Cell therapy as a treatment of secondary lymphedema: a systematic review and meta-analysis.

BACKGROUND: Lymphedema, the accumulation of interstitial fluid caused by poor lymphatic drainage, is a progressive and permanent disease with no curative treatment. Several studies have evaluated cell-based therapies in secondary lymphedema, but no meta-analysis has been performed to assess their efficacy. METHODS: We conducted a systematic review and meta-analysis of all available preclinical and clinical studies, with assessment of their quality and risk of bias. RESULTS: A total of 20 articles using diverse cell types were selected for analysis, including six clinical trials and 14 pre-clinical studies in three species. The meta-analysis showed a positive effect of cell-based therapies on relevant disease outcomes (quantification of edema, density of lymphatic capillaries, evaluation of the lymphatic flow, and tissue fibrosis). No significant publication bias was observed. CONCLUSION: Cell-based therapies have the potential to improve secondary lymphedema. The underlying mechanisms remain unclear. Due to relevant heterogeneity between studies, further randomized controlled and blinded studies are required to substantiate the use of these novel therapies in clinical practice.

One-Step Nucleic Acid Amplification (OSNA) of Sentinel Lymph Node in Early-Stage Endometrial Cancer: Spanish Multicenter Study (ENDO-OSNA).

The objective of this study was to evaluate the efficacy of one-step nucleic acid amplification (OSNA) for the detection of sentinel lymph node (SLN) metastasis compared to standard pathological ultrastaging in patients with early-stage endometrial cancer (EC). A total of 526 SLNs from 191 patients with EC were included in the study, and 379 SLNs (147 patients) were evaluated by both methods, OSNA and standard pathological ultrastaging. The central 1 mm portion of each lymph node was subjected to semi-serial sectioning at 200 µm intervals and examined by hematoxylin-eosin and immunohistochemistry with CK19; the remaining tissue was analyzed by OSNA for CK19 mRNA. The OSNA assay detected metastases in 19.7% of patients (14.9% micrometastasis and 4.8% macrometastasis), whereas pathological ultrastaging detected metastasis in 8.8% of patients (3.4% micrometastasis and 5.4% macrometastasis). Using the established cut-off value for detecting SLN metastasis by OSNA in EC (250 copies/µL), the sensitivity of the OSNA assay was 92%, specificity was 82%, diagnostic accuracy was 83%, and the negative predictive value was 99%. Discordant results between both methods were recorded in 20 patients (13.6%). OSNA resulted in an upstaging in 12 patients (8.2%). OSNA could aid in the identification of patients requiring adjuvant treatment at the time of diagnosis.

Factors involved in prolapse recurrence one year after anterior vaginal repair.

INTRODUCTION AND HYPOTHESIS: The aim of this study was to identify which factors are associated with anatomic and symptomatic prolapse recurrence in the anterior compartment 1 year after traditional anterior vaginal repair. Our study hypothesis was that major defects in pelvic floor support structures before surgery are associated with higher recurrence rates. METHODS: This was a prospective multicenter study including women with symptomatic anterior compartment prolapse who underwent primary vaginal surgery. Prolapse examination was performed using the Pelvic Organ Prolapse Quantification (POP-Q) system, prolapse symptoms were described using the Pelvic Floor Distress Inventory short form (PFDI-20), and levator ani avulsion and hiatal area were identified by translabial 3D ultrasonography. RESULTS: During the inclusion period, 455 patients were recruited and 442 (97.1%) attended the 1-year follow-up. In three cases, ultrasound data were not available, and the remaining 439 formed the study group. Anatomic and symptomatic recurrence rates were 45.1% and 6.8%, respectively. Levator avulsion increased the risk of anatomic (OR: 1.96) and symptomatic (OR: 2.60) recurrence; abnormal distensibility of the levator hiatal area increased the risk of anatomic (OR: 2.51) and symptomatic (OR: 2.43) recurrence; advanced prolapse increased the risk of anatomic recurrence: POP-Q stage 3 (OR: 2.34) and POP-Q stage 4 (OR: 5.47). CONCLUSIONS: Major defects in pelvic floor support structures before surgery are associated with higher recurrence rates 1 year after native tissue vaginal repair. Advanced stage of prolapse increases the risk of anatomic recurrence, while levator avulsion and abnormal distensibility of the levator hiatus area increase the risk of both anatomic and symptomatic recurrence.

