomatology reported. CONCLUSION: It is important to understand the beginning of the urinary symptoms in the pregnant women, to prevent the worsening of it. It is required, however, a long term follow-up on our patients to verify if the urinary incontinence persists or disappears by the time is needed.

Tension-free cystocele repair: an analysis after a follow-up of 24 months.

AIM: The aim of the study is to verify whether tension free cystocele repair is really a good choice for the correction of moderate or severe cystocele. The surgical approach is transvaginal and involves the use of nonabsorbable prolene mesh. METHODS: We enrolled 177 women with a combined genital prolapse, characterized by second degree cystocele, first degree hysterocele and first degree rectocele or more severe conditions. All the patients underwent a complete urologic and gynecologic work-up before the surgical treatment consisting in a Y-shaped mesh placed on the prevesical fascia. This technique was implemented providing a tension free prosthesis. RESULTS: Our results on a total of 169 patients after a follow-up of 24 months are the following: 19 patients (11%) reported a recurrent cystocele (grade II) of which 9 patients at 6 months follow-up presented a vaginal wall erosion that determined a surgical explantation of the mesh; 2 patients (1%) showed a persistent dyspareunia and were treated with estrogen therapy that gave an improvement of the symptomatology although it did not disappear; 10 (6%) patients, among the women treated only for cystocele repair (cystocele III ), complained of stress urinary incontinence of 1st degree; and, finally, 150 patients (89%) didn't report any recurrence of cystocele. CONCLUSION: Given the good results obtained after a follow-up of 24 months (89% of the cure rate), we can consider this procedure simple, mini-invasive, reproducible and efficient with low morbidity and good tolerance. It is a promising approach in the management of pelvic floor dysfunctions that induces minimal foreign body reaction.

[Laparoscopic hysterectomy after GnRh analogue therapy]. / Isterectomia laparoscopica dopo trattamento con analoghi del GnRh.

AIM: The aim of this clinical prospective study was to evaluate the effectiveness of the GnRh analogues treatment carried out before the implementation of a laparoscopic hysterectomy on patients affected by fibromatosis and metrorrhagia. METHODS: We examined a cohort of 40 women sharing an average uterine volume of 510+/-95 cm3 observed in a time span of 22 months. Precociously, in the follicular phase we treated our sample of patients with only one ampoule of triptorelin 11.25 mg in a short-term regime. At the end of the treatment, after about 3 months, we re-scanned by ultrasound the uterine volume before carrying out the surgical treatment. RESULTS: The presurgical treatment with GnRh analogues allowed a significant reduction of the uterine volume of about 4% in 34 cases (85% patients) as confirmed by ultrasound. The Student t test revealed significant difference before and after the treatment with a P value <0.05. Further, we obtained an increase of about 2-3 g of hemoglobin. The average treatment time was of about 130 min (ranging from 110 to 160 min). The only intrasurgical complication consisted in a vescical lesion which we repaired without consequences. In the postsurgical period we incurred in only 3 cases of fever (38.5 degrees C) which required an antibiotic therapy. The average length of hospitalization was three days. CONCLUSION: The presurgical treatment with GnRh analogues can be considered a valuable option in the management of the uterine leiomyomas pathology.

[Chronic pelvic pain in women and prevalent orthostatic work. Preliminary results of a study on health staff of the surgical field]. / Dolore pelvico cronico nella donna e lavoro ortostatico prevalente. Risultati preliminari di uno studio condotto sul personale sanitario dell'area chirurgica.

BACKGROUND: The purpose of this research is to estimate the causal and/or pre-existing causal influence of some working factors, such as the standing (position) in pelvic pain syndrome, in relation to the reduction in working performance. METHODS: The research was carried out by means of an inclusive questionnaire, the purpose being to analyse anamnestic and working information. The questionnaire was proposed to a group of female sanitary staff selected in relation to their working activity. RESULTS: Examination of the questionnaire shows prominently the association between pelvic pain and orthostatic working activity, kept not below 4-6 hours each duty. In fact, 70% of the people selected have reported this mutual relationship. CONCLUSIONS: Working activities in the orthostatic position can produce pelvic pain, whose origin and intensity seem to be related to extended orthostatic working activity. The mechanism by which the upright position can produce an outbreak of pelvic pain in women seems to be linked to the compression on abdominal vessels, with slowing-down and reduction of the hematic uterine discharge.