Glucocorticoid sparing effect of Janus Kinase inhibitors compared to biological Disease Modifying Anti-Rheumatic Drugs in rheumatoid arthritis, a single-center retrospective analysis.

BACKGROUND: Glucocorticoid sparing in rheumatoid arthritis (RA) treatment is crucial to minimizing adverse effects associated with long-term use. Janus kinase inhibitors (JAKi) could potentially offer a more potent glucocorticoid-sparing effect than biological Disease-Modifying Antirheumatic Drugs (bDMARDs). MATERIAL AND METHODS: This is a single-center retrospective analysis of RA patients treated with JAKi or bDMARDs. Glucocorticoid tapering, rescue therapy and discontinuation were analyzed through mixed-effects models, Poisson regression, and multivariable logistic regression, respectively, adjusting for baseline disease activity, demographic factors, and treatment line. RESULTS: A total of 716 RA patients treated with JAKi (n = 156) or bDMARDs (n = 560) were evaluated. JAKi treatment was associated with a more rapid reduction in glucocorticoid dose within the first 6 months and 60% higher odds of discontinuation compared with bDMARDs (adjusted odds ratio 1.63, 95% CI 1.02-2.60, p 0.039). Despite a higher baseline glucocorticoid dose, over 50% of JAKi-treated patients discontinued glucocorticoids after 12 months, vs ∼40% for bDMARDs. The need for glucocorticoid rescue therapy was significantly higher in the bDMARD group (rate ratio 2.66 (95% CI, 1.88-3.74)). CONCLUSION: Our findings indicate that JAK inhibitors facilitate more rapid glucocorticoid tapering compared with bDMARDs in RA patients. These results underscore the potential of JAK inhibitors to reduce long-term glucocorticoid exposure, highlighting their value in RA management strategies, including minimizing glucocorticoid-related adverse effects.

Fortifying the foundation: assessing the role of uterine ligament integrity in uterine prolapse and beyond.

BACKGROUND: Pelvic floor stability is influenced by various biomechanical, anatomical, and physiological factors. Understanding these dynamics is crucial for improving the treatment of pelvic organ prolapse (POP) and related conditions. OBJECTIVE: To analyze the key factors affecting pelvic floor integrity and explore both non-surgical and surgical interventions to enhance stability and treatment outcomes. METHODS: This review draws from biomechanical research to assess the role of the uterosacral ligament in pelvic support, while also examining the potential of both traditional and emerging therapeutic approaches, including non-surgical interventions like vitamin C supplementation. RESULTS: - The uterosacral ligament demonstrates superior strength and stiffness, making it essential for structural support of pelvic organs. - Non-surgical interventions, such as vitamin C supplementation, show potential in improving ligament integrity and preventing pelvic floor disorders. - Emerging surgical techniques, including tendon-based procedures and injectable fibrous hydrogel composites, offer promising improvements in outcomes for patients with pelvic organ prolapse. - Additional factors such as muscle strength and neural deficiencies contribute to the complexity of pelvic floor biomechanics, indicating the need for multifaceted treatment approaches. CONCLUSION: This analysis provides a comprehensive framework for understanding and managing pelvic floor stability by integrating biomechanical, physiological, and anatomical insights. The findings highlight the potential for personalized treatment strategies to improve patient outcomes in pelvic floor disorders.

The impact of epigallocatechin gallate, vitamin D, and D-chiro-inositol on early surgical outcomes of laparoscopic myomectomy: a pilot study.

