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BACKGROUND: Placenta accreta spectrum (PAS) disorders are associated with a high risk of maternal morbidity, especially when surgery is performed in emergency conditions. In this context we aimed to report on the incidence of emergency cesarean section (CS) in patients with a high probability of placenta accreta spectrum (PAS) disorders on prenatal imaging and to compare the maternal and neonatal outcomes of patients requiring compared to those not requiring an emergency CS. DATA SOURCES: Medline, Embase, Cochrane and Clinicaltrial.gov databases were searched. STUDY ELIGIBILITY CRITERIA: Case-control studies reporting the outcome of pregnancies with high probability of PAS on prenatal imaging confirmed at birth delivered by unplanned emergency CS for maternal or fetal indications compared to those who had a planned elective CS. The outcomes observed were the occurrence of emergency CS, incidence of placenta accreta and increta/percreta, preterm birth < 34 weeks of gestation and indications for emergency delivery. We analyzed and compared the outcomes of patients with emergency CS with those with elective including: estimated blood loss (EBL) (ml), number of packed red blood cells (PRBC) units transfused and blood products transfused, transfusion of more than 4 units of PRBC ureteral, bladder or bowel injury, disseminated intra-vascular coagulation (DIC), re-laparotomy after the primary surgery, maternal infection or fever, wound infection, vesicouterine or vesicovaginal fistula, admission to neonatal intensive care unit, maternal death, composite neonatal morbidity, admission to NICU, fetal or neonatal loss, Apgar score < 7 at 5 minutes, neonatal birthweight. STUDY APPRAISAL AND SYNTHESIS METHOD: Quality assessment of the included studies was performed using the Newcastle-Ottawa Scale for case-control and cohort studies Random-effect meta-analyses of proportions, risk and mean differences were used to combine the data. RESULTS: Eleven studies with 1290 pregnancies complicated by PAS were included in the systematic review. Emergency CS was reported in 36.2% (95% CI 28.1-44.9) pregnancies with PAS at birth, of which 80.3% (95% CI 36.5-100) occurred before 34 weeks of gestation. The main indication for emergency CS was antepartum bleeding which complicated 61.8% (95% CI 32.1-87.4) of the cases. Emergent CS had a higher EBL during surgery (pooled MD 595 ml, 95% CI 116.1-1073.9, p< 0.001), PRBC (pooled MD 2.3 units, 95% CI 0.99-3.6, p< 0.001) and blood products (pooled MD 3.0, 95% CI 1.1-4.9, p= 0.002) transfused compared to scheduled CS. Patients with emergency CS had a higher risk of requiring transfusion of more than 4 units of PRBC (OR: 3. 8, 95% CI 1.7-4.9; p= 0.002) bladder injury (OR: 2.1, 95% CI 1.1-4.00; p= 0.003), DIC (OR 6.1, 95% CI 3.1-13.1; p<0.001) and admission to ICU (OR 2.1, 95% CI 1. 4-3.3; p<0.001). Newborns delivered in emergency had a higher risk of adverse composite neonatal outcome (OR 2.6, 95% CI 1.4-4.7; p= 0.019), admission to NICU (OR: 2.5, 95% CI 1.1-5.6; p= 0.029), Apgar score <7 at 5 minutes (OR 2.7, 95% CI 1.5-4. 9; p= 0.002) and fetal or neonatal loss (OR: 8.2, 95% CI 2.5-27.4; p<0.001. CONCLUSIONS: Emergency CD complicates about 35% of pregnancies affected by PAS disorders and is associated with a higher risk of adverse maternal and neonatal outcome. Large prospective studies are needed to evaluate the clinical and imaging signs that can identify those patients with a high probability of PAS at birth, at risk of requiring an emergency CS, intrapartum hemorrhage and peri-partum hysterectomy.
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OBJECTIVES: Extracellular vesicles (EVs) are cell-derived particles released during different pathophysiological processes and emerging as relevant players in inter-cellular crosstalk. Previous studies have highlighted the role of EVs as potential biomarkers for several pregnancy complications, including miscarriage, pre-eclampsia and gestational diabetes. Despite that, the actual distribution of EVs through gestation has not been reported yet. The aim of this study was to report the concentration of different sub-types of EVs in the first, second and third trimester of pregnancy and to correlate them with different pregnancy and ultrasound characteristics. STUDY DESIGNS: Prospective observational study including uncomplicated pregnancies in the first, second and third trimester of pregnancy. The first aim of the study was to report the concentration of the EVs derived from endothelial, epithelial, platelet and leukocyte cells of maternal peripheral blood samples in the first, second and third trimester pregnancy using polychromatic flow cytometry. The secondary aim was to correlate EVs with neonatal birthweight and fetal Dopplers, including uterine and umbilical arteries. Un and multivariate analyses were used to compute the data. RESULTS: 64 women (20 in the first, 22 in the second and 22 in the third trimester of pregnancies) were included in the analysis. There was no difference in the median concentration of either platelet, leukocyte and endothelial EVs between the first, second and third trimester of pregnancy. The concentration of epithelial derived EVs was higher in the third compared to first and second trimester of pregnancy. When analyzing the percentage of EV vesicles through gestation, there was no difference in the percentage of either leukocyte or endothelial EVs through gestation. Conversely, the median percentage of platelet derived vesicles was higher in the first (48.7 %, IQR 34.1-58.5) compared to second (34.0 %, IQR 22.7-44.9) and third (9.13 %, IQR 5.01-12.1) trimester of pregnancy, while the median percentage of third trimester (6.01, IQR 2.42-7.34) epithelial derived vesicles was higher than that of the second (1.53 %, IQR 0.65-2.98), but not of the first (4.45 %, IQR 1.44-6.07) trimester. Finally, we found no association between the median concentration or percentage of endothelial, epithelial, leukocyte vesicles, neonatal birthweight and fetal or maternal Dopplers. CONCLUSIONS: Distribution of EVs examined does not change during the three trimesters of pregnancy and is not influenced by neonatal birthweight or maternal and fetal Dopplers. The findings from this study allows a more objective interpretation of studies comparing EVs in pregnancies with compared to those without obstetric complication. EVs in future can be used for "liquid biopsy" for the early diagnosis of pathological pregnancies up to the development of possible screening protocols.
