Glucagon-like peptide-1 receptor agonists and safety in the preconception period.

PURPOSE OF REVIEW: Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) are becoming increasingly popular for the treatment of type II diabetes and obesity. Body mass index (BMI) thresholds at in vitro fertilization (IVF) clinics may further drive the use of these medications before infertility treatment. However, most clinical guidance regarding optimal time to discontinue these medications prior to conception is based on animal data. The purpose of this review was to evaluate the literature for evidence-based guidance regarding the preconception use of GLP-1 RA. RECENT FINDINGS: 16 articles were found in our PubMed search, 10 were excluded as they were reviews or reported on animal data. Included were 3 case reports detailing pregnancy outcomes in individual patients that conceived while on a GLP-1 RA and 2 randomized controlled trials (RCTs) and a follow-up study to one of the RCTs that reported on patients randomized to GLP-1 RA or metformin prior to conception. No adverse pregnancy or neonatal outcomes were reported. SUMMARY: There are limited data from human studies to guide decision-making regarding timing of discontinuation of GLP-1 RA before conception. Studies focused on pregnancy and neonatal outcomes would provide additional information regarding a safe washout period. Based on the available literature a 4-week washout period prior to attempting conception may be considered for the agents reviewed in this publication.

Robot-assisted laparoscopic repair of cesarean scar defect: a systematic review of clinical evidence.

We aim to assess the available evidence concerning the robot-assisted repair of cesarean scar defect. A systematic PubMed and Scopus search was conducted. All databases were assessed up to May 23, 2022. Studies reporting data on robot-assisted repair of cesarean scar defect were included in this review. Data of 34 patients are presented. The mean age of the patients was 34.8 years old. The mean number of times a woman has been pregnant (gravidity) was 3.1, while the mean number of parity among the included women was 1.9. The mean number of previous cesarean sections among the included women is 1.8. The commonest symptoms at presentation of cesarean scar defect were vaginal bleeding, dysmenorrhea, abdominal pain, secondary infertility amenorrhea and ectopic cesarean scar pregnancy. The gestational age at time of surgery ranged between 6 and 14 weeks. The mean operative time was 165.2 min, while the reported blood loss during the operation ranged between 0 and 400 ml. Bladder perforation was the only intraoperative complication reported (1 out of 34, 2.9%). No conversion to open was reported. The mean interval between the last cesarean section and the development of cesarean scar defect was 22.8 months. Subsequent pregnancy after robotic assisted repair was reported in 16 out of 34 patients (47.1%). Robot-assisted treatment for cesarean scar defect has acceptable effectiveness and risks. Based on available data, uterus-sparing therapy should be considered in patients with cesarean scar pregnancies or symptomatic cesarean scar defect who wish to preserve their fertility. Finally, the role of a combined robotic and hysteroscopic correction of cesarean scar defect for reducing the blood loss and reducing the following obstetrical complications warrants future research.

An exploratory study of associations with spontaneous preterm birth in primigravid pregnant women with a normal cervical length.

BACKGROUND: Predictors of spontaneous preterm birth in primigravid women remain undetermined. AIM: We evaluated whether biomarkers in vaginal secretions and/or differences in the dominant bacterium in the vaginal microbiome predicted the risk for spontaneous preterm birth in primigravid women with a cervical length >25mm. STUDY DESIGN: In a prospective study, 146 second trimester pregnant women with their first conception and a cervix >25mm were enrolled. The vaginal microbiome composition was characterized by analysis of 16S ribosomal RNA gene sequences. The concentrations of d- and l-lactic acid, matrix metalloproteinase (MMP) 2, 8 and 9 and tissue inhibitor of metalloproteinase (TIMP) 1 and 2 in vaginal secretions were measured by ELISA. Cervical length was determined by vaginal ultrasonography. Pregnancy outcome data were subsequently collected. There was a spontaneous preterm birth (SPTB) in 13 women (8.9%) while in an additional 8 women (5.5%) preterm delivery was medically indicated. Lactobacillus iners was the dominant vaginal bacterium in 61.5% of women with a SPTB but only in 31.2% of those who delivered at term (p = .0354). The vaginal concentration of TIMP-1 (p = .0419) and L-lactic acid (p = .0495) was higher in women with a SPTB as compared to those who delivered at term. Lactobacillus iners dominance was associated with elevated levels of TIMP-1 (p = .0434) and TIMP-2 (p = .0161) and lower levels of D-lactic acid (p < .0001) compared to when L. crispatus was dominant. CONCLUSION: In this exploratory study of primigravid women, elevations in vaginal TIMP-1 and L- lactic acid and L. iners dominance in the vaginal microbiome are associated with an increased occurrence of SPTB.