PURPOSE: A prospective investigation to assess the impact of 3 months of treatment with epigallocatechin gallate (EGCG), vitamin D and D-chiro-inositol (DCI) in the treatment of uterine fibroids (UF) with laparoscopic myomectomy as evidenced by surgical outcomes and effect on liver function. METHODS: Non-pregnant or lactating women aged between 30 and 40 years were scheduled for laparoscopic myomectomy to treat symptoms or looking to conceive. After enrollment, patients were assigned to either (1) intervention group, assuming a total of 300 mg EGCG, 50 µg vitamin D, and 50 mg DCI divided in 2 pills per day for 3 months, or (2) control group, including untreated women scheduled to undergo laparoscopic myomectomy after 3 months. RESULTS: 91 patients completed the study. The comparison of the surgical outcomes between the intervention (n = 44) and the control (n = 47) groups revealed that the treatment significantly reduces the duration of surgery (41.93 ± 7.56 min vs 56.32 ± 10.63 min, p < 0.001). Moreover, the treatment also reduced blood loss during surgery (149.09 ± 25.40 mL vs 168.41 ± 21.34 mL, p < 0.001), resulting in treated patients having higher Hb levels at discharge 11.27 ± 0.82 mL vs 10.56 ± 0.82 mL, p < 0.01). The surgery induced an increase in AST and in total bilirubin regardless of the assigned group, and the treatment induced no change in liver function. CONCLUSIONS: Our data suggest that EGCG plus vitamin D, and DCI could represent a safe option for women with UF scheduled for laparoscopic myomectomy, improving surgical outcomes without affecting liver functionality.

PCOS and vitamin D: a clinical appraisal.

PURPOSE: Polycystic ovary syndrome (PCOS) is the most common endocrine-reproductive disease linked not just to infertility but also to serious comorbidities. There is a reported association between low vitamin D levels and multiple health conditions including PCOS. This narrative review aims to analyze the role of vitamin D in PCOS development, use of the vitamin D in the treatment of PCOS, and the molecular basis of these observations. METHODS: A Medline and PubMed research was performed, during the years 1990-2023, using a combination of keywords on such topic. According to the author's evaluation and target, papers were identified and included for a narrative review. RESULTS: There are associations between lower levels of vitamin D and PCOS, as well as with insulin resistance, metabolic syndrome, hyperandrogenemia, metabolic and endocrine disorders as well as the onset of oxidative stress and pro-inflammatory milieu, in PCOS women. CONCLUSION: Vitamin D has a role in pathologic changes linked to PCOS. Molecular and clinical investigations which give new information about the role of vitamin D in the development of PCOS and related endocrine and metabolic disturbance are further needed.

From 3D to 2D-4K laparoscopic sacral colpopexy: are we addicted to technology?

OBJECTIVE: A study analyzing perioperative outcomes related to a sudden switch from 3D to 2D-4K technology for laparoscopic sacral colpopexy by expert pelvic surgeons: are we addicted to technology? MATERIAL AND METHODS: After a sudden transition from 3D to 2D-4K laparoscopic technology, a total of 115 consecutive pelvic prolapse patients who underwent sacral colpopexy from June 2020 to September 2021 were retrospectively assessed from our database. Perioperative parameters, operative times (OT), and intraoperative difficulty scales were assessed. One-year follow-ups were analyzed for the study. Primary endpoints were OT; secondary endpoint was the evaluation of complications linked to this procedure. RESULTS: We found statistical differences in OT and intraoperative difficulty scales between medians of the last 3D procedures and the first ten 2D-4K surgeries, without differences between operators. Only after more than 20 surgeries, we observed no significant differences between 3D and 2D-4K sacral colpopexy. We observed no statistical differences in terms of anatomic failure, PGI-I, and intra-postoperative complications. CONCLUSION: The transition of urogynecology from an exclusive vaginal approach to 2D-3D-4K laparoscopy significantly increased the level of technology necessary for surgical treatment of prolapse. This could, as a result, lead to pelvic surgeons becoming increasingly dependent on technology.

Laparoscopic posterior vaginal plication plus sacral colpopexy for severe posterior vaginal prolapse: A randomized clinical trial.

