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1.
Minerva Ginecol ; 72(1): 30-35, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32153161

RESUMO

INTRODUCTION: Myasthaenia gravis (MG) is the most common disease of the neuromuscular junction; clinical presentation of the disease includes a variety of symptoms, the most frequent beign the only ocular muscles involvement, to the generalized myasthenic crisis with diaphragmatic impairment and respiratory insufficiency. It is most common in women between 20 ad 40 years. EVIDENCE ACQUISITION: We performed a comprehensive search of relevant studies from January1990 to Dicember 2019 to ensure all possible studies were captured. A systematic search of Pubmed databases was conducted. EVIDENCE SYNTHESIS: Pregnancy has an unpredictable and variable effect on the clinical course of MG; however, a stable disease before is likely not to relapse during pregnancy. exacerbations can still occur more often during the first trimester and the post partum period. The transplacental passage of antibodies results in a neonatal transient disease, whereas the major concern is related to foetal malformations such as fetal arthrogryposis and polyhydramnios. The overall neonatal outcome described in literature is variable, perinatal mortality in women with MG is generally the same as non affected patients, although in one study the risk of premature rupture of the membranes was higher. Treatment of MG in pregnangncy includes pyridostigmine and corticosteroids, although the latter have been associated with higher risk of cleft palate, premature rupture of the membranes and preterm delivery. These drugs appear also to be safe in breastfeeding. In MG patients spontaneous vaginal delivery should be encouraged, for surgery could cause acute worsening of myasthenic symptoms; also an accurate anesthesiological evaluation must be performed prior to both general and local anesthesia due to increased risk of complications. CONCLUSIONS: Most of the myasthenic women could have uneventful pregnancy with good obstetrical outcomes, both for mother and neonate. However, a careful planning of pregnancy and multidisciplinary team approach, composed by neurologists, obstetricians, neonatologists and anesthesiologists, is required to manage these pregnancies.

2.
Minerva Ginecol ; 72(1): 55-58, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-32153165

RESUMO

INTRODUCTION: Tubal patency is one of the mandatory and necessary conditions to be granted in order to guarantee a good pregnancy rate. Numerous studies have been conducted to compare the various testing techniques for tubal evaluation in order to optimize the diagnostic-therapeutic process. Aim of this review is to clarify if hysterosalpingo-foam sonography could be considered as a useful tool not only in the diagnostic procedure, but also in treatment of infertility. EVIDENCE ACQUISITION: We performed a comprehensive search of relevant studies from January 2010 to December 2019 to ensure all possible studies were captured. A systematic search of PubMed databases was conducted. EVIDENCE SYNTHESIS: Over the years, increasingly less invasive approaches have been used to test tubal patency. For many years Laparoscopic with chromopertubation (DLS) has been considered the reference standard, then less invasive procedures have been introduced, such as hysterosalpingography (HSG). Sonohysterosalpingography (HyCoSy) represents a non-invasive procedure with accuracy comparable to HSG. Several studies have been made on different contrast agents that could be used on this procedure and recent studies considered hysterosalpingo-foam sonography (HyFoSy) procedure as a new technique used for the study of tubal function performed on unfertile women. Nowadays, HyFoSy is largely used in the study of tubal patency, but it is not completely clear the role of this technique as treatment of imperviousness of Fallopian tubes, leading to an increase in pregnancy rate after its use. CONCLUSIONS: As described in the literature for other procedures, similarly with HyFoSy, the tubal flushing improves the chance of an embryo implanting and establishing a spontaneous pregnancy. More prospective studies should be taken to better analyze the singular maternal risk fators, hoping to offer more complete indications to recommend HyFoSy.