Increased male live-birth rates after blastocyst-stage frozen-thawed embryo transfers compared with cleavage-stage frozen-thawed embryo transfers: a SART registry study.

OBJECTIVE: To investigate whether there is a difference in live-birth gender rates in blastocyst-stage frozen-thawed embryo transfers (FETs) compared with those in cleavage-stage FETs. DESIGN: Retrospective cohort study. SETTING: Academic medical center. PATIENTS: All women with recorded live births who underwent FET at either the blastocyst or cleavage stage, reported to the Society for Assisted Reproductive Technology during 2004-2013. INTERVENTIONS: None. MAIN OUTCOME MEASURES: The primary outcome was live-birth gender rates. Demographic criteria were also collected. The chi-square analyses were used for bivariate associations, and multiple logistic regression models were used for adjusted associations, with all two-sided P<.05 considered statistically significant. RESULTS: A statistically significant increase was noted in the number of live male births after blastocyst-stage FET compared with that after cleavage-stage FET (51.9% vs. 50.5%). After controlling for potential confounders including age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.03, 1.08), body mass index (OR, 1.08; 95% CI, 1.04, 1.12), and male factor infertility (OR, 1.06; 95% CI, 1.03, 1.08), the increase in male live births after blastocyst-stage FET remained statistically significant. CONCLUSIONS: In patients undergoing FETs, blastocyst-stage transfers are associated with higher male gender live-birth rates compared with cleavage-stage transfers.

Changes in the Vaginal Microbiome during the Pregnancy to Postpartum Transition.

Substantial changes in the composition of the vaginal microbiome occur following the end of pregnancy. To identify potential drivers of microbiome changes in individual women during the pregnancy to postpartum transition, we evaluated vaginal samples from 48 pregnant women during their first and third trimesters and postpartum. We determined the species composition of vaginal communities and the vaginal fluid levels of compounds involved in mediating changes in host physiology and the immune system at each time point. We used linear mixed-effects models to characterize associations. Consistent with previous reports, but with a larger sample size, a US population, and variations in the dominant bacteria, the vaginal microbiome was found to be more diverse during the postpartum period. There was a lower abundance of Lactobacillus and significantly higher proportions of Streptococcus anginosus and Prevotella bivia. Moreover, we uniquely demonstrated that postpartum vaginal secretions were also altered postpartum. There were elevated levels of hyaluronan and Hsp70 and decreased levels of the D- and L-lactic acid isomers. We posit that these variations are consequences of alterations in the vagina after delivery that profoundly alter the host environment and, thus, lead to changes in the capability of different bacterial species to survive and proliferate.

Soluble T cell immunoglobulin mucin domain 3 (sTim-3) in maternal sera: a potential contributor to immune regulation during pregnancy.