AIM: A randomized clinical trial proposing a new laparoscopic prosthetic and fascial approach to severe posterior vaginal prolapse. The primary endpoint was to evaluate the objective and subjective outcomes of our laparoscopic posterior plication (LPP) combined to "two-mesh" sacral colpopexy (laparoscopic sacral colpopexy [LSC]) in severe posterior vaginal prolapse, with a 1-year follow-up. The secondary endpoint was to evaluate the safety of this surgical procedure. METHODS: This is single-center prospective randomized double-blinded clinical trial. A total of 130 consecutive patients with anterior and/or apical pelvic organ prolapse (POP) (POP-Q stage ≥II) and severe posterior vaginal prolapse (posterior POP-Q stage ≥III) were prospectively assessed for inclusion into the study from November 2018 to January 2020. Patients underwent "two-meshes" LSC and were randomized in Group A (LSC plus LPP) and Group A (LSC alone). Of the 130 included subjects, 8 were excluded, not meeting inclusion criteria. Cure rate was evaluated objectively, using POP-Q study, and subjectively using PGI-I, POPDI-6, and FSDS questionnaires. Complications were assessed intra-, peri-, and postoperatively. Twelve-month follow-ups were analyzed for the study. RESULTS: We found in LSC plus LPP Group a significant improvement of Ap and genital hiatus POP-Q points. Our subjective study showed, at 12 months, a statistical difference in PGI-I successful outcomes rate in favor of LPP. Also the FSDS resulted significantly much more improved in Group A. We observed no statistical differences in terms of postoperative complications. CONCLUSIONS: Our LPP approach to LSC could be considered an effective and safe technique to POP patients with severe posterior prolapse.

Myomectomy in adult women of reproductive age: a propensity score-matched study for pregnancy rates.

PURPOSE: To study whether it is better to perform or not a myomectomy, in terms of surgical and reproductive outcomes in patients of advanced reproductive age, by an observational prospective study in university-affiliated and Community Hospitals. MATERIALS AND METHODS: 40 years and older patients affected by non-submucous symptomatic uterine fibroids and desiring future fertility were enrolled and treated by laparoscopic intracapsular myomectomy by (LIM) or by open laparotomy (OIM), or by a non-surgical management as control group, while attempting to conceive. The primary outcome measures were fibroid characteristics, pre- and post-surgical parameters, pregnancy achievement; the secondary outcome measures were the spontaneous or ART pregnancy outcomes, eventual week of abortion and type of delivery. Propensity scores have been calculated with logistic regression for binary and continuous variables. RESULTS: 202 patients completed the study: 112 operated by LIM, 40 by OIM and 50 patients as control group. Patients undergoing OIM have a worse surgical outcome than LIM. No difference was seen in pregnancy either after myomectomy or control group during follow-up. In the LIM group, there were 44 pregnancies (39.2%), and in the OIM group, there were 9 (22.5%) and 16 in the control group (32%). The weeks of delivery were statistically greater for the control group versus the surgical groups, with no difference in Apgar score between the 3 groups. CONCLUSION: Patients aged over 40 years did not show substantial differences in reproductive outcome, whether operated or not. Myomectomy in over 40-year-old patients has no detrimental effect on future pregnancy rates and over when compared to expectant management.

Uterine Aging and Reproduction: Dealing with a Puzzle Biologic Topic.

Uterine aging is the process of the senescence of uterine tissue, observed in all middle-aged mammals. Since the aging-related changes in the uterus are associated with infertility and poor pregnancy outcomes, with a lack of studies discussing uterine aging, authors reviewed uterine aging and its consequences on reproduction. MEDLINE, Scopus, and PubMed searches during the years 1990-2023 were performed using a combination of keywords and terms on such topics. According to the author's evaluation, articles were identified, selected, and included in this narrative review. The aging process has an unfavorable impact on the uterus of mammals. There are different and selected molecular pathways related to uterine aging in humans and animals. Uterine aging impairs the function of the uterine myometrium, neurofibers of the human uterus, and human endometrium. These biological pathways modulate oxidative stress, anti-inflammatory response, inflammation, mitochondrial function, DNA damage repair, etc. All these dysregulations have a role in poorer reproductive performance and pregnancy outcomes in older mammals. The most recent data suggest that uterine aging is accompanied by genetic, epigenetic, metabolic, and immunological changes. Uterine aging has a negative impact on the reproductive performance in mammalian species, but it could be potentially modulated by pharmacological agents, such as quercetin and dasatinib.

Smooth Muscle Tumor of Uncertain Malignant Potential (STUMP): A Comprehensive Multidisciplinary Update.