3.
Curr Oncol Rep ; 22(3): 22, 2020 Feb 08.
Artigo em Inglês | MEDLINE | ID: mdl-32036457

RESUMO

PURPOSE OF REVIEW: The aim of this review is to determine, in the light of recent evidences, the role of lymphadenectomy in ovarian cancer. RECENT FINDINGS: The lymphadenectomy in ovarian neoplasms (LION) trial reports no better outcomes and higher complication and mortality rates associated with lymphadenectomy. Even if performed by expert hands, lymphadenectomy has a cost in terms of longer operative time, blood loss, higher rates of transfusions, and intensive unit care. If on the one hand retroperitoneal staging is not correlated to survival benefits both in early and advanced ovarian cancer, on the other hand it is associated with an increased surgery-related morbidity. Surgical treatment of isolated nodal recurrences seems to be feasible and associated with survival benefits.

4.
Eur J Obstet Gynecol Reprod Biol ; 246: 60-66, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31962257

RESUMO

BACKGROUND: Maturity of the autonomic nervous system (ANS) is of paramount importance for fetal adaptation to extrauterine life and for early neurological development. Markers of ANS maturity, such as electrophysiological heart rate parameters, are of interest as tools to determine prenatal fetal maturity. The available technology, fetal magnetocardiography is expensive and not suitable for clinical use. Detection of fetal electrocardiographic signals using traditional ECG leads on the maternal abdomen may be brought to the bedside, but is technically challenging. Our group has recently developed an innovative system consisting of a standard ECG with external leads applied on the maternal abdomen coupled with a software that extracts the fetal heart signal from the maternal noise. OBJECTIVE: To validate the use of this innovative non-invasive system to detect fetal ECG (fECG) and its ability to detect changes in electrophysiological fetal cardiac parameters associated with ANS maturation. STUDY DESIGN: we recruited 50 pregnant women between 24 and 41 weeks and they received non-invasive recording of fECG. RESULTS: fECG was measurable at all gestational ages. Fetal heart rate variability (RR interval) and other associated parameters, such as low and high frequency increased with gestational age, particularly up to the 31st week. CONCLUSIONS: This study shows that non-invasive fECG is feasible throughout a broad range of gestational ages and allows detecting electrophysiological parameters of the fetal heart that may be used a surrogate of ANS maturity. Technological implementation of this system and its further exploitation may generate new tool to estimate fetal maturity.

5.
Int J Gynaecol Obstet ; 148(2): 174-180, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31657456

RESUMO

OBJECTIVE: To evaluate the predictive value of obesity, comorbidities, and fragility on overall and severe complication rate and survival among patients surgically treated for endometrial cancer. METHODS: Consecutive patients with endometrial cancer treated at the Royal Infirmary Hospital of Edinburgh from June 1, 2015, to June 30, 2017, were retrospectively enrolled in an observational study. Considering pre-existing medical conditions, comorbidities, and complications, modified fragility index (mFI) was calculated. Logistic regression was used to evaluate predicting variables of overall (G1-G4) and severe (G3-G4) complication rate. RESULTS: One hundred patients were surgically treated for endometrial cancer. Elevated mFI >3 was related to a statistically higher access rate to the high dependency unit (HDU) or intensive care unit (ITU) (33.3% vs 6.6%, P=0.013). Overall, 31 women had postoperative complications. Using multivariate analysis, it was shown that undergoing laparotomy (odds ratio [OR] 7.06, 95% confidence interval [CI] 2.52-19.71; P<0.001) and having an mFI >3 (OR 7.19, 95% CI 1.43-36.25; P=0.021) were independent predictors of overall complications (G1-G4). Moreover, only smoking (OR 5.01, 95% CI 1.15-21.75; P=0.031) and mFI >3 (OR 5.16, 95% CI 1.07-24.94; P=0.047) were independent factors for severe complications (G3-G4). CONCLUSION: Modified fragility index was an important predictor of complications among patients treated for endometrial cancer and could be a useful tool for assisting clinicians in perioperative management.