OBJECTIVE: The immune checkpoint inhibitor, membrane-bound T cell immunoglobulin mucin domain 3 (Tim-3), binds to galectin-9 (gal-9) and promotes immune tolerance during pregnancy. Soluble Tim-3 (sTim-3) competes with Tim-3 for binding to gal-9 and modulates its activity. Our objective was to evaluate the influence of sTim-3 on immune responses and outcome in pregnant women. STUDY DESIGN: Peripheral blood from 71 pregnant women was separated into mononuclear cell (PBMC) and plasma fractions. The PBMCs were lysed and tested for Tim-3 by ELISA. Plasma was assayed for sTim-3, gal-9, tumor necrosis factor-α (TNF-α), interleukin-10 (IL-10) and the stress-inducible 70 kDa heat shock protein (hsp70) by enzyme-linked immunosorbent assay (ELISA). Correlations were analyzed by the Spearman rank correlation test. RESULTS: The higher the sTim-3 level in plasma the lower was the PBMC Tim-3 concentration (p = .0135), suggesting that sTim-3 results from the release of membrane-bound Tim-3. Plasma sTim3 levels were positively correlated with levels of gal-9 (p < .0001), TNF-α (p = .0071) and hsp70 (p = .0144), but not with IL-10. The sTim-3 level was positively associated (p = .0276) with gestational age at delivery. There was no association between sTim-3 and gestational age at sample collection, maternal age, gravidity, parity or body mass index. CONCLUSION: The release of Tim-3 from membranes and sTim-3 reacting with gal-9 may increase proinflammatory immunity and the stress response. The release of sTim-3 from lymphoid cells into the circulation and its binding to gal-9 may modulate Tim-3-mediated activity and help optimize immune regulation during pregnancy.

The influence of race on cervical length in pregnant women in Brazil.

OBJECTIVES: Short cervical length is a predictor of preterm birth. We evaluated if there were racial differences in variables associated with cervical length in pregnant Brazilian women. METHODS: Cervical length was determined by vaginal ultrasound in 414 women at 21 weeks gestation. All women were seen at the same clinic and analyzed by the same investigators. Women found to have a short cervix (≤25 mm) received vaginal progesterone throughout gestation. Composition of the vaginal microbiome was determined by analysis of the V1-V3 region of the gene coding for bacterial 16S ribosomal RNA. Demographic, clinical and outcome variables were determined by chart review. Subjects were 53.4% White, 37.2% mixed race and 9.4% Black. RESULTS: Pregnancy, medical history and education level were similar in all groups. Mean cervical length was shorter in Black women (28.4 mm) than in White (32.4 mm) or mixed race (32.8 mm) women (p≤0.016) as was the percentage of women with a short cervix (23.1, 12.2, 7.8% in Black, White, mixed race respectively) (p≤0.026). Mean cervical length increased with maternal age in White (p=0.001) and mixed race (p=0.045) women but not Black women. There were no differences in bacterial dominance in the vaginal microbiota between groups. Most women with a short cervix delivered at term. CONCLUSIONS: We conclude that Black women in Brazil have a shorter cervical length than White or mixed race women independent of maternal age, pregnancy and demographic history or composition of the vaginal microbiome.

Torquetenovirus Titer in Vaginal Secretions from Pregnant and Postpartum Women: Association with Absence of Lactobacillus crispatus and Levels of Lactic Acid and Matrix Metalloproteinase-8.

Vaginal samples from women with term deliveries were tested for torquetenovirus (TTV) by gene amplification, matrix metalloproteinase (MMP)-8 and D- and L-lactic acid by ELISA, and microbiome composition by analysis of the bacterial 16S ribosomal RNA gene. TTV was detected in 43.2%, 31.5%, and 41.4% of first trimester, third trimester, and postpartum samples, respectively. The viral titer was higher in postpartum than in the first (p = 0.0018) or third (p = 0.0013) trimester. The mean gestational age at delivery was lower in women positive for TTV in their first trimester (p = 0.0358). In the first and third trimester, the MMP-8 level was higher if TTV was also present (p < 0.0091). The D-lactic acid level was lower in first trimester samples if TTV was present (p = 0.0334). Lactobacillus crispatus dominance in first and third trimester samples was higher when TTV was absent (p < 0.0033). We conclude that TTV is present in the vagina in many women with normal pregnancy outcomes and that its occurrence is associated with a lack of L. crispatus dominance, an increase in vaginal MMP-8 and a decrease in D-lactic acid.

T-cell immunoglobulin mucin-3 and galectin-9 levels in peripheral blood mononuclear cells predict fetal acidemia in twin pregnancies.