Background and Objectives: The uterine smooth muscle tumors of uncertain malignant potential (STUMP) are tumors with pathological characteristics similar to leiomyosarcoma, but that do not satisfy histological criteria for leiomyoma. These are problematic lesions with intermediate morphologic features; thus, diagnosis and treatment are difficult. This narrative review aims to review data in the literature about STUMPs, particularly focusing on management and therapeutic options and strategies for women who desire to preserve fertility. Material and Methods: authors searched for "uterine smooth muscle tumor of uncertain malignant potential" in PubMed and Scopus databases, from 2000 to March 2023. Pertinent articles were obtained in full-text format and screened for additional references. Only articles in English language were included. Studies including full case description of patients with histopathological diagnosis of STUMP in accordance with Stanford criteria were included. Results: The median age was 43 years old. Symptoms are similar to those of leiomyomas, with a mean diameter of 8.0 cm. Total hysterectomy with or without bilateral salpingo-oophorectomy is the standard care for women if fertility desire is satisfied. Myomectomy alone can be considered for young patients. Although these tumors have not a high malignant potential, several studies described recurrence and metastases. Conclusions: STUMPs are complex uterine smooth muscle tumors, with a rare but reasoned clinical-diagnostic management. Considering the high clinical and histological complexity of these tumors, high level of expertise is mandatory.

Local anesthesia for Altis® single incision sling in women with stress urinary incontinence.

OBJECTIVE: Local anesthesia for single incision slings has shown a good objective and subjective cure rate in women with stress urinary incontinence. The aim of the present study was to verify the efficacy and safety of local anesthesia during Altis® single incision placement. MATERIAL AND METHODS: One hundred sixty-six consecutive patients (83 patients for each group: local resp. spinal anesthesia) were selected from our database for this retrospective study among women who underwent an Altis® implantation for SUI from September 2016 to June 2021, after unsuccessful previous conservative treatment. Primary endpoints were objective and subjective cure rates; secondary endpoint was the evaluation of complications linked to this procedure. RESULTS: A total of 155 included patients completed our 12 months follow-up. Baseline characteristics were similar between the groups. Operative time (percentage difference of 50%; p < 0.05) and the Intraoperative Difficulty Scale resulted lower in spinal patients. No differences were found between populations in terms of objective (cough stress test and urodynamics) and subjective (PGI-I and FSDS questionnaires) cure rate and postoperative complications. CONCLUSION: Local anesthesia for Altis® implantation could be considered a safe alternative to spinal anesthesia and an effective opportunity to avoid general anesthesia, increasing the possibility of outpatient implantation of this sling system.

Laparoscopic ventral rectopexy plus sacral colpopexy: continuous locked suture for mesh fixation. A randomized clinical trial.

PURPOSE: Laparoscopic ventral rectopexy (LVR) plus sacral colpopexy (LSC) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to rectal-mesh fixation during LVR with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 80 patients with severe POP and obstructed defecation syndrome (ODS) from November 2016 to January 2021. Patients underwent a "two-meshes" LSC plus LVR and were randomized, regarding rectal mesh fixation, in Group A (extracorporeal interrupted 0 delayed absorbable sutures) and Group B ("U-shaped" running locked 0 delayed absorbable suture). Our primary endpoints were the operative times (OT); the secondary endpoints were the incidence of anatomical failures, vaginal mesh erosions and surgical complications. RESULTS: A total of 75 patients completed the study. Baseline characteristics were similar between the groups. Overall OT (156 vs 138 min; p < 0.05; treatment reduction of 11.5%) and LVR mesh fixation time (29 vs 16 min; p < 0.05; treatment reduction of 44%), resulted in significantly lower in Group B. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. PGI-I, FSDS and Wexner questionnaires resulted significantly improved after surgery, without statistical differences between the studied surgical procedures. CONCLUSION: Laparoscopic continuous locked 0 absorbable suture for LVR mesh fixation guaranteed a faster and effective alternative to multiple interrupted sutures. The significant OT reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LVR. CLINICAL TRIAL REGISTRATION: NCT05254860 (13/02/2017).

Biomechanical Forces Determine Fibroid Stem Cell Transformation and the Receptivity Status of the Endometrium: A Critical Appraisal.