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Diabetes Gestacional , Vesículas Extracelulares , Gravidez , Recém-Nascido , Humanos , Feminino , Peso ao Nascer , Trimestres da Gravidez , Terceiro Trimestre da GravidezRESUMO
Endometrial carcinoma (EC) harboring POLE exonuclease domain mutations occurs in 5-15% of ECs and frequently affects young women with low body mass index (BMI). It presents at early stage as high grade endometrioid histotype with intense tumor infiltrating lymphocytes and has good clinical outcomes and favorable prognosis. In this article we report the case of a 32-year-old woman with endometriod EC (EEC) exhibiting a "ultramutated" molecular profile and an excellent prognosis despite tumor size and grading. Herein, to highlight the importance of defining POLE status in ECs for both clinical and therapeutic implications for patients.
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Carcinoma Endometrioide , Neoplasias do Endométrio , Humanos , Feminino , Adulto , Carcinoma Endometrioide/diagnóstico , Carcinoma Endometrioide/genética , Carcinoma Endometrioide/patologia , Mutação , Proteínas de Ligação a Poli-ADP-Ribose/genética , Neoplasias do Endométrio/diagnóstico , Neoplasias do Endométrio/genética , Neoplasias do Endométrio/patologia , Prognóstico , Exonucleases/genéticaRESUMO
Placental site trophoblastic tumor (PSTT), also known as atypical choriocarcinoma, syncytioma, chorioepitheliosis or trophoblastic pseudotumor, is a rare gestational trophoblastic disease (0.25-5% of all trophoblastic tumors) and it is composed by neoplastic proliferation of intermediate trophoblasts at placental implantation site. It consists of aggregates or sheets of large, polyhedral to round, predominantly mononucleated cells with a characteristic vascular and myometrial invasion. Main differential diagnoses are gestational choriocarcinoma (GC) and epitelioid trophoblastic tumor (ETT). We present a case of PSTT in a 25-year-old woman. Neoplastic cells showed moderate/high nuclear pleomorphism, abundant amphophilic, eosinophilic and clear cytoplasm, numerous mitotic figures (10 mitoses/10 HPF), and myometrial invasion. Other features are necrosis, vascular invasion with replacement of myometrial vessels by tumor cells and hemorrhage. The patient showed typical low serum ß-hCG levels and high serum humane placental lactogen (hPL) levels.
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Coriocarcinoma , Neoplasias Trofoblásticas , Tumor Trofoblástico de Localização Placentária , Neoplasias Uterinas , Feminino , Humanos , Gravidez , Adulto , Tumor Trofoblástico de Localização Placentária/diagnóstico por imagem , Tumor Trofoblástico de Localização Placentária/cirurgia , Placenta/patologia , Gonadotropina Coriônica , Neoplasias Uterinas/diagnóstico , Neoplasias Uterinas/cirurgia , Neoplasias Uterinas/patologia , Neoplasias Trofoblásticas/diagnóstico , Neoplasias Trofoblásticas/patologia , Coriocarcinoma/diagnóstico , Coriocarcinoma/patologiaRESUMO
OBJECTIVES: To objectively assess the quality of the published clinical practice guidelines (CPGs) on the management of pregnancies complicated by placenta accreta spectrum (PAS)disorders. METHODS: MEDLINE, Embase, Scopus, and ISI Web of Science databases were searched. The following aspects related to the management of pregnancies with suspected PAS disorders were evaluated: risk factors for PAS, prenatal diagnosis, role of interventional radiology and ureteral stenting, and optimal surgical management. The assessment of risk of bias and quality assessment of the CPGs were performed using the (AGREE II) tool (Brouwers et al., 2010). To define a CPG as of good quality we adopted a cut-off score >60%. RESULTS: Nine CPGs were included. Specific risk factors for referral were assessed by 44.4% (4/9) of CPGs, mainly consisting in the presence of placenta previa and a prior cesarean delivery or uterine surgery. About 55.6% of CPGs (5/9) suggested ultrasound assessment of women with risk factors for PAS in the second and third trimester of pregnancy and 33.3% (3/9) recommended magnetic resonance imaging (MRI); 88.9% (8/9) of CPGs recommended cesarean delivery at 34-37 weeks of gestation. There was not generally consensus on the use of interventional radiology and ureteral stenting before surgery for PAS. Finally, hysterectomy was the recommend surgical approach by 77.8% (7/9) of the included CPGs. CONCLUSION: Most of the published CPGs on PAS are generally of good quality. There was general agreement among the different CPGs on PAS as a regard as risk stratification, timing at diagnosis and delivery but not on the indication for MRI, use of interventional radiology and ureteral stenting.