6.
Eur J Obstet Gynecol Reprod Biol ; 244: 16-20, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31770687

RESUMO

OBJECTIVE: The present study analyzed long-term outcomes and complications of laparoscopic lateral suspension (LLS) with mesh to treat apical and anterior pelvic organ prolapse (POP). STUDY DESIGN: A prospective cohort study on 125 patients with vaginal bulge and apical +/- anterior prolapse scheduled for LLS who consecutively underwent LLS between April 2013 and January 2017 in Gynecologic Department of Santa Chiara Hospital in Trento and University of Pisa. The main outcome measure was anatomic and symptomatic POP outcome; the secondary outcomes measures were recurrence, reoperation rate, de novo posterior POP and complications. Percentage distribution of the pre- and postoperative POP-Q stages was compared at mean follow-up. Wilcoxon signed rank sum test was used to compare preoperative POP-Q stage and postoperative POP-Q stage ate mean follow up, for each patient (paired data) and for each type of prolapse. RESULTS: 120 patients were included in the study. At 2 years 89 % of patients were asymptomatic and anatomic success rate was 94.2 % for the anterior compartment, 94.9 % for the apical compartment. Concerning posterior compartment prolapse 2 (1.7 %) patients referred stage 3 de novo prolapse during follow-up. The complication rate of Clavien-Dindo >3 was 0,8 %. Repeat surgery for POP occurred in 6.4 % of cases. The appearance of POP-Q recurrences was concentrated at 6 months follow-up. BMI > 25 was correlated with de novo posterior compartment appearance during follow-up. CONCLUSIONS: LLS for the treatment of apical and anterior POP is a technique with optimal results in term of safety and effectiveness after 2 years follow-up.

7.
Case Rep Womens Health ; 24: e00151, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31709157

RESUMO

Over the last twenty years, robotic surgery has become an increasingly important form of surgical intervention. However, it can have complications. Trocar site hernia (TSH), also known as port site hernia (PSH), is an uncommon complication, but in the case of bowel incarceration or strangulation it can cause significant morbidity. The lateral trocar sites usually do not need fascial closure, given their low susceptibility to hernia development. In this paper, we present a rare case of an incarcerated TSH from an 8 mm left lateral port after robotic colposacropexy. The patient was a 74-year-old woman with fourth-degree vaginal vault prolapse. She underwent robot-assisted colposacropexy and adnexectomy and was eventually discharged 3 days after surgery, with flatus. A few hours later, the woman developed generalized malaise and acute abdominal pain in the lower left quadrant, with no flatus or bowel movements. CT imaging revealed a small bowel dilatation with a transition point along the left lateral 8 mm trocar site. Laparotomy confirmed an incarcerated ischemic small bowel loop. This required a surgical 40 cm small bowel resection. Although uncommon, TSH is an important clinical entity to recognize after minimally invasive surgery. While it is known that a trocar site port of 10 mm or more does require fascial closure, it is not known whether the same is true of lateral 8 mm sites. Further studies are needed to reconsider the importance of lateral trocar site port fascial closure after robot-assisted surgery.

9.
BMC Surg ; 19(1): 146, 2019 Oct 16.
Artigo em Inglês | MEDLINE | ID: mdl-31619236

RESUMO

BACKGROUND: Simulation in laparoscopic surgery is nowadays recognized as a valid instrument for learning and training surgeons in different procedures. However, its role as evaluation test and self-assessment tool to verify basic surgical skills is still under discussion. METHODS: Thirty-three residents in obstetrics and gynecology at University of Pisa, Italy were recruited, and they received a simulation program consisting of 5 tasks. They had to perform basic laparoscopic surgery maneuvers as creating pneumoperitoneum, positioning trocars under vision, demonstrating the appropriate use of dominant and non-dominant hand and making single stitch and knot. They were evaluated with a modified OSATs scale. RESULTS: Senior trainees had better score than junior trainees (p value< 0,005) and after different sessions of simulation scores of both groups significantly improved (p < 0,001), especially for the junior group. All the trainees reported self-assessments that matched with the evaluation of external observers demonstrating the importance of simulation also as auto-evaluation test. CONCLUSIONS: In this study, we demonstrated the role of simulation as powerful tool to evaluate and to self-assess surgical technical skills and to improve own capacities, with the use of a modified OSATs scale adapted to specific exercises.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/educação , Internato e Residência , Laparoscopia/educação , Treinamento por Simulação , Competência Clínica , Ginecologia/educação , Humanos , Itália , Cirurgiões/educação
10.
Maturitas ; 128: 1-3, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31561815