Myometrium cells are an important reproductive niche in which cyclic mechanical forces of a pico-newton range are produced continuously at millisecond and second intervals. Overproduction and/or underproduction of micro-forces, due to point or epigenetic mutation, aberrant methylation, and abnormal response to hypoxia, may lead to the transformation of fibroid stem cells into fibroid-initiating stem cells. Fibroids are tumors with a high modulus of stiffness disturbing the critical homeostasis of the myometrium and they may cause unfavorable and strong mechanical forces. Micro-mechanical forces and soluble-chemical signals play a critical role in transcriptional and translational processes' maintenance, by regulating communication between the cell nucleus and its organelles. Signals coming from the external environment can stimulate cells in the format of both soluble biochemical signals and mechanical ones. The shape of the cell and the plasma membrane have a significant character in sensing electro-chemical signals, through specialized receptors and generating responses, accordingly. In order for mechanical signals to be perceived by the cell, they must be converted into biological stimuli, through a process called mechanotransduction. Transmission of fibroid-derived mechanical signals to the endometrium and their effects on receptivity modulators are mediated through a pathway known as solid-state signaling. It is not sufficiently clear which type of receptors and mechanical signals impair endometrial receptivity. However, it is known that biomechanical signals reaching the endometrium affect epithelial sodium channels, lysophosphatidic acid receptors or Rho GTPases, leading to conformational changes in endometrial proteins. Translational changes in receptivity modulators may disrupt the selectivity and receptivity functions of the endometrium, resulting in failed implantation or early pregnancy loss. By hypermethylation of the receptivity genes, micro-forces can also negatively affect decidualization and implantation. The purpose of this narrative review is to summarize the state of the art of the biomechanical forces which can determine fibroid stem cell transformation and, thus, affect the receptivity status of the endometrium with regard to fertilization and pregnancy.

Vaginal mesh repair SYSTEMS for pelvic organ prolapse: Anatomical study comparing transobturator/trangluteal versus single incision techniques.

INTRODUCTION: The present study aim to compare the anatomic landmarks of two pelvic floor repair systems, in order to identify the potential neurovascular lesions related to different mesh fixation techniques. METHODS: Abdominal and perineal dissections of 10 fresh cadavers after prolapse surgery using transobturator/transgluteal versus single incision techniques. Neuro-vascular structures of obturator region and perineum were isolated. Distances between needles and anatomical structures were measured. RESULTS: During transobturator anterior repair, the superficial cannula passed 2.5 ± 0.6 cm medially to the obturator canal. The distance of superficial arm to the anterior obturator vessels was 2.2 ± 0.4 cm. The distance of deep cannula to the posterior obturator vessels branches was 1.3 ± 0.5 cm. In two of these cases we observed a lesion of posterior obturator vessels. During single incision repair the distance between the obturator canal and the superficial arms was 2.3 ± 0.7. The mean distances of superficial arms to the anterior and posterior obturator vessels were, respectively, 2.3 ± 0.5 cm and 3.2 ± 0.7 cm. During transgluteal posterior repair the distance between the cannula guide and the ischial spine was 1.7 ± 0.5 cm while it measured 2.3 ± 0.4 cm when single incision posterior device was placed. CONCLUSIONS: Anterior transobturator system presents an increased risk of posterior obturator vessels branches injury. During posterior transgluteal repair the distance of the ischio-anal fossa to sacrospinous ligament represents a way that could rule against the correct needle positioning with increased risk of pudendal lesions. Single incision approach offers an easier access to the sacrospinous ligament with lower risk of pudendal lesions.

Laparoscopic sacral colpopexy and a new approach to mesh fixation: a randomized clinical trial.

PURPOSE: Laparoscopic sacral colpopexy (LSC) plus supracervical hysterectomy (LSH) for pelvic organ prolapse (POP) is a high-complexity surgical procedure. The aim of the present study was to evaluate a new approach to vaginal-mesh fixation during LSC with continuous locked suture. METHODS: This is a prospective randomized double-blinded clinical trial enrolling 90 patients with severe POP from January 2016 to April 2017. Patients underwent LSH plus a "two-meshes" LSC and were randomized, regarding mesh fixation, in Group 1 (extracorporeal interrupted 3-0 delayed absorbable sutures) and Group 2 (running locked 3-0 delayed absorbable suture). Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. RESULTS: A total of 42 patients for group completed the study. Baseline characteristics were similar between the groups. Overall mesh fixation time (24 vs. 39 min; p < 0.01), and operative time (121 vs. 138 min; p < 0.05) resulted significantly lower in Group 2. No differences were found in terms of anatomic failure, vaginal mesh erosion or intra- or post-operative complications. CONCLUSIONS: Laparoscopic continuous locked 3-0 absorbable suture for anterior and posterior mesh fixation during LSC guaranteed a faster and effective alternative to multiple interrupted sutures. The significant operative time reduction linked to this technique should be considered even more helpful when performing a highly complex surgery such as LSC.