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Placenta Acreta , Placenta Prévia , Gravidez , Feminino , Humanos , Placenta Acreta/diagnóstico , Diagnóstico Pré-Natal , Cesárea , Terceiro Trimestre da Gravidez , Estudos Retrospectivos , Placenta , Ultrassonografia Pré-NatalRESUMO
INTRODUCTION: The aim of this systematic review was to report the role of lactoferrin supplementation for the prevention of preterm birth (PTB) in women at risk. EVIDENCE ACQUISITION: PubMed and Embase databases were searched. Inclusion criteria were studies exploring maternal and perinatal outcomes in women at high-risk for preterm birth receiving compared to those not receiving lactoferrin during pregnancy. The primary outcome was preterm PTB<37 weeks; the secondary outcomes were gestational age at birth, PTB<34 and 28 weeks, preterm premature rupture of the membranes (PPROM), chorioamnionitis and admission to Neonatal Intensive Care Unit. Random effect meta-analyses were used to analyze the data. EVIDENCE SYNTHESIS: Six studies (333 pregnancies) were included. Overall, women taking lactoferrin had a lower risk of PTB<37 weeks of gestation with an OR of 0.43 (95% CI: 0.2-0.9). Likewise, gestational age at delivery was higher in women-taking compared to those not-taking lactoferrin (MD=0.46 weeks, SD=0.17, P=0.006). The other included studies explored the role of lactoferrin in affecting the inflammatory profile in the amniotic fluid of women undergoing invasive test, without reporting its actual role in preventing PTB. CONCLUSIONS: Prophylactic administration of lactoferrin can reduce the risk of PTB in women at risk. Further large and adequately powered randomized trial are needed in order to elucidate the actual role of lactoferrin in reducing the risk of preterm birth and in affecting perinatal outcomes in women at risk.
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Corioamnionite , Ruptura Prematura de Membranas Fetais , Nascimento Prematuro , Gravidez , Recém-Nascido , Feminino , Humanos , Nascimento Prematuro/prevenção & controle , Lactoferrina/uso terapêutico , Ruptura Prematura de Membranas Fetais/prevenção & controle , Corioamnionite/prevenção & controle , Unidades de Terapia Intensiva NeonatalRESUMO
INTRODUCTION: The occurrence of PAS has been recently associated with the presence of twin pregnancy. Aim of this review is to report the risk factors, histopathological correlation, diagnostic accuracy of prenatal ultrasound and clinical outcome of twin pregnancies complicated by placenta accreta spectrum (PAS) disorders. EVIDENCE ACQUISITION: PubMed, Embase, Cinahl, Clinical Trial.Gov and Google Scholar databases were searched. Inclusion criteria were studies on twin pregnancies complicated by PAS. The outcomes explored were risk factors for PAS (including placenta previa, prior uterine surgery or assisted reproductive technology, ART), histopathology (placenta accreta and increta/percreta), detection rate of prenatal ultrasound and clinical outcome, including need for blood transfusion, hysterectomy, emergency or scheduled Cesarean delivery (CD), and maternal death. Random effect meta-analyses of proportions were sued to combine the data. EVIDENCE SYNTHESIS: Two studies considering 103 pregnancies were included in this systematic review: 41.86% (95% CI 27.0-57.9) of twin pregnancies complicated by PAS disorders had a prior CD, 28.22% (95% CI 13.4-46.0) presented placenta previa and 58.14% (95% CI 42.1-73.0) of twin pregnancies were conceived by ART. 74.49% (95% CI 41.6-96.5) of PAS in twin pregnancies were placenta accreta, while 25.51% (95% CI 3.5-58.4) were placenta increta or percreta. Prenatal diagnosis of PAS in twin pregnancies was accomplished only in 27.91% (95% CI 15.3-43.7) of cases. Finally, only one study consistently reported the clinical outcome of PAS in twins. 31.67% (95% CI 20.3-45.0) of women required blood transfusion, 26.67% (95% CI 16.1-39.7) had hysterectomy, while there was no case of maternal death. 44.19% of women had an emergency CD. CONCLUSIONS: There is still limited evidence on the clinical course of PAS disorders in twin pregnancies. Placenta previa, prior uterine surgery (mainly CD), and ART are the most commonly risk factors for PAS disorders in twins. Prenatal diagnosis of PAS in twins is lower compared to what reported in singleton. Finally, about 30% of women with a twin pregnancy complicated by PAS required blood transfusion and hysterectomy.