Purposes: The pH in the umbilical artery at delivery provides information on the fetal environment and is related to postnatal outcomes. The ability to predict fetal acidemia at delivery would improve clinical management and neonatal well-being. We hypothesized that an alteration in maternal immunity would accompany placental changes that precede a decrease in pH in the fetal circulation in twin gestations.Methods: Peripheral blood mononuclear cells (PBMCs), obtained from 86 women with twin pregnancies, were lysed and assayed for concentrations of T-cell immunoglobulin mucin domain 3 (Tim-3) and galectin-9 (gal-9) by ELISA. Tim-3-gal-9 interaction is a primary mechanism promoting immune suppression. At delivery, the pH of arterial cord blood was determined.Results: In eight women (9.3%), the pH in the placental arteries from both twins was <7.15, indicating fetal acidosis. In the remaining 78 women the arterial pH was ≥7.15 in both twins. The median Tim-3 level was 361 pg/ml when arterial pH was <7.15 and 199 pg/ml when pH was ≥7.15 (p = .003). Similarly, gal-9 was 31.2 versus 12.4 ng/ml when pH was <7.15 or ≥7.15, respectively (p = .001). A Tim-3 concentration >260 pg/ml predicted arterial pH <7.15 with a sensitivity of 87.5%, specificity of 79.5% and negative predictive value of 98.4%. A gal-9 level >18.4 predicted arterial pH <7.15 with a sensitivity of 100%, specificity of 73.8% and a negative predictive value of 100%.Conclusion: We conclude that elevations in Tim-3 and gal-9 in PBMCs during gestation predict the subsequent occurrence of a pH <7.15 in the fetal arteries at delivery in twin gestations.

Effect of Caffeine Intake on Postoperative Ileus: A Systematic Review and Meta-Analysis.

BACKGROUND: Postoperative ileus prolongs both hospital stay and patients' morbidity, having at the same time a great impact on health care costs. Coffee, a worldwide popular, cheap beverage might have an important effect on the motility of the postoperative bowel. METHODS: PubMed, Scopus, and Cochrane Central Register of Controlled Trials were systematically searched. RESULTS: Four studies met the inclusion criteria of our meta-analysis. A total of 341 patients were included. The postoperative administration of coffee significantly reduces the time to first bowel movement, the time to first flatus and the time to tolerance of solid diet. Safe conclusions could not be drawn regarding the additional use of laxatives, the necessity for reinsertion of nasogastric tube or the need for reoperation as all the aforementioned outcomes did not present any statistically significance. None of the complications were attributed to the administration of coffee. CONCLUSION: The administration of coffee as a postoperative ileus prevention measure can change the way postoperative enhanced recovery is applied. Even though the mechanism of action of coffee is not fully known, currently available literature demonstrates a significant improvement in gastrointestinal motility without having any impact on postoperative morbidity. Studies with higher methodological quality can offer a more careful evaluation of the clinical use of this popular beverage.

Insulin-like growth factor-1 and soluble FMS-like tyrosine kinase-1 prospectively predict cancelled IVF cycles.

PURPOSE: To identify biomarkers that prospectively predict IVF cycle cancellation. METHODS: In this prospective study, sera were obtained prior to any intervention, from women about to undergo an IVF cycle. The sera were assayed by ELISA for levels of insulin-like growth factor (IGF)-1, IGF-2, IGF binding protein (BP)-1, and soluble fms-like tyrosine kinase (sFLT-1). The cancellation or progression of the IVF cycle was subsequently obtained by chart review. Associations between serum components and outcome were analyzed by the Mann-Whitney test. Receiver operator curves were constructed to evaluate the strength of the correlations between biomarkers and cycle cancellation, as assessed from the area under the curve (AUC). RESULTS: A total of 205 women were included. Twenty-seven (13.2%) cycle cancellations due to poor response were recorded. Women with a cancelled cycle had reduced anti-Mullerian hormone (AMH) values (p < 0.001) and antral follicle count (p = 0.003). There were no significant differences between the two groups with regard to age and BMI. Median concentrations of IGF-1 and sFLT-1 were elevated in sera from women whose IVF cycles were cancelled as compared to those with ongoing cycles (p = 0.015 and p < 0.001, respectively); AUC for IGF-1 and sFLT-1 were 0.67 and 0.75, respectively. Concentrations of sFLT-1 remained significantly higher in patients with cancelled cycles even after controlling for AMH levels. There were no differences in IGF-2 and IGFBP-1 levels between the two groups. CONCLUSIONS: Measurement of circulating IGF-1 and sFLT-1 levels prior to initiation of an IVF cycle has the potential to identify women whose cycles have an increased likelihood to be subsequently cancelled.