RESUMO

Sleep disorders increase in prevalence during the menopausal transition and they constitute a complex phenomenon. Insomnia, the main sleep disorder, can be a primary disorder or it can be secondary to hot flushes (HF), mood disorders, psychosocial factors, medical conditions, and other sleep disturbances, such as obstructive sleep apnoea (OSA) or restless legs syndrome (RLS). Menopausal women complaining of persistent sleep disorders should be referred to a sleep specialist for comprehensive sleep management because unrecognized and untreated sleep disorders can have dramatic health-related consequences. Women suffering from insomnia related to vasomotor symptoms (VMS) can be treated with hormone replacement therapy (HRT). Primary insomnia will be preferentially improved with cognitive behavioural therapy (CBT-I) or with non-benzodiazepine hypnotics or melatonin. CBT-I is a highly efficacious treatment for postmenopausal women with insomnia. Using antidepressants to treat sleep disruption in the absence of depression is not recommended; instead, the United States Food and Drug Administration (FDA) approved paroxetine as the first non-hormonal treatment for HF. Sleep disorders in menopausal women should not be underestimated. It is necessary to diagnose the specific causal disorder and then to provide treatment to improve sleep quality and quality of life.


Assuntos
Terapia Cognitivo-Comportamental , Fogachos/complicações , Menopausa , Transtornos do Humor/complicações , Qualidade de Vida , Transtornos do Sono-Vigília/diagnóstico , Sono , Gerenciamento Clínico , Feminino , Humanos , Pessoa de Meia-Idade , Transtornos do Sono-Vigília/etiologia , Transtornos do Sono-Vigília/terapia
11.
Int Urogynecol J ; 2019 Aug 06.
Artigo em Inglês | MEDLINE | ID: mdl-31388718

RESUMO

INTRODUCTION AND HYPOTHESIS: Robotic abdominal lateral suspension (RALS) is an innovative mini-invasive surgical technique that allows treating apical and anterior prolapse. The safety and efficacy of this strategy have not yet been tested. METHODS: We completed a prospective case series of 115 RALS to treat apical and anterior prolapse stage III or IV, with no or minimal (stage I) posterior defect. Clinical evaluation was performed with a simplified POP quantification system (POP-Q). Mean follow-up was 28 ± 4 months. Primary outcomes were objective and subjective cure; secondary outcomes were reoperation rate for recurrence, erosion rate and complications. Objective cure was defined as POP-Q ≤ 1. Subjective cure was defined as absence of vaginal bulge. Patient's satisfaction was measured using the Patient Global Impression of Improvement Scale (PGI-I). RESULTS: There was a significant improvement in POP-Q score in all treated compartments with an objective cure rate of 88.7% for the anterior and 93.1% for the apical compartment (p < 0.0001). Subjective cure rate was 82%. The emergence of de novo high rectoceles was not significant in the cohort, as much as the development of de novo stress or urge urinary incontinence. Reoperation rate for POP was 11.3% (8 recurrent cystoceles without apical descent and 5 apical and anterior relapses). No postoperative complications of Clavien-Dindo grade ≥ 3a were seen. Mesh exposure rate was 0.9%; 58.2% patients compiled a PGI-I score at 18-24 months post-surgery, reporting high satisfaction rates. CONCLUSIONS: RALS is highly effective at a mid-term follow-up for the treatment of advanced apical and anterior POP.