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Morte Materna , Placenta Acreta , Placenta Prévia , Gravidez , Feminino , Humanos , Placenta Acreta/diagnóstico por imagem , Placenta Acreta/epidemiologia , Placenta Acreta/patologia , Gravidez de Gêmeos , Placenta Prévia/diagnóstico por imagem , Placenta Prévia/epidemiologia , Placenta Prévia/patologia , Fatores de RiscoRESUMO
OBJECTIVE: To report the pregnancy outcomes of women with prior endometrial cancer and endometrial hyperplasia managed with fertility-sparing treatments. METHODS: Medline and Embase databases were searched. Inclusion criteria were studies reporting the pregnancy outcomes of women who had undergone fertility-sparing treatments for endometrial hyperplasia or early endometrioid endometrial cancer. Outcomes explored were pregnancy, miscarriage and livebirth rates according to the type of progestin treatment used. Subgroup analyses according to the type of diagnostic follow-up were also performed. Meta-analyses of proportions using a random effects model were used to combine data. RESULTS: Twenty-nine studies (1036 women) were included, and 82.8% [95% confidence interval (CI) 72.3-91.2] of women achieved complete remission. Pregnancy rates were 56.3% (95% CI 41.6-70.5) with megestrol (MA) or medroxyprogesterone acetate (MPA), 63.1% (95% CI 37.0-85.6) with levonorgestrel-releasing intrauterine device (LNG-IUD), 57.9% (95% CI 37.7-76.8) with MA or MPA and metformin, 59.8% (95% CI 48.3-70.7) with MPA and LNG-IUD, 15.4% (95% CI 4.3-42.2) with gonadotropin-releasing hormone analogue (GnRHa) combined with LNG-IUD or letrozole, and 40.7% (95% CI 24.5-59.3) with LNG-IUD and GnRHa. Miscarriage rates were 17.4% (95% CI 12.2-23.4), 14.3% (95% CI 6.4-24.7), 57.9% (95% CI 37.7-76.8), 26.9% (95% CI 14.6-39.3), 100% (95% CI 34.0-100) and 18.2% (95% CI 5.1-47.7), respectively, and livebirth rates were 68.8% (95% CI 56.0-80.3), 80.8% (95% CI 69.5-90.0), 69.9% (95% CI 56.1-82.0), 25.97 (95% CI 14.6-39.3), 0% (95% CI 0-66.0) and 81.8% (95% CI 52.3-94.8), respectively. Finally, stratifying the analysis considering the endometrial sampling method alone, the pregnancy rate was 68.6% (95% CI 51.2-83.6; 10 studies, I2 = 83.5%) in women who underwent hysteroscopy and 60.5% (95% CI 53.4-67.5; 13 studies, I2 = 39.8%) in women managed with dilatation and curettage biopsy; the miscarriage and livebirth rates were 13.2% (95% CI 8.0-19.5; I2 = 0%) and 81.2% (95% CI 67.4-91.8; I2 = 67.3%), respectively, for hysteroscopy, and 25.2% (95% CI 17.8-33.3; I2 = 15.5%) and 67.5% (95% CI 58.8-75.5; I2 = 0%), respectively, for dilatation and curettage biopsy. CONCLUSION: Fertility-sparing treatment in women with endometrial cancer or hyperplasia is associated with an overall good response to therapy, good chance of achieving pregnancy and a good livebirth rate. Diagnostic follow-up with hysteroscopy was associated with a higher pregnancy rate, although this requires confirmation in adequately powered randomized trials.
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Aborto Espontâneo , Hiperplasia Endometrial , Neoplasias do Endométrio , Preservação da Fertilidade , Dispositivos Intrauterinos Medicados , Lesões Pré-Cancerosas , Aborto Espontâneo/epidemiologia , Hiperplasia Endometrial/tratamento farmacológico , Hiperplasia Endometrial/patologia , Neoplasias do Endométrio/tratamento farmacológico , Feminino , Preservação da Fertilidade/métodos , Humanos , Hiperplasia , Levanogestrel , Acetato de Medroxiprogesterona , Gravidez , Resultado da GravidezRESUMO
Extracellular vesicles (EVs) are a heterogeneous group of cell-derived submicron vesicles released under physiological or pathological conditions. EVs mediate the cellular crosstalk, thus contributing to defining the tumor microenvironment, including in epithelial ovarian cancer (EOC). The available literature investigating the role of EVs in EOC has been reviewed following PRISMA guidelines, focusing on the role of EVs in early disease diagnosis, metastatic spread, and the development of chemoresistance in EOC. Data were identified from searches of Medline, Current Contents, PubMed, and from references in relevant articles from 2010 to 1 April 2020. The research yielded 194 results. Of these, a total of 36 papers, 9 reviews, and 27 original types of research were retained and analyzed. The literature findings demonstrate that a panel of EV-derived circulating miRNAs may be useful for early diagnosis of EOC. Furthermore, it appears clear that EVs are involved in mediating two crucial processes for metastatic and chemoresistance development: the epithelial-mesenchymal transition, and tumor escape from the immune system response. Further studies, more focused on in vivo evidence, are urgently needed to clarify the role of EV assessment in the clinical management of EOC patients.