Vaginal Biomarkers That Predict Cervical Length and Dominant Bacteria in the Vaginal Microbiomes of Pregnant Women.

In many impoverished regions of the world, it may not be possible to assess two major risk factors for preterm birth: a short cervical length and the depletion of vaginal lactobacilli. We determined whether measuring specific compounds in vaginal fluid might be a simple, noninvasive, and cost-effective way to predict the bacteria that dominate the vaginal microbiome and indicate the presence of a shortened cervix (<25 mm). Vaginal fluid samples were prospectively collected from mid-trimester pregnant women, and the concentrations of d- and l-lactic acid, tissue inhibitor of matrix metalloproteinases TIMP-1 and TIMP-2, matrix metalloproteinases MMP-2 and MMP-8, the 70-kDa heat shock protein, a2 isoform of vacuolar ATPase, and sequestrome-1 were quantified by an enzyme-linked immunosorbent assay (ELISA). The compositions of vaginal microbiomes were assessed by analysis of the V1-V3 regions of 16S rRNA genes, while cervical length was determined by transvaginal ultrasonography. The vaginal microbiomes could be clustered into five community state types (CSTs), four of which were dominated by a single Lactobacillus species. The dominance of Lactobacillus crispatus or Lactobacillus jensenii in the vaginal microbiome predicted the level of d-lactic acid present. Several of the biomarkers, especially TIMP-1, in combination with the subject's age and race, were significantly associated with cervical length. Using piecewise structural equation modeling, we established a causal network that links CST to cervical length via biomarkers. We concluded that measuring levels of TIMP-1 and d-lactic acid in vaginal secretions might be a straightforward way to assess the risk for preterm birth due to a short cervix and microbiome composition.IMPORTANCE Premature birth and its complications are the largest contributors to infant death in the United States and globally. A short cervical length and the depletion of Lactobacillus species are known risk factors for preterm birth. However, in many resource-poor areas of the world, the technology to test for their occurrence is unavailable, and pregnant women with these risk factors are neither identified nor treated. In this study, we used path analysis to gain an unprecedented understanding of interactions between vaginal microbiome composition, the concentrations of various compounds in vaginal secretions, and cervical length. We identified low-cost point-of-care measures that might be used to identify pregnant women at risk for preterm birth. The use of these measures coupled with appropriate preventative or treatment strategies could reduce the incidence of preterm births in poor areas of the world that lack access to more sophisticated diagnostic methods.

Evaluation of lysophosphatidic acid in vaginal fluid as a biomarker for ovarian cancer: A pilot study.

There remains a need to differentiate between women with a benign or a malignant adnexal mass prior to surgery. As part of an ongoing evaluation of vaginal fluid compounds as potential tumor biomarkers we evaluated whether vaginal lysophosphatidic acid (LPA) predicted the subsequent diagnosis of a malignant adnexal mass. In this prospective pilot study vaginal fluid was obtained from 100 post-menopausal women referred for evaluation of a suspicious adnexal mass and tested for LPA by ELISA. Clinical data and serum CA125 results were obtained only after completion of all laboratory testing. Twenty eight of the women were subsequently diagnosed with an ovarian malignancy, four had a borderline tumor and 68 had a benign diagnosis. Among women with a malignant ovarian mass, 11 (39.3%) had an endometrioid adenocarcinoma +/- Clear cell tumor components, 6 (21.4%) had a high grade serous carcinoma, 3 (10.7%) had a mucinous tumor, 2 each (7.1%) had a malignant mixed mesodermal or a granulosa tumor and 1 each (3.6%) had a Clear cell tumor, a mixed cell tumor, leimyosarcoma or metastatic adrenal tumor. Compared to the median vaginal LPA level in women with benign lesions (1.5 µM), LPA was significantly elevated only in women with endometrioid ovarian cancer (7.9 µM) (p = 0.0137). Of the 6 endometrioid tumors in which values for both plasma CA125 and vaginal LPA were available 5 were positive only for LPA while one was only CA125 positive. Detection of LPA in vaginal secretions may be of value for the noninvasive diagnosis of endometrioid ovarian malignancies in post-menopausal women.