Accessory polar renal artery not pre-operatively visualized at extra-peritoneal para-aortic lymphadenectomy.

The objective of this video is to describe the technique of extra-peritoneal para-aortic laparoscopic lymphadenectomy and emphasize potential vascular risks that should be taken into account during the procedure.The procedure was performed at Donostia University Hospital, a tertiary referral and educational center in San Sebastián, Spain.A 58-year-old woman, body mass index 25.4 kg/m2, G2P2, with a diagnosis of intermediate-risk endometrial adenocarcinoma, International Federation of Gynecology and Obstetrics (FIGO) IBG2 based on pre-operative endometrial histology and pre-operative magnetic resonance imaging (MRI), but upstaged to high-risk endometrial adenocarcinoma on final report (IBG3). In our hospital, risk stratification is based on pelvic MRI (myometrial invasion, cervical invasion) and biopsy (histology and grade) to tailor surgery. Computed tomography (CT) scan pre-operatively is only performed for type 2 endometrial carcinoma and grade 3 histologies.The local institutional review board was consulted, which confirmed that the study was exempt from requiring approval.The patient underwent an extra-peritoneal para-aortic laparoscopic lymphadenectomy, trans-peritoneal bilateral pelvic lymphadenectomy, and a total hysterectomy and bilateral salpingo-oophorectomy.It is mandatory to check pre-operative imaging studies in order to identify vascular anomalies that are not uncommon and may increase the risk of vascular complications.1 Frequently these vascular anomalies, such as a retro-aortic left renal vein, or a double vena cava or left vena cava, may be a casual finding in the pre-operative study, and often such findings are not reported by the radiologist. It is vitally important that the surgeon checks for and identifies any such anomolies, as the risk of complications may be decreased if anomalies of this type are detected pre-operatively.In addition, in the case of existing polar renal arteries, these are frequently not identified in the pre-operative study,2 leading to a risk of injury and partial renal necrosis. There are several anatomical variations of the renal arteries, with an aortic lower polar artery found in 3% of cadavers and 1% of patients on CT, more frequently on the right side.3 Renovascular hypertension4 secondary to an injury of an accessory polar renal artery (APRA) has also been described.Although vascular anomalies, especially venous ones, are more frequently found at the infra-renal left level, in this video we show access to the right side of the dissection and the care that needs to be taken in order not to damage a vascular structure at this level. Special caution is required with the right side of the dissection so as not to injure any perforating veins, including Fellow's vein, when pushing all the nodes to the roof of the dissection.The dissection maneuvers are fine and blunt, establishing bridges of tissue to be sectioned, and thus identifying vascular structures, such as a right APRA that is to be identified and preserved.The surgeon must have a good knowledge of retro-peritoneal vascular anatomy, they should examine pre-operative imaging studies to check for vascular anomalies, and they need to possess an accurate surgical technique to avoid potential vascular injury during laparoscopic para-aortic lymphadenectomy.

Prevention of lymphorrhea in aortic lymphadenectomy.

The objective of this video 1 is to describe the technique to avoid postoperative lymphorrhea after a lumboaortic lymphadenectomy. All procedures were performed at Donostia University Hospital, a tertiary referral and educational center in San Sebastián, Spain. Lumboaortic extra-peritoneal lymphadenectomy was performed for several gynecological malignancies (endometrial and cervical cancer). During the procedure, afferent lymphatic capillaries were identified at the infra-renal aortic level and clipped to avoid retrograde lymphorrhea at this level. Numerous strategies have been described to reduce the likelihood of lymphorea and lymphocele formation.1 Harmonic scalpel and other sealing advanced devices are not useful to secure lymphatic leakage at this level, although some authors have published a clinical benefit in their use,2 while clips have been found useful to prevent leakage in other lymphatic locations.3 The use of harmonic scalpel, biological agents or surgical patch has been ineffective in our experience, but sealing clips and peritonization (marsupialization),4 once the procedure is concluded, could be an effective approach. Performing simple gestures during lumboaortic lymphadenectomy can help to reduce the appearance of posterior lymphorrhea.