13.
J Robot Surg ; 13(4): 585-588, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31062181

RESUMO

Uterine fibromatosis is common in women, with an estimated prevalence of up to 15-50% after 35 years. About 80% of women affected by fibromatosis have symptoms and require medical or surgical treatment. Nowadays, the gold standard for the surgical treatment of uterine fibromatosis is the use of minimally invasive surgery. The surgical skills and improvements offered by robotic approach can be relevant in reproductive surgery, in particular in minimally invasive myomectomy. However, the lack of tactile feedback of robotic platform is an important technical drawback that can reduce the accuracy of surgical procedures. Here, we present the design and the preliminary test of the wearable fabric, yielding display wearable haptic interfaces able to generate a real-time tactile feedback in terms of stiffness for applications in gynecologic robotic surgery. We preliminarily tested the device in the simulation of a real scenario of conservative myomectomy with the final purpose of increasing the accuracy and precision during surgery. The future goal is the integration of a haptic device with the commercially available robotic surgical systems with the purpose of improving the precision and accuracy of the surgical operation, thus allowing a better understanding concerning the anatomical relationship of the target structures. This in turn could determine a change in the surgical strategy in some cases, letting some patients selected for a demolitive approach retaining their uterus. This could improve surgical outcomes in fertile women enrolled for minimally invasive surgery for uterine fibroids and may be a facilitation for young gynecological surgeons or during residency teaching plans and learning programs.


Assuntos
Procedimentos Cirúrgicos Robóticos/instrumentação , Miomectomia Uterina/métodos , Dispositivos Eletrônicos Vestíveis , Feminino , Fibroma/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/instrumentação , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Procedimentos Cirúrgicos Robóticos/métodos , Percepção do Tato , Miomectomia Uterina/instrumentação , Neoplasias Uterinas/cirurgia , Útero/cirurgia
14.
Female Pelvic Med Reconstr Surg ; 25(4): 309-312, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29389678

RESUMO

OBJECTIVE: The aim of this study is to assess the efficacy of orally administered combination of hyaluronic acid (HA), chondroitin sulfate (CS), curcumin, and quercetin for the prevention of postcoital recurrent urinary tract infection (UTI) in reproductive age women. METHODS: Ninety-eight consecutive patients in reproductive age affected by UTI were considered for the study. All 98 patients received a combination of HA, CS, curcumin, and quercetin two tablets per diem for the first month and one tablet every day for the next 5 months. We investigate recurrence of UTI with the Urinary Tract Infection Symptoms Assessment and the Pelvic Pain and Urinary Urgency Frequency. The quality of life and sexual function were valued using 36-Item Short Form Survey, Female Sexual Function Index, and the Female Sexual Distress Scale questionnaires. The same investigations were performed at the first visit and after 6 months of treatment. RESULTS: The symptoms associated with UTI significantly decreased after 6 months of treatment, in particular dysuria episodes diminished and number of voiding decreased (P < 0.0001). During the treatment period, only seven patients (7.1%) experienced a UTI recurrence, confirmed by positive urine culture with bacteriuria of greater than 10 colony forming units/mL. The Pelvic Pain and Urinary Urgency Frequency, Female Sexual Function Index, Female Sexual Distress Scale, and 36-Item Short Form Survey showed a statistically significant improvement after 6 months. CONCLUSIONS: Oral administration of a combination of HA, CS, curcumin, and quercetin is a valid and well-tolerated nonantibiotic treatment for prevention of postcoital UTI in reproductive age women.


Assuntos
Adjuvantes Imunológicos/uso terapêutico , Ácido Hialurônico/uso terapêutico , Prevenção Secundária/métodos , Infecções Urinárias/prevenção & controle , Adjuvantes Imunológicos/administração & dosagem , Administração Oral , Adulto , Anti-Inflamatórios não Esteroides/uso terapêutico , Antioxidantes/uso terapêutico , Sulfatos de Condroitina/uso terapêutico , Coito , Curcumina/uso terapêutico , Combinação de Medicamentos , Disuria/etiologia , Disuria/prevenção & controle , Feminino , Humanos , Ácido Hialurônico/administração & dosagem , Quercetina/uso terapêutico , Índice de Gravidade de Doença , Inquéritos e Questionários , Infecções Urinárias/complicações , Adulto Jovem
15.
Int Urogynecol J ; 30(5): 725-731, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-29959466