Laparoscopic sacral colpopexy: how to place the posterior mesh into rectovaginal space?

AIMS: Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by an anterior mesh suspension to the sacral promontory and a posterior tension-free mesh fixation. METHODS: Totals of 150 age-BMI and parity matched consecutive POP patients were selected from our Diaconesses Hospital database among women who underwent a laparoscopic supracervical hysterectomy (LSH) plus sacral colpopexy (LSC) from June 2005 to March 2010. We analyzed two group of LSC populations, according to different tension-free apical fixation of the posterior mesh: Promontory (P) group and Utero-Sacral (US) group. Studied endpoints were the anatomical and functional results linked to these different tension-free posterior mesh placements. RESULTS: Baseline characteristics were similar between the groups. No differences in terms of anatomical and functional outcomes were observed between the groups. Pelvic organ mobility at rest versus under Valsalva highlighted a significant reduction of median differential vaginal apex only in the P population (preoperative: 30 mm and 32 mm; postoperative: 8 mm and 24 mm; for P and US, respectively; P < 0.01). No differences were found in terms of intra- or post-operative complications. CONCLUSIONS: Uterosacral tension-free fixation of posterior mesh during LSC could be considered a simple procedure and guarantees a more physiological movement of the pelvic organs if compared with promontory suspension.

A new approach to supracervical hysterectomy during laparoscopic sacral colpopexy for pelvic organ prolapse: A randomized clinical trial.

AIMS: Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by long operative times and, when combined with supracervical hysterectomy, by a high risk of spreading of unsuspected cancerous tissue. The aim of the present study was to compare, in patients who underwent hysterectomy plus LSC for severe POP, different methods for cervical incision and uterine morcellation. METHODS: This is a prospective single Institution randomized double-blinded clinical trial enrolling 124 patients with severe POP from June 2014 to May 2015. Patients underwent laparoscopic supracervical hysterectomy (LSH) plus LSC for pelvic organ prolapse and were randomized in Group 1 (monopolar hook and conventional mechanical morcellator) and Group 2 (bipolar laparoscopic loop and bipolar morcellator), for supracervical incision and uterine morcellation, respectively. Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. RESULTS: A total of 50 patients for group completed the study. Baseline characteristics were similar between the groups. Cervical cutting time (32 vs. 3.10 sec; P <0.01), morcellation (4.10 vs. 2.13 min; P <0.01) and operative time (131 vs. 118 min; P <0.05) resulted significantly lower in Group 2. No differences were found in terms of intra- or post-operative complications. CONCLUSIONS: Laparoscopic bipolar loop and morcellator guaranteed a faster and hemostatic tool during supracervical incision and a controlled and rotation-free uterine extraction. The significant surgical time reduction linked to these devices should be considered even more helpful and effective to perform a complex procedure represented by LSH plus LSC. Neurourol. Urodynam. 36:798-802, 2017. © 2016 Wiley Periodicals, Inc.

Anatomical insights into sacrocolpopexy for multicompartment pelvic organ prolapse.

AIMS: Pelvic organ prolapse occurs in 50% of parous women. Laparoscopic sacrocolpopexy (LSCP) is a common surgical procedure for restoring pelvic anatomy and function. The aim of this study is to evaluate surgical anatomy and anatomical modifications induced by standardized LSCP. METHODS: Ten fresh female cadavers underwent LSCP, six subsequently underwent standard anatomical dissection, and four had sagittal anatomical dissection. Four cadavers were used as control subjects; two of them underwent standard anatomical dissection, and two had sagittal anatomical dissection. RESULTS: Vesicovaginal space dissection resulted in an arrow-shaped space limited by the trigone and vesical branches of the uterine artery. Rectovaginal space dissection resulted in an inverted V-shaped space marked by the utero-sacral and rectovaginal ligaments, the cranial end of the perineal body and the levator ani muscle. Exposing the longitudinal vertebral ligament through a peritoneal and presacral fascia incision along the medial border of the right common iliac artery allowed the identification and the preservation of the right hypogastric nerve. The anterior mesh stretched across the proximal half of the anterior vaginal wall, and the cervix towards the sacral promontory provided excellent cervix suspension and anterior-vaginal wall support with a concomitant stretch of the pubocervical fascia. The median angle formed by the axis of the infra-levatorial vagina with the axis of the supra-levatorial vagina changed from 142° to 171° and determined the linearization-ventralization of the vaginal canal. CONCLUSIONS: LSCP can be performed in a nerve-sparing, standardized fashion, providing excellent apical suspension and anterior vaginal wall support. Neurourol. Urodynam. 35:813-818, 2016. © 2015 Wiley Periodicals, Inc.