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Carcinoma Epitelial do Ovário/genética , Transição Epitelial-Mesenquimal/genética , Vesículas Extracelulares/genética , MicroRNAs/genética , Neoplasias Ovarianas/genética , RNA Neoplásico/genética , Antineoplásicos/uso terapêutico , Carcinoma Epitelial do Ovário/diagnóstico , Carcinoma Epitelial do Ovário/tratamento farmacológico , Carcinoma Epitelial do Ovário/imunologia , Comunicação Celular/efeitos dos fármacos , Linhagem Celular Tumoral , Resistencia a Medicamentos Antineoplásicos/genética , Detecção Precoce de Câncer , Transição Epitelial-Mesenquimal/imunologia , Vesículas Extracelulares/imunologia , Vesículas Extracelulares/patologia , Feminino , Regulação Neoplásica da Expressão Gênica , Humanos , Metástase Linfática , MicroRNAs/imunologia , Neoplasias Ovarianas/diagnóstico , Neoplasias Ovarianas/tratamento farmacológico , Neoplasias Ovarianas/imunologia , RNA Neoplásico/imunologia , Transdução de Sinais , Evasão Tumoral , Microambiente Tumoral/genética , Microambiente Tumoral/imunologiaRESUMO
OBJECTIVE: In this series we investigate the safety, feasibility and efficacy of our laparoscopic modified Shull technique describing the fundamental aspects of this surgical procedure in order to add a new feasible abdominal approach for apex resuspension. STUDY DESIGN: A retrospective case series of 10 patients referring to our Urogynecological department for symptomatic apical prolapse, enrolled consecutively between September 2018 and November 2018. All women underwent the presented technique which we described in detail explaining the fundamental tips and tricks of our procedure. We examined perioperative details, postoperative complication- evaluated with Clavien-Dindo's classification-, anatomical outcome and subjective satisfaction, assessed with the Patient Global Impression of Improvement questionnaire. RESULTS: All women presented symptomatic apical prolapse of II-III grade. No perioperative complications including ureteral damages were recorded. There was only one case of de novo stress urinary incontinence. At 1-year follow-up the POP-Q apex was well suspended in all women with only 2 cases of asymptomatic anterior recurrence. All patients reported a complete resolution of pelvic organ prolapse (POP)-related symptoms and were fully satisfied with the treatment received. CONCLUSION: Laparoscopic modified Shull technique suggests safety, feasible and efficacy in the treatment of apical prolapse. In addition, this report represents a useful instrument for surgeon to understand key aspects of this surgical procedure allowing to him to perform the described technique in a safe and timely manner.
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Laparoscopia , Prolapso de Órgão Pélvico , Feminino , Procedimentos Cirúrgicos em Ginecologia , Humanos , Ligamentos/cirurgia , Prolapso de Órgão Pélvico/cirurgia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
STUDY OBJECTIVE: To reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin. DESIGN: Step-by-step demonstration and explanation of technique using videos from patients. SETTING: Gynecologic oncology unit at a university hospital. PATIENT: A 54-year-old woman with uterine fibromatosis and metrorrhagia. INTERVENTION: TLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]. MEASUREMENTS AND MAIN RESULTS: Laparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature. CONCLUSION: We present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure.
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Histerectomia/métodos , Laparoscopia/métodos , Artéria Uterina/cirurgia , Estudos de Viabilidade , Feminino , Humanos , Leiomioma/patologia , Leiomioma/cirurgia , Ligadura/métodos , Metrorragia/patologia , Metrorragia/cirurgia , Pessoa de Meia-Idade , Técnicas de Sutura , Suturas , Artéria Uterina/patologia , Embolização da Artéria Uterina/métodos , Neoplasias Uterinas/patologia , Neoplasias Uterinas/cirurgia , Útero/irrigação sanguínea , Útero/cirurgiaRESUMO
OBJECTIVES: This retrospective, multicentric study investigates quality-of-life issues and emotional distress in gynecological cancer survivors submitted to pelvic exenteration (PE). METHODS: The Global Health Status scale of European Organization for Research and Treatment of Cancer (EORTC) Core Quality of Life Questionnaire (QLQ-C30; the EORTC QLQ-CX24 (CX24), and EORTC QLQ-OV28 questionnaires were administered at least 12 months from surgery only in women with no evidence of further recurrence after PE. Statistical analysis was performed by the analysis of variance (for repeated measures. RESULTS: Ninety-six subjects affected by gynecological malignancies receiving PE were enrolled in the study. Anterior PE was performed in 47 patients (49%), posterior PE was performed in 29 cases (30.2%), and total PE performed in 20 women (20.8%). In 38 cases (39.6%), a definitive colostomy was performed. Urinary diversion with continent pouch was created in 11 patients. (11.5%), whereas in the remaining cases, a noncontinent pouch was reconstructed. Patients showed a significant discomfort in attitude to disease (71.5 ± 4.7), body image (48.9 ± 6.4), financial difficulties (56.2 ± 5.8), gastrointestinal symptoms (constipation, 47.8 ± 5.1; diarrhea, 62.4 ± 6.6; appetite loss, 43.6 ± 6.7), insomnia (64.5 ± 6.6), Global Health Status (64.6 ± 3.8), physical functioning (65.8 ± 4.6), role functioning (58.8 ± 5.8), and emotional functioning (67.4 ± 4.2). A higher number of ostomies (hazard rate [HR], 7.613; P = 0.012), the creation of a noncontinent bladder (HR, 8.230; P = 0.009), and of definitive colostomy (HR, 8.516; P = 0.008) emerged as independent predictors of poorer Global Health Status scores. Older age (HR, 11.235; P = 0.003), vaginal/vulvar cancer (HR, 7.369; P = 0.013), total/posterior PE (HR, 7.393; P = 0.013), higher number of ostomies (HR, 7.613; P = 0.012), the creation of a noncontinent bladder (HR, 8.230; P = 0.009), and of definitive colostomy (HR, 8.516; P = 0.008) emerged as independent predictors of lower body image levels. CONCLUSIONS: Long-term psycho-oncological support is strongly recommended. The reduction of ostomies seems the most effective way to improve patients' quality of life.
