Cumulative Sum Analysis of Learning Curve Process for Vaginal Natural Orifice Transluminal Endoscopic Surgery Hysterectomy.

STUDY OBJECTIVE: This study aimed to evaluate the learning curve of vaginal natural orifice transuminal endoscopic surgery (vNOTES) hysterectomy in expert minimal invasive and vaginal surgery team. DESIGN: This is a cohort study on a retrospective analysis. SETTING: Department of Obstetrics and Gynecology of Cannizzaro Hospital in Catania Italy. PATIENTS: First 50 women underwent vNOTES hysterectomy between February 2021 and February 2022. INTERVENTION: vNOTES hysterectomy performed by a team with optimal skills in laparoscopic and vaginal surgery. MEASUREMENT AND MAIN RESULTS: Primary outcome was surgical time. Secondary outcomes were intraoperative and postoperative complications, length of hospitalization, and first 24-hour postoperative pain. All patients underwent hysterectomy for benign indications: 27 fibromatosis, 13 metrorrhagia, and 10 precancerous. Concomitant procedures have been bilateral adnexectomy in 35 cases and bilateral salpingectomy in 15 cases. The median age was 51 years (range, 42-64). Median body mass index was 26 kg/m2 (range, 21-42). The median operative time was 75 minutes (range, 40-110). The median hospital stay was 2 days (range, 1-4). There was 1 intraoperative adverse event (bladder lesion) and 1 postoperative grade 3 complication (hemoperitoneum). The median visual analog scale score for pain assessment during the first 24 hours after surgery was 3 (range, 1-6). The experience in our surgical center with the first 25 vNOTES hysterectomies showed an accumulation of initial experience in the first 5 cases with stable operating time and a gradual reduction of mean operating time in the subsequent 17 surgeries. The learning curve plotted by cumulative sum analysis shows 3 phases: phase 1 of competence (cases 1-5), phase 2 of proficiency (cases 6-26), and phase 3 of mastering the procedure (after the 31st case) with the management of more complex cases. CONCLUSION: vNOTES hysterectomy is a feasible and reproducible approach for benign indications with a short learning curve and low rate of perioperative complications. For a team skilled in minimally invasive surgery, 5 cases are required to rich competence and 25 to rich proficiency in vNOTES hysterectomy. Mastering phase, with the introduction of more complex cases, should be addressed after 30 surgeries.

Uterosacral Ligament Suspension Sec Shull by Vaginal Natural Transluminal Endoscopic Surgery (vNOTES).

This step-by-step video demonstrates the feasibility of the Shull technique via vaginal natural transluminal endoscopic surgery (vNOTES) in a patient experiencing pelvic organ prolapse (POP) with apical support loss. A 51-year-old woman with apical pelvic organ prolapse quantification (POP-Q) stage III and a right benign ovarian cyst underwent a total hysterectomy and bilateral adnexectomy with vaginal dome uterosacral ligament suspension performed via vNOTES. Total operating time was 82 minutes, with negligible blood loss. The patient remained in hospital for 2 days. There were no intra- or postoperative complications at 30 days post-surgery, and there was complete repair of the apical defect at 6-month follow-up. The advantages of NOTES include avoiding abdominal incisions, eliminating complications associated with the trocar sound, and reducing postoperative pain and length of hospital stay. vNOTES provides safe entry, easy access, and direct visualization of the peritoneal cavity and pelvic anatomy. The Shull technique by vNOTES is technically feasible and permits clear and safe identification of uterosacral ligaments.

Progression Free Survival, Overall Survival, and Relapse Rate in Endometrioid Ovarian Cancer and Synchronous Endometrial-Ovarian Endometrioid Cancer (SEO-EC): Results from a Large Retrospective Analysis.