Contribution of Epithelial Cells to Defense Mechanisms in the Human Vagina.

PURPOSE OF REVIEW: The vaginal milieu in women differs from that of other mammals, including non-human primates, in composition of secretions, the endogenous microbiota, and level of acidity. These changes apparently reflect evolutionary variations that maximized productive responses to a uniquely human vaginal environment. This review will highlight recent findings on properties of human vaginal epithelial cells that contribute to maintenance of a healthy vaginal environment. RECENT FINDINGS: Vaginal epithelial cells are responsive to the composition of the vaginal microbiome even in women who are in apparently good health and do not exhibit any adverse physical symptoms. This is especially important during pregnancy when immune defenses are modified and an effective epithelial cell-derived anti-microbial activity is essential to prevent the migration to the uterus of bacteria potentially harmful to pregnancy progression. When Lactobacillus crispatus numerically predominates in the vagina, epithelial cell activity is low. Conversely, predominance of Lactobacillus iners, Gardnerella vaginalis, or other non-Lactobacilli evokes production and release of a large variety of compounds to minimize the potentially negative consequences of an altered microbiome. The extent of autophagy in vaginal epithelial cells, a basic process that functions to maintain intracellular homeostasis and engulf microbial invaders, is also sensitive to the external microbial environment Vaginal epithelial cells bind and release norepinephrine and upregulate their anti-microbial activity in response to external stress. Vaginal epithelial cells in women are responsive to local conditions that are unique to humans and, thereby, contribute to maintenance of a healthy milieu.

Robotic assisted laparoscopic cerclage: A systematic review.

INTRODUCTION: The gold standard in the management of cervical incompetence is cerclage via vaginal approach. Minimally invasive techniques, such as robotic, have been also described. MATERIALS AND METHODS: A systematic search was performed in PubMed and Scopus, searching evidence on robotic assisted laparoscopic cerclage in both pregnant and non pregnant women. RESULTS: Sixty-four patients were included in this study. Cervical insufficiency, failure of transvaginal cerclage, and short cervix were the most frequent indications for robotic assisted cerclage. Mean operative time was 107.3 minutes. Mean estimated blood loss was 62.8 mL. Four patients converted to laparotomy. No postoperative complications were reported. Pregnancy after robotic cerclage was reported in 59 patients with mean gestational age at delivery of 36.4 weeks. The majority of pregnant women who underwent robotic assisted cerclage gave birth to live neonates. CONCLUSION: Till now, evidence does not show a clear advantage of robotic over laparoscopic approach, under the evaluation of the current literature. However, further comparative studies might be essential to clarify the possible role of da Vinci robot in this field; this might be quite difficult even in the near future based on the fact that only five cases per year are described in the current literature.

Epigenetics and the vaginal microbiome: influence of the microbiota on the histone deacetylase level in vaginal epithelial cells from pregnant women.