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Neoplasias dos Genitais Femininos/cirurgia , Exenteração Pélvica/reabilitação , Qualidade de Vida , Adulto , Idoso , Imagem Corporal/psicologia , Feminino , Neoplasias dos Genitais Femininos/epidemiologia , Neoplasias dos Genitais Femininos/psicologia , Neoplasias dos Genitais Femininos/reabilitação , Nível de Saúde , Humanos , Pessoa de Meia-Idade , Exenteração Pélvica/psicologia , Exenteração Pélvica/estatística & dados numéricos , Estudos Retrospectivos , Inquéritos e Questionários , Derivação Urinária/psicologia , Derivação Urinária/reabilitação , Derivação Urinária/estatística & dados numéricosRESUMO
OBJECTIVES: This multicentric retrospective study investigates the early and long-term self-reported urinary, bowel, and sexual dysfunctions in early-stage cervical cancer patients who submitted to laparoscopic total mesometrial resection (L-TMMR), total laparoscopic radical hysterectomy, vaginal-assisted laparoscopic radical hysterectomy, and laparoscopic-assisted radical vaginal hysterectomy. METHODS: Cervical cancer patients, FIGO (International Federation of Gynecology and Obstetrics) stage IA2-IB1/IIA1 who submitted to nerve-sparing radical hysterectomy were recruited. Pelvic functions were assessed within 30 days (early outcome) and 12 months after surgery (long-term outcome). RESULTS: Two hundred thirteen subjects receiving nerve-sparing radical hysterectomy were enrolled. Laparoscopic total mesometrial resection was performed in 46 patients (21.6%), total laparoscopic radical hysterectomy in 65 patients (30.5%), vaginal-assisted laparoscopic radical hysterectomy in 54 patients (25.4%), and laparoscopic-assisted radical vaginal hysterectomy in 48 women (22.5%). Operative time was significantly lower in the L-TMMR group (240 minutes; range, 120-670 minutes; P = 0.001). The overall perioperative complication rate was 11.3%, with no statistically significant differences among the 4 groups. Stress incontinence and sensation of bladder incomplete emptying were detected, respectively, in 54 patients (25.6%) and 65 patients (30.7%) with a significantly lower prevalence among those in the L-TMMR group, which resulted, respectively, in 11.1% (P = 0.022) and 13.3% (P = 0.036). The prevalence rates of constipation, sensation of incomplete bowel emptying, and effort during evacuation were significantly higher among those in the L-TMMR group, resulting in, respectively, 37% (P = 0.001), 42.3% (P = 0.012), and 50% (P = 0.039). One hundred forty-nine patients (70%) were sexually active. Fifty-eight women (38.9%) reported low enjoyment, 83 women (55.7%) medium enjoyment, and 8 women (5.4%) reported high enjoyment, without statistically significant differences among the 4 groups. CONCLUSIONS: Laparoscopic total mesometrial resection is associated with improved long-term urinary autonomic functions and worse gastrointestinal autonomic outcome. Further larger prospective trials are needed to evaluate both the oncological and functional outcomes in order to establish the most appropriate surgical approach for early-stage cervical cancer patients.
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Sistema Nervoso Autônomo/fisiopatologia , Neoplasias do Colo do Útero/fisiopatologia , Neoplasias do Colo do Útero/cirurgia , Adulto , Idoso , Feminino , Humanos , Histerectomia/métodos , Enteropatias/etiologia , Enteropatias/fisiopatologia , Laparoscopia , Mesentério/cirurgia , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Autorrelato , Disfunções Sexuais Fisiológicas/etiologia , Disfunções Sexuais Fisiológicas/fisiopatologia , Micção , Neoplasias do Colo do Útero/patologia , Adulto JovemRESUMO
BACKGROUND: The study aimed too investigate the rate of hepatoceliac lymph node (HCLN) involvement, as well as its association with clinicopathologic features, together with morbidity of HCLN resection and the prognostic impact of metastatic HCLN status on patients with advanced ovarian cancer (OC) undergoing cytoreductive surgery. METHODS: All consecutive patients with stages 3c to 4 epithelial OC who underwent HCLN surgery from January 2010 to September 2016 were analyzed for surgical procedures, pathology, and oncologic outcomes. RESULTS: During the study period, 85 patients underwent HCLN resection. Absence of visible tumor at the end of surgery was documented for 73 of the patients (85.9%). The median number of HCLNs removed was 6 (range 1-18). Histopathologic evaluation was able to identify HCLN metastasis in 45 (52.9%) of the 85 cases. No difference in the rate of surgical morbidity according to pathologic status of HCLN was observed. As of December 2016, the median follow-up period was 36 months (range 6-54 months). Recurrence of disease was observed in 35 (41.2%) of the 85 cases. Relapse of disease most frequently occurred for the patients with metastatic HCLN involvement (65.7%) compared with the patients who had no HCLN involvement (34.3%) (p = 0.048). The median progression-free survival values were 16 months (95% confidence interval [CI], 12-19 months) for the patients with metastatic HCLNs and 22 months (95% CI, 12-19 months) for the patients with no HCLN involvement (p = 0.035). CONCLUSIONS: The study confirmed that HCLN surgery is feasible with acceptable morbidities for patients with advanced OC. Metastatic HCLNs are a marker of disease severity associated with worst oncologic outcome.