Background and Objectives: We aimed to evaluate Progression Free Survival (PFS), Overall Survival (OS), and relapse rate in women affected by endometrioid ovarian cancer and synchronous endometrial-ovarian endometrioid cancer (SEO-EC). As secondary outcome, we assessed whether systematic pelvic and para-aortic lymphadenectomy could be considered a determinant of relapse rate in this population. Materials and Methods: We performed a retrospective analysis of women with diagnosis of endometrioid ovarian cancer or SEO-EC between January 2010 to September 2020, and calculated PFS, OS and relapse rate. Results: In almost all the patients (97.6%) who underwent systematic pelvic and para-aortic lymphadenectomy, there were no lymph node metastases confirmed by histology. We did not find a significant difference (p = 0.6570) for the rate of relapse in the group of women who underwent systematic pelvic and para-aortic lymphadenectomy (4/42; 9.5%) compared with the group of women who did not undergo the same procedure (1/21; 4.8%). During a median follow-up was 23 months, both PFS and OS were excellent. Conclusions: Women affected by early-stage low-grade endometrioid cancer and SEO-EC without apparent lymph node involvement at pre-operative imaging showed a very low rate of lymph node metastasis and similar relapse rate with or without lymphadenectomy.

Prognostic factors and surgical treatment in vulvar carcinoma: Single center experience.

AIM: Vulvar carcinoma represents 3-5% of all female genital cancers; the main surgical treatment is radical vulvectomy and inguinal lymphadenectomy. The aim of this study is to analyze prognostic factors in the patients underwent to primary surgery for vulvar carcinoma. METHODS: One hundred and eighteen cases of vulvar carcinoma underwent surgery between 2006 and 2016 at Operative Unit of Gynecology and Obstetrics of Cannizzaro Hospital (Catania, Italy) were retrospective analyzed. Risk factors for relapse (age, tumor size, FIGO stage, type of surgery, lymphadenectomy, margins status, metastatic nodes and radiotherapy) were evaluated by logistic regression. Univariate analysis of prognostic factors (age, tumor size, FIGO stage, metastatic inguinal nodes and type of surgery) was obtained by Cox proportional hazard model. Overall survival was calculated by Kaplan-Meier curves either for the entire population and for comparison between positive and negative variables (margin status, nodes and radiotherapy) with log-rank test to determine significance. Statistical significance was reached for P < 0.05. RESULTS: Type of surgery (radical local excision vs. radical vulvectomy) and positive inguinal nodes were identified as risk factors for relapse. Positive inguinal nodes and positive margins were identified as prognostic factors either for overall survival and disease specific survival; tumor size greater than 4 cm was identified as prognostic factors for overall survival. Overall survival was 38.4% and it was significantly higher in the patients with negative margins and nodes. CONCLUSIONS: Nodes status, resection margins, age and type of surgery represent prognostic factors have to be considered for adjuvant treatment in the patients affected from vulvar carcinoma.

HPV genotype determination and E6/E7 mRNA detection for management of HPV positive women.

BACKGROUND: Clinical management of HPV positive women is difficult since many of the infections, including high-risk oncogene genotypes (hr-HPV), are transient. Therefore only a limited number of patients have a high-grade lesion and sending all HPV positive women for colposcopy would only increase costs and unnecessary treatment, with serious psychological consequences for patients. The need has emerged to identify other HPV related markers able to correctly detect women with a high-risk of developing high-grade lesions. Genotyping and the search for E6/E7 mRNA are among the possible candidates. METHODS: The study was carried out by means of an observational analysis of the data relative to 674 HR-HPV positive women who we had observed from January 2013 to June 2015; the data had been gathered in a database at the HPV Center of the University Hospital of Catania, Italy. Women were considered eligible for this study if the following data was present in the database: Pap TEST, histologic evaluation, HPV TEST and E6/E7 mRNA detection. We calculated the Odds Ratio (OR) of woman who were mRNA positive, with CIN2+ lesions, and Odds Ratio of HPV16 positive women. RESULTS: Transcripts were detected in 23.6% (69/292) of the women with CIN1 and in 97.2% (210/220) of those with CIN2 + . Regarding genotyping, the 81,8% (180/220) of the women with CIN2+ had genotype 16, while only 18.1% (40/220) had genotype 18, 31, 33, 45. We calculated the OR in the group of HPV16 women with CIN2+ (OR = 4.62; 95% CI = 3.13 to 6.82), this value increased (OR = 106.12; 95% CI = 53.71 to 209.69) in women with CIN2+ and positive mRNA. DISCUSSION: The presence of the HPV16 genotype in our study was associated with a risk 5 times greater of developing a high-grade lesion (CIN2+) (OR = 4.62 95% CI:3.13-6.82); this supports the hypothesis that it would be opportune to have targeted protocols for the management of HPV 16 positive women. The results showed that there was an association between E6/E7 mRNA expression and histology (OR = 106.12; 95% CI = 53.71 to 209.69). The E6/E7 mRNA test showed a higher prevalence of E6 and E7 transcripts in patients with higher-grade lesions. CONCLUSION: The results of this study suggest that the HPV genotype determination and E6/E7 mRNA detection would find an important application for management of HPV positive women.