RESUMO

BACKGROUND: Minimally-invasive sacrocolpopexy is the gold standard procedure for advanced apical prolapse. Nonetheless, sacrocolpopexy has potential serious complications leading many surgeons to avoid this excellent surgical procedure. To overcome these limitations, preoperative planning with 3D models of the female pelvis is proposed. The aim of the study is to evaluate the feasibility of pelvic anatomy reconstruction with the ITK-SNAP software and highlight its potential benefits in this intervention. METHODS: Thirty patient-specific 3D models of the female pelvis were created using ITK-SNAP and the EndoCAS Segmentation Pipeline extension for image segmentation: contrast-enhanced computed tomography (CE-CT) data sets of women who underwent examinations for reasons other than prolapse were used. The distances of pelvic structures from the sacral promontory were standardised and measured, and correlations among these distances were evaluated with Spearman's correlation coefficient. RESULTS: Pelvic anatomy reconstruction was feasible for all CE-CT data sets. A statistically significant correlation was found between the distances of the cava bifurcation and common iliac vessels from the sacral promontory. An area for proximal mesh attachment was defined: it is free from the passage of iliac vessels in 97.5% of cases. A significant statistical correlation was found between the distances of the midpoint of the bispinous diameter and the uterine cervix from the sacral promontory; a process of linear regression showed that the latter measure can be estimated by multiplying the first one by 0.86. CONCLUSIONS: Pre-surgical 3D reconstructions of the female pelvis using ITK-SNAP could help achieve widespread use of sacrocolpopexy: further comparative studies are needed to evaluate the outcomes with and without their use.


Assuntos
Imagem Tridimensional/instrumentação , Pelve/anatomia & histologia , Tomografia Computadorizada por Raios X/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/efeitos adversos , Humanos , Imagem Tridimensional/normas , Laparoscopia/efeitos adversos , Prolapso de Órgão Pélvico/cirurgia , Período Pré-Operatório
16.
Gynecol Endocrinol ; 35(2): 155-159, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30324854

RESUMO

The aim of this study was to assess the effectiveness and safety of Ospemifene in the improvement of urgency component in women affected by mixed urinary incontinence (MUI) who underwent surgery with mid-urethral sling (MUS). Eighty-one patients with MUI underwent surgical intervention with MUS were enrolled. After surgical intervention 38 patients received Ospemifene 60 mg one tablet daily per os for 12 weeks. Physical examination, 3-day voiding diary, urodynamic testing were performed at the start and the follow-up after 12 weeks in the Trans-Obturator-Tape (TOT)-Alone group and TOT-Ospemifene. Patients completed the Overactive Bladder Symptom and Health-Related Quality of Life Short-Form (OAB-Q SF), International Consultation on Incontinence Questionnaire (ICIQ-UI-SF), and King' s Health Questionnaire (KHQ). A significant difference between the two groups was observed in peak flow (ml/s), in first voiding desire (ml), in maximum cystometric capacity (ml), and in detrusor pressure at peak flow (cmH2O) at urodynamic evaluation. A significative difference between the two groups at voiding diary was observed in the mean number of voids, urgent micturition episodes/24 h, urge urinary incontinence, and in nocturia events. The OAB-Q symptoms and OAB-Q (HRQL) scores after 12 weeks showed a significative difference between the two groups. Ospemifene is an effective potential therapy after MUSs in women with MUI improving urgency symptoms and quality of life.


Assuntos
Moduladores Seletivos de Receptor Estrogênico/uso terapêutico , Slings Suburetrais , Tamoxifeno/análogos & derivados , Incontinência Urinária por Estresse/terapia , Incontinência Urinária de Urgência/terapia , Procedimentos Cirúrgicos Urológicos , Idoso , Terapia Combinada , Feminino , Humanos , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida , Tamoxifeno/uso terapêutico , Incontinência Urinária por Estresse/complicações , Incontinência Urinária por Estresse/fisiopatologia , Incontinência Urinária de Urgência/complicações , Incontinência Urinária de Urgência/fisiopatologia , Urodinâmica
17.
Minerva Ginecol ; 71(1): 4-17, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30318878