Assuntos
Adenocarcinoma de Células Claras/patologia , Artéria Celíaca/patologia , Cistadenocarcinoma Seroso/patologia , Neoplasias do Endométrio/patologia , Neoplasias Hepáticas/secundário , Linfonodos/patologia , Neoplasias Ovarianas/patologia , Adenocarcinoma de Células Claras/cirurgia , Adulto , Idoso , Artéria Celíaca/cirurgia , Cistadenocarcinoma Seroso/cirurgia , Procedimentos Cirúrgicos de Citorredução , Neoplasias do Endométrio/cirurgia , Feminino , Seguimentos , Humanos , Neoplasias Hepáticas/cirurgia , Excisão de Linfonodo , Linfonodos/cirurgia , Metástase Linfática , Pessoa de Meia-Idade , Neoplasias Ovarianas/cirurgia , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto JovemRESUMO
STUDY OBJECTIVE: To assess the feasibility of total robotic radical surgery (TRRS) in patients with locally advanced cervical cancer (LACC) who receive chemoradiation therapy (CT/RT). DESIGN: A prospective (preplanned) study of a nonrandomized controlled trial (Canadian Task Force classification level 2). SETTING: Catholic University of the Sacred Hearth, Rome, Italy. PATIENTS: Between September 2013 and January 2016, a total of 40 patients with LACC (Fédération Internationale de Gynécologie et d'Obstétrique stage IB2-III) were enrolled in the study. INTERVENTIONS: Robotic radical hysterectomy (RRH) plus pelvic and/or aortic lymphadenectomy was attempted within 6 weeks after CT/RT. The feasibility of TRRS as well as the rate, pattern, and severity of early and late postoperative complications were analyzed. MEASUREMENTS AND MAIN RESULTS: After CT/RT, 29 patients (72.5%) underwent type B2 RRH, and 11 (27.5%) underwent type C1 RRH. Pelvic lymphadenectomy was performed in all cases. TRRS was successful in 39 of 40 cases (feasibility rate = 97.5%). In patients successfully completing TRRS, the median operating time was 185 minutes (range, 100-330 minutes), and the median blood loss was 100 mL (range, 50-300 mL). The median time of hospitalization counted from the first postoperative day was 2 days (range, 1-4 days). No intraoperative complications were recorded. During the observation period (median = 18 months; range, 4-28 months), 9 of 40 (22.5%) experienced postoperative complications, for a total number of 12 complications. As of April 2016, recurrence of disease was documented in 5 cases (12.5%). CONCLUSION: TRRS is feasible in LACC patients administered preoperative CT/RT, providing perioperative outcomes comparable with those registered in early-stage disease, and LACC patients receiving neoadjuvant chemotherapy.
Assuntos
Carcinoma de Células Escamosas/terapia , Quimiorradioterapia Adjuvante , Histerectomia/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Neoplasias do Colo do Útero/terapia , Adulto , Idoso , Carcinoma de Células Escamosas/patologia , Carcinoma de Células Escamosas/cirurgia , Terapia Combinada , Progressão da Doença , Estudos de Viabilidade , Feminino , Humanos , Histerectomia/efeitos adversos , Histerectomia/instrumentação , Laparoscopia/efeitos adversos , Laparoscopia/instrumentação , Laparoscopia/métodos , Excisão de Linfonodo/efeitos adversos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/efeitos adversos , Neoplasias do Colo do Útero/patologia , Neoplasias do Colo do Útero/cirurgiaRESUMO
STUDY OBJECTIVE: To report our experience with robotic total mesometrial resection (R-TMMR) comparing perioperative results with a series of laparoscopic total mesometrial resections (L-TMMRs). DESIGN: Multicenter retrospective case-control study (Canadian Task Force classification II-2). SETTING: Catholic University of the Sacred Heart of Rome (Italy) and Campobasso (Italy). PATIENTS: From July 2013 to August 2015 all cervical cancer patients with preoperative FIGO stage IA2 to IB1 were assessed at preoperative magnetic resonance imaging scan and clinically confirmed by investigation under anesthesia, complying strictly with the FIGO criteria. Surgical and postsurgical data of the TMMR procedures were collected. INTERVENTIONS: R-TMMR and L-TMMR for early cervical cancer were performed. MEASUREMENTS AND MAIN RESULTS: Twenty-one women underwent R-TMMR (cases) and 42 patients were submitted to L-TMMR (control subjects) for early cervical cancer. The median estimated blood loss was 150 mL in the cases and 200 mL in the control subjects (p = .992). The median operative time, calculated from the beginning of intraperitoneal procedures to skin closure, was 246 minutes in the cases and 260 minutes in the control subjects (p = .913). The median time to discharge from the hospital was postoperative days 4 (range, 2-5) and 6 (range, 4-15) for R-TMMR and L-TMMR, respectively (p = .001). CONCLUSION: The few differences we registered do not seem to be clinically relevant, thus making the 2 procedures comparable. Further prospective trials are needed to confirm our results.