Efficacy of a Fibrin Sealant (Tissucol Duo) for the Preventionof Lymphocele after Laparoscopic Pelvic Lymphadenectomy:A Randomized Controlled Trial.

STUDY OBJECTIVE: To assess the efficacy of Tissucol Duo (Baxter AG, Vienna, Austria) fibrin sealant in decreasing the incidence of lymphocele (LC) after pelvic laparoscopic lymph node dissection using harmonic shears. DESIGN: Randomized controlled trial (Canadian Task Force classification level I). SETTING: Tertiary referral and educational center. PATIENTS: Seventy-four patients randomized to the use of sealant per hemipelvis. INTERVENTION: Fibrin sealant. MEASUREMENTS AND MAIN RESULTS: After bilateral pelvic lymphadenectomy a fibrin sealant was used in 1 hemipelvis but not the other, applied in 41 patients (55.4%) to the left and 33 patients (44.6%) to the right hemipelvis. The primary outcome was the incidence of LC after surgery in symptomatic and asymptomatic patients. Imaging (ultrasound, computed tomography, and magnetic resonance) was performed to detect LC at 3, 6, and 12 months after surgery. Overall, 26 patients (35.1%) developed LC, and 4 were symptomatic (5.4%). Allowing patients to serve as their own treatment group and control, the hemipelvis treated with Tissucol Duo corresponding to the treatment group and that not treated to the control group, LCs were found in 17 (23%) and 14 (19%) cases, respectively, but the difference was not significant. The mean initial LC maximum diameter was 27.1 mm (standard deviaiotn, 35.2), and LCs tended to decrease in size during the first year to a mean of 8.7 mm. CONCLUSION: Application of Tissucol Duo fibrin sealant after laparoscopic pelvic lymphadenectomy using ultrasonic shears does not decrease the occurrence of symptomatic or asymptomatic LC.

Extrofia vesical en el recién nacido. Diagnóstico antenatal y postnatal / Bladder exstrophy in the newborn. Antenatal and postnatal diagnosis

Entre las semanas 6ª y 7ª de amenorrea, el disco embrionario se pliega en cuatro direcciones: cefálico, caudal y laterales, izquierdo y derecho. Cada uno de los pliegues converge a nivel del ombligo con lo que se oblitera el celoma extraembrionario. Las cinco anomalías asociadas a defectos de pared abdominal son el onfalocele, la gastrosquisis, la ectopia cordis, la anomalía body stalk y la extrofia de cloaca en la que se incluye, la extrofia vesical. Presentamos el caso de una gestante con feto afecto de genitales ambiguos diminutos cuyo diagnóstico postnatal fue la extrofia vesical (AU)

Between the 6th and 7th weeks of amenorrhea, the embryonic disc folds on both longitudinal and transverse plains. The embryonic plate converges at the level of the umbilicus, thereby closing the extracelomic area. The following five anomalies are associated with abdominal wall defects: onphalocele, gastroschisis, ectopia cordis, Body stalk anomaly and cloacal exstrophy which includes bladder extrophy. We describe the case of a pregnant woman with fetus diagnosed with ambiguous genitalia during pregnancy, and postnatal diagnosis of bladder exstrophy (AU)

Prevalence of Chlamydia trachomatis infection in parturient women in Gipuzkoa, Northern Spain.

The prevalence of Chlamydia trachomatis infection in Southern Europe is poorly understood and its identification is essential for the design of appropriate prevention policies. The prevalence of C. trachomatis in 2011-2014 was determined through polymerase chain reaction in urine samples from 11,687 unselected parturient women from the Basque Country, Spain (San Sebastián area). The overall age-adjusted prevalence was 1.0 % (95 % CI 0.8-1.2). The prevalence of infection in women younger than 25 years was 6.4 % and decreased substantially with increasing age: 2.0 % in 25-29 year-olds and 0.5 % in older women (P < 0.001). The prevalence was higher in parturient of foreign origin (1.9 %, 95 % CI 1.3-2.5) than in Spanish parturients (0.8 %, 95 % CI 0.6-1.0), (P < 0.001). The results of this study support the need to screen young women as part of antenatal care in Spain.