RESUMO

Over the past two decades, minimally invasive surgery (MIS) abdominal surgery has increasingly been used to treat pelvic organ prolapse. Besides the several advantages associated with minimal invasiveness, this approach bridged the gap between the benefits of vaginal surgery and the surgical success rates of open abdominal procedures. The most commonly performed procedure for suspension of the vaginal apex for postoperative vaginal prolapse by robotic-assisted laparoscopy is the sacrocolpopexy. Conventional laparoscopic application of this procedure was first reported in 1994 by Nezhat et al. and had not gained widespread adoption due to lengthy learning curve associated with laparoscopic suturing. Since FDA approval of the da Vinci® robot for gynecologic surgery in 2005, minimally invasive abdominal surgery for pelvic organ prolapse has become increasingly popular, as robotic-assisted laparoscopic sacrocolpopexy is an option for those surgeons without experience or training in the conventional route. Robotic surgery has made its way into the armamentarium of POP treatment and has allowed pelvic surgeons to adapt the "gold standard" technique of abdominal sacrocolpopexy to a minimally invasive approach with improved intraoperative morbidity and decreased convalescence. In fact, repair of pelvic organ prolapse can be performed robotically, and sometimes surgeons can feel suturing and dissection during the procedures less challenging with the assistance of the robot. However, even if robotic surgery may confer many benefits over conventional laparoscopy, these advantages should continue to be weighed against the cost of the technology. To date, as long-term outcomes, evidence about robotic sacrocolpopexy for a repair of pelvic organ prolapse are not conclusive, and much more investigations are needed to evaluate subjective and objective outcomes, perioperative and postoperative adverse events, and costs associated with these procedures. It is plausible to think that the main advantage is that robotics may lead to a widespread adoption of minimally invasive techniques in the field of pelvic floor reconstructive surgery. The following review will address the development and current state of robotic assistance in treating pelvic floor reconstruction discussing available data about the techniques of robotic prolapse repair as well as morbidity, costs and clinical outcomes.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/métodos , Prolapso de Órgão Pélvico/cirurgia , Procedimentos Cirúrgicos Robóticos/métodos , Feminino , Procedimentos Cirúrgicos em Ginecologia/economia , Humanos , Laparoscopia/economia , Laparoscopia/métodos , Procedimentos Cirúrgicos Minimamente Invasivos/economia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Diafragma da Pelve/cirurgia , Procedimentos Cirúrgicos Reconstrutivos/economia , Procedimentos Cirúrgicos Reconstrutivos/métodos , Procedimentos Cirúrgicos Robóticos/economia
18.
Front Surg ; 5: 51, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30234125

RESUMO

Introduction: Surgical treatment of ureteral endometriosis is necessary to relieve urinary symptoms of obstruction and to preserve renal function. Which surgical approach to ureteral endometriosis should be considered the most appropriate is debated, due to the lack of scientific evidence. The aim of the present study is to assess the feasibility and to describe the perioperative outcomes of minimally invasive treatment of deep ureteral endometriosis using robotic assistance, highlighting the technical benefits and the limits of this approach. Method: A case-series including 31 consecutive patients affected by high-stage endometriosis including ureteral endometriosis using robotic assistance in our Department between November 2011 and September 2017. Results: All procedures were successfully completed by robotic technique, resulting in full excision of the parametrial nodules involving the ureter. Mean operating time was 184.8 ± 81 min. Mean hospital stay was 4.02 ± 3 days. Perioperative complications occurred in five patients and 4 out of 5 involved the urinary tract. Conclusions: Robotic surgery for deep infiltrating endometriosis of the ureter was feasible and allowed complete resection of ureteral nodules in all cases. No intraoperative complications arose, but a non-negligible rate of urinary tract complications was detected. This calls for a careful assessment of the benefits and specific risks associated with the use of robotic surgery for the treatment of deep infiltrating endometriosis of the ureter.