Neoadjuvant Chemotherapy plus Radical Surgery in Locally Advanced Cervical Cancer: Retrospective Single-Center Study.

BACKGROUND: Several pretreatment variables have been found to correlate with the clinical outcome of patients treated with NACT plus radical hysterectomy, such as FIGO stage, tumor size, and lymph node status. METHODS: A single-center retrospective observational study to evaluate the use of NACT in LACC, particularly in the lymph-node-positive subpopulation. The study, conducted at the Maternal and Child Department of "Cannizzaro Hospital" in Catania, included patients treated between 2009 and 2019. Multivariate analysis was performed to analyze responses to NACT according to clinicopathologic parameters. Kaplan-Meyer disease-free survival (DFS) and overall survival (OS) curves were generated according to different lymph node status subgroups. RESULTS: A total of 151 consecutive patients were enrolled in the study. Significant independent risk factors for response to NACT were preoperative tumor diameter, parametrium involvement, and lymphoma vascular space invasion (LVSI). T initial diameter at NMR was found to be the independent prognostic predictor for general (p = 0.024) and lymph node (LND) response (p = 0.028). Tumors between 2 and 6 cm have a better response to NACT than tumors > 6 cm, and LVSI absence was an independent prognostic factor for LND response to NACT. Survival DFS and OS curves were significant for positive vs. negative pathologic LND. CONCLUSIONS: Neoadjuvant chemotherapy followed by surgery cannot be considered a standard of care in patients with locally advanced cervical cancer, particularly in the subgroup with pre-NACT imaging suspected for LND metastases.

Uterine Tumours Resembling Ovarian Sex-Cord Tumors: A Case Report and Review of the Literature.

Uterine tumors resembling ovarian sex-cord tumors (UTROSCT) are thought to develop from pluripotent uterine mesenchymal cells or endometrial stromal cells with secondary sex-cord differentiation. The patient was a 73-year-old postmenopausal woman who had abnormal vaginal bleeding, and she underwent a laparoscopic hysterectomy with bilateral salpingo-oophorectomy. The diagnosis was a case of UTROSCT. A scoping review of the UTROSCT case report present in the literature has been conducted, and 63 articles were found, of which 45 were considered for the 66 clinical cases examined. At the time of diagnosis, six metastatic localizations were found in 59 patients undergoing demolitive surgery (10.2%). Recurrences were diagnosed in 13/59 (22%) patients with multiple locations. A molecular study was performed in 18/66 cases (27.3%) and genetic alterations were found in 10/18 (55.6%) patients. UTROSCTs are considered rare uterine tumors, typically with a favorable prognosis, and are generally considered to have a good prognosis. But, from the review done, they may already manifest themselves at advanced stages, with the possibility of recurrences even at a distance. It would, therefore, be important to be able to define the most aggressive forms and, perhaps, molecular investigation with sequencing could help identify patients most at risk.

Evaluation of Borderline Ovarian Tumor Recurrence Rate after Surgery with or without Fertility-Sparing Approach: Results of a Retrospective Analysis.