BACKGROUND: Histone deacetylase (HDAC) influences the acetylation status of histones at gene promotor loci, providing an epigenetic mechanism that regulates gene expression. METHODS: We determined if variations in the composition of the vaginal microbiome in pregnant women were associated with alterations in the level of HDAC1 in vaginal epithelial cells and whether this influenced the concentration of compounds present in vaginal fluid. Vaginal epithelial cells were obtained from 150 women in their first trimester of pregnancy, lysed and assayed for HDAC1 by ELISA. Composition of the vaginal microbiome was determined by classification of sequences amplified from the V1-V3 region of bacterial ribosomal 16S rRNA genes. Vaginal secretions were assayed for total protein, matrix metalloproteinase (MMP)-8, the 70kDa heat shock protein (hsp70) and the D- and L-lactic acid isomers. RESULTS: Lactobacilli were numerically dominant in 119 (79.3%) of the women, with Lactobacillus crispatus being the most prevalent (45.3% of women). Gardnerella was the most prevalent non-Lactobacillus species (10.7% of women). The median HDAC1 level in epithelial cells was 6.1 ng/mL when lactobacilli predominated vs. 20.5 ng/mL when non-lactobacilli were dominant (P=0.0039). Levels were lowest when L. crispatus was dominant (3.8 ng/mL) and highest with Streptococcus dominance (38.1 ng/mL). The concentration of HDAC1 was negatively correlated with the D-lactic acid level (P=0.0183) and positively correlated with concentrations of MMP-8 and hsp70 (P<0.0001) in the vaginal fluid. CONCLUSIONS: We propose that the composition of the vaginal microbiome and level of D-lactic acid, by influencing the HDAC1 level in vaginal epithelial cells, may epigenetically contribute to variations in the concentration of compounds in vaginal fluid.

Outcomes of stress urinary incontinence in women undergoing TOT versus Burch colposuspension with abdominal sacrocolpopexy.

INTRODUCTION AND HYPOTHESIS: To compare postoperative rates of stress urinary incontinence (SUI) in patients with pelvic organ prolapse and SUI undergoing abdominal sacrocolpopexy (ASC) with Burch colposuspension or a transobturator tape (TOT) sling. METHODS: In this retrospective cohort study, medical records of 117 patients who underwent ASC with Burch (n = 60) or TOT (n = 57) between 2008 and 2010 at NYU Winthrop Hospital were assessed. Preoperative evaluation included history, physical examination, cough stress test (CST), and multichannel urodynamic studies (MUDS). Primary outcomes were postoperative continence at follow-up up to 12 weeks. Patients considered incontinent reported symptoms of SUI and had a positive CST or MUDS. Secondary outcomes included intra- and postoperative complications. Associations were analyzed by Fisher's exact, McNemar's and Wilcoxon-Mann-Whitney tests. RESULTS: The groups were similar regarding age, BMI, parity, Valsalva leak point pressure (VLPP), and prior abdominal surgery (p = 0.07-0.76). They differed regarding preoperative SUI diagnosed by self-reported symptoms, CST, or MUDS (TOT 89.5-94.7%, Burch 60.7-76.3%, p < 0.0001-0.007). The TOT group had lower rates of postoperative SUI (TOT 12.5%, Burch 30%, OR = 0.15, 95% CI 0.04, 0.62). Relative risk reduction (RRR) in postoperative SUI for the TOT group compared with the Burch group was 79%-86%. There were no differences concerning intra- and postoperative complications. The Burch group had a higher rate of reoperation for persistent/recurrent SUI (Burch 25%, TOT 12% p = 0.078). CONCLUSIONS: The TOT group experienced a greater reduction in postoperative incontinence, and the Burch group underwent more repeat surgeries. The TOT sling may be superior in patients undergoing concomitant ASC.

Robotic-assisted inguinal lymphadenectomy: a systematic review.

BACKGROUND: Lymphadenectomy represents the standard treatment for various types of cancer. The introduction of robotics in lymph node dissection may have an important impact on post-lymphadenectomy complications. METHODS: A systematic literature review was performed. RESULTS: In our review, robotic inguinal lymphadenectomy was performed on 51 patients. Penile squamous cell carcinoma was the most common histological type of the primary neoplasia. No intra-operative complications were reported. One case of conversion to open was reported. The mean duration of hospitalization was 2 days. The duration of drainage ranged from 7 to 72 days. The most common postoperative complications were lymphocele (13.7%), lymphedema (7.8%), cellulitis (7.8%), seroma (3.9%), abscess (3.9%), wound breakdown/wound infection (3.9%), sepsis (1.9%), prolonged lymphorrhea (1 out of 51 patients, 1.9%) and skin necrosis (1 out of 51 patients, 1.9%). CONCLUSIONS: Until now there has not been sufficient evidence regarding the role of robotics in groin lymph node dissection, though this approach appears to be safe and oncologically effective, with morbidity rates relatively lower compared to open surgery.