19.
Autoimmun Rev ; 17(10): 956-966, 2018 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-30118899

RESUMO

BACKGROUND: The optimal treatment of women with primary antiphospholipid syndrome (APS) is still debated. About 20-30% of women with APS remain unable to give birth to healthy neonates despite conventional treatment, consisting of prophylactic-dose heparin and low-dose aspirin. These cases are defined "refractory obstetric APS". The early identification of risk factors associated with poor pregnancy outcome could be the optimal strategy to establish criteria for additional therapies, such as hydroxychloroquine, steroids, intravenous immunoglobulin, and plasma exchange. PURPOSE: The aim of the present study was to review current literature about risk factors for poor pregnancy outcome. SEARCH METHODS: The PubMed database was used to search for peer-reviewed original and review articles concerning risk factors for pregnancy outcome in APS from 1st January 1990 to 15th January 2018. OUTCOMES: History of pregnancy morbidity and/or thrombosis, the association with SLE and/or other autoimmune diseases are well known history-based predictive factors for obstetrical complications, such as miscarriage, maternal venous thromboembolism, intrauterine foetal demise, preeclampsia, and neonatal death. Moreover, laboratory findings associated with poor pregnancy outcome are:triple antiphospholipid antibodies aPL positivity, double aPL positivity, single aPL positivity, false-positive IgM for CMV, and hypocomplementemia. Triple positivity is confirmed as the most significant risk factor by a large body of evidence. Furthermore, the abnormal uterine arteries Doppler velocimetry results are confirmed to be strongly associated with poor pregnancy outcomes in APS. The good performance of the uterine arteries velocimetry, as a negative predictive factor, was reported by different studies. On the contrary, in case of abnormal uterine arteries results, the relevance of a careful surveillance is highlighted for the high risk of maternal-foetal complications. Nevertheless, this tool is a late indicator to suggest any additional treatments. CONCLUSIONS: In order to prevent obstetrical complications and establish the optimal combination therapy, the knowledge at preconception or at the beginning of pregnancy of risk factors associated with poor pregnancy outcome could be a crucial step for management and treatment of APS. In addition, in the preconception assessment a regimen with low-dose aspirin, folic acid, and vitamin D supplementation should be offered, and a treatment strategy has to be established (conventional vs additional therapy). In fact, additional treatment has to be tailored for each patient.


Assuntos
Síndrome Antifosfolipídica/terapia , Complicações na Gravidez/terapia , Resultado da Gravidez , Anticorpos Antifosfolipídeos/análise , Síndrome Antifosfolipídica/diagnóstico , Síndrome Antifosfolipídica/imunologia , Síndrome Antifosfolipídica/patologia , Feminino , Humanos , Gravidez , Complicações na Gravidez/diagnóstico , Complicações na Gravidez/patologia , Fatores de Risco
20.
Crit Rev Oncol Hematol ; 128: 30-42, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29958629

RESUMO

Treatments for gynecological cancer include surgery, chemotherapy, and radiation. However, overall survival is not improved, and novel approaches are needed. Immunotherapy has been proven efficacious in various types of cancers and multiple approaches have been recently developed. Since numerous gynecological cancers are associated to human papilloma virus (HPV) infections, therapeutic vaccines, targeting HPV epitopes, have been developed. The advancing understanding of the immune system, regulatory pathways and tumor microenvironment have produced a major interest in immune checkpoint blockade, Indeed, immune checkpoint molecules are important clinical targets in a wide variety of tumors, including gynecological. In this review, we will describe the immunotherapeutic targets and modalities available and review the most recent immunotherapeutic clinical trials in the context of gynecological cancers. The synergic results obtained from the combination of HPV therapeutic vaccines with radiotherapy, chemotherapy, or immune checkpoint inhibitors, may underlie the potential for a novel therapeutic scenario for these tumors.


Assuntos
Biomarcadores Tumorais/antagonistas & inibidores , Vacinas Anticâncer/uso terapêutico , Pontos de Checagem do Ciclo Celular/efeitos dos fármacos , Neoplasias dos Genitais Femininos/tratamento farmacológico , Biomarcadores Tumorais/imunologia , Feminino , Neoplasias dos Genitais Femininos/imunologia , Humanos
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