Borderline ovarian tumors (BOTs) comprise 15-20% of primary ovarian neoplasms and represent an independent disease entity among epithelial ovarian cancers. The present study (Clinical Trial ID: NCT05791838) aimed to report a retrospective analysis of the management and outcomes of 86 consecutive BOTs patients, 54 of which were at a reproductive age. All patients with BOTs undergoing surgical treatment from January 2010 to December 2017 were included. Data were retrospectively reviewed. High levels of Ca-125 were observed in 25.6% of the FIGO stage I patients and 58.3% of the advanced disease patients. Fertility-sparing surgery and comprehensive surgical staging were performed in 36.7% and 49.3% of the patients, respectively. Laparotomy was the most frequent surgical approach (65.1%). The most common diagnosis at frozen sections was serous BOT (50.6%). Serous BOTs have significantly smaller tumor diameters than mucinous BOTs (p < 0.0001). The mean postoperative follow-up was 29.8 months (range 6-87 months). Three patients experienced a recurrence, with an overall recurrence rate of 3.5% (10% considering only the patients who underwent fertility-sparing treatment). BOTs have low recurrence rates, with excellent prognosis. Surgery with proper staging is the main treatment. Conservative surgery is a valid option for women with reproductive potential.

Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery: An Italian initial experience.

Background: The aim of this study is to evaluate the initial feasibility, safety, and outcomes of hysterectomy performed by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) at three institutions in Italy. Materials and methods: All women who underwent vNOTES hysterectomy ± salpingo-oophorectomy for benign indications at three tertiary referral medical centers between July 2019 and April 2021 were included in a retrospective analysis. All vNOTESs were performed with the use of Alexis® and Vpath Gel paths® (Applied Medical). Perioperative data were extracted from patient records. Patient satisfaction and dyspareunia were prospectively inquired about at 60 days and 6 months. Results: Forty-six patients underwent vNOTES in the study period. Indications for surgery included myomas ± metrorrhagia (52.2%), H-Sil/in situ cervical cancer (10.7%), adenomyosis ± metrorrhagia (8.7%), BRCA 1-2 mutations (6.5%), endometrial hyperplasia (6.5%), ovarian cyst + history of breast cancer (6.5%), metrorrhagia (6.5%), and hydatidiform mole (2.2%). The mean operation time was 91.1 (±32.6) minutes. The mean hemoglobin drop was 1.2 (±0.8). The mean visual analog scale at 24 h for post-operative pain was 3.3 (±1.8). Secondary to our limited experience with the surgical technique, we favor discharge only from day 1. The mean length of hospital stay was 2 (±1.4) days. Two conversions to conventional laparoscopy were reported (4.3%), due to an obliterated pouch of Douglas and a preoperative complication. Two post-operative complications were reported (4.3%). Overall, our data on peri- and post-operative outcomes are similar to those already published for vNOTES. Conclusion: Our initial experience suggests that introducing vNOTES as an alternative to conventional surgery is feasible and may offer some advantages in selected women.

Domain-Specificity of Creativity: A Study on the Relationship Between Visual Creativity and Visual Mental Imagery.

Creativity refers to the capability to catch original and valuable ideas and solutions. It involves different processes. In this study the extent to which visual creativity is related to cognitive processes underlying visual mental imagery was investigated. Fifty college students (25 women) carried out: the Creative Synthesis Task, which measures the ability to produce creative objects belonging to a given category (originality, synthesis and transformation scores of pre-inventive forms, and originality and practicality scores of inventions were computed); an adaptation of Clark's Drawing Ability Test, which measures the ability to produce actual creative artworks (graphic ability, esthetic, and creativity scores of drawings were assessed) and three mental imagery tasks that investigate the three main cognitive processes involved in visual mental imagery: generation, inspection and transformation. Vividness of imagery and verbalizer-visualizer cognitive style were also measured using questionnaires. Correlation analysis revealed that all measures of the creativity tasks positively correlated with the image transformation imagery ability; practicality of inventions negatively correlated with vividness of imagery; originality of inventions positively correlated with the visualization cognitive style. However, regression analysis confirmed the predictive role of the transformation imagery ability only for the originality score of inventions and for the graphic ability and esthetic scores of artistic drawings; on the other hand, the visualization cognitive style predicted the originality of inventions, whereas the vividness of imagery predicted practicality of inventions. These results are consistent with the notion that visual creativity is domain- and task-specific.