Assuntos
Laparoscopia , Procedimentos Cirúrgicos Robóticos , Neoplasias do Colo do Útero/cirurgia , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Itália , Pessoa de Meia-Idade , Duração da Cirurgia , Estudos RetrospectivosRESUMO
STUDY OBJECTIVE: The aim of this study was to evaluate the surgical and oncologic outcomes of robotic hysterectomy with or without or less pelvic and aortic lymphadenectomy in severely obese patients (body mass index [BMI] ≥ 40 kg/m(2)) with endometrial cancer. MATERIAL AND METHODS: Between August 2010 and November 2014, patients with histologically confirmed endometrial cancer and BMI ≥40 kg/m(2) were deemed eligible for the study and underwent RH with or without pelvic and aortic lymphadenectomy. RESULTS: Seventy patients were divided into 3 groups according to their BMI: group A, BMI between 40 and 45 kg/m(2) (50 patients); group B, BMI between 45 and 50 kg/m(2) (10 patients); and group C, BMI above 50 kg/m(2) (10 patients). No significant statistical differences were found between the 3 groups in terms of operation time, blood loss, hospital stay, and oncologic results. Pelvic lymphadenectomy was performed in 42%, 30%, and 20% of patients in groups A, B, and C, respectively. An intraoperative complication occurred in 1 patient in group A, early postoperative complications in 4 patients in group A and in 1 patient in group C, and a late postoperative complication occurred in 1 patient in group A. No conversions to laparotomy were necessary; however, 3 patients underwent conversions to laparoscopy in group A and 1 patient in both groups B and C. CONCLUSION: Our study showed that robotic surgery in severely obese patients with endometrial cancer is safe and feasible. Moreover, it seems that an increase in BMI does not change the surgical and oncologic outcomes. However, randomized controlled trials are needed to confirm these results.
Assuntos
Neoplasias do Endométrio/cirurgia , Histerectomia , Laparoscopia , Obesidade Mórbida/complicações , Complicações Pós-Operatórias/cirurgia , Procedimentos Cirúrgicos Robóticos , Idoso , Índice de Massa Corporal , Feminino , Humanos , Histerectomia/métodos , Complicações Intraoperatórias/cirurgia , Laparoscopia/métodos , Tempo de Internação , Excisão de Linfonodo/métodos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/etiologia , Procedimentos Cirúrgicos Robóticos/métodosRESUMO
STUDY OBJECTIVE: To evaluate the feasibility of a novel laparoscopic procedure for complete eradication of diaphragmatic endometriosis (DE). DESIGN: A retrospective multicenter study (Canadian Task Force Classification II-2). SETTING: University tertiary referral centre. PATIENTS: A consecutive series of 9 women with DE. INTERVENTIONS: Laparoscopic en bloc eradication using Sugarbaker's peritonectomy technique with or without diaphragmatic resection for DE. All surgical procedures were performed by the same surgeon in 2 tertiary referral centers (Charitè University, Berlin, Germany, and Catholic University of the Sacred Heart, Foundation John Paul II, Campobasso, Italy). MEASUREMENTS AND MAIN RESULTS: Rate of conversion to laparotomy, perioperative outcomes, intra- and postoperative complications, and recurrence rate. The procedures were successfully performed in all patients laparoscopically without conversion to laparotomy. All patients also presented with multiple endometriotic lesions in the Morison pouch, and in 3 cases a deep infiltration of the right diaphragm was observed that required partial diaphragmatic resection. In 2 women, pulmonary nodules were also detected, and lung laparoscopic resection was attempted to eradicate the disease. A chest drain was placed in 7 women and was removed after a median time of 6 days (range, 4-10 days). No intra- or postoperative complications were recorded. To complete the diaphragmatic peritonectomy, the median operative time required was 180 minutes (range, 90-240 minutes). The median estimated blood loss was 100 mL (range, 50-300 mL), and the median hospital stay was 10 days (range, 5-17 days). After a median follow-up of 6 months, we observed symptomatic relief for all study patients without major surgery-related morbidity. In 1 woman, laparoscopic adhesiolysis was performed after 18 months from surgery without signs of recurrent endometriosis. CONCLUSION: Laparoscopic en bloc eradication of DE with Sugarbaker's peritonectomy is highly effective in the management of symptomatic DE, with no major intra-/postoperative complications and very favorable perioperative outcomes.