Literature review, surgical decision making algorithm, and AGREE II-S comparison of national and international recommendations and guidelines in pelvic organ prolapse surgery.

The average lifespan has increased over time due to improvements in quality of life, leading to an aging population that stays healthy for longer. Pelvic organ prolapse (POP), whether uterine or vaginal, is a problem that severely impairs quality of life and imposes significant restrictions. The present study provides the reader with a summary of the many surgical techniques used in POP surgery, comparing international guidelines, offering an algorithm that is simple to understand, and allows the reader to quickly choose the table that includes the best surgical therapy for each individual. Using relevant keywords, the writers searched the PubMed and Scopus databases for relevant publications from 2000 to April 2023. Studies with cases of oncologic disorders or prior hysterectomy performed for another reason were not included in the analysis. Ten distinct international guidelines are highlighted and examined in the present study. We used the Appraisal of Guidelines for Research and Evaluation II-S (AGREE II-S) method to assess their quality, and incorporated the results into the conclusion. Worldwide, anterior colporrhaphy is the preferred method of treating anterior compartment abnormalities, and mesh is virtually always used when recurrence occurs (which happens in about half of the cases). Worldwide, posterior colporrhaphy is commonly used to repair posterior compartment abnormalities. Only a few national guidelines (the Iranian guideline, Acta Obstetricia et Gynecologica Scandinavica [AOGS], and the German-speaking countries) permit the use of mesh or xenograft in cases of recurrence. There is agreement on the abdominal approach (sacrocolpopexy) with mesh for treating apical deformities. Sacrospinous-hysteropexy is the standard method used to guide the vaginal approach; mesh is typically used to aid in this process. There are just three recommendations that do not include vaginal operations: HSE, AOGS, and Iran. Of obliteration techniques, colpocleisis is unquestionably the best. In conclusion, our analysis highlights the significance of customized methods in POP surgery, taking into account the requirements and preferences of each patient. To choose the best surgical therapy, criteria and patient features must be carefully considered.

Adenomyosis and fertility-sparing surgery: A literature appraisal.

Adenomyosis is an intricate pathological condition that negatively impacts the uterus. It is closely related to the more well-known endometriosis, with which it shares parallels in terms of diagnosis, therapy, and both microscopic and macroscopic features. The purpose of this narrative review is to give a clear univocal definition and outlook on the different, patient-adapted, surgical treatments. MEDLINE and PubMed searches on these topics were conducted from 1990 to 2022 using a mix of selected keywords. Papers and articles were identified and included in this narrative review after authors' revision and evaluation. From the literature analysis, authors reported the following surgical techniques: laparoscopic double/triple-flap method, laparotomic wedge resection of the uterine wall, laparotomic transverse H-incision of the uterine wall, laparotomic wedge-shaped excision, and laparotomic complete debulking excision by asymmetric dissection technique. Each of these techniques has strengths and weaknesses, but the literature data on the pregnancy rate are somewhat limited. The only certain information is the risk of uterine rupture up to 6.0% after surgical treatment for uterine adenomyosis. Over the years, the surgical approach continued to reach a positive result by minimally invasive treatment, with less hospitalization, less postoperative pain, and less blood loss. Over the years, the gynecological surgeon has gained the skills, training and increasingly sophisticated surgical techniques to target effective therapy. That's why a hysterectomy is no longer the only surgical resource to treat adenomyosis, but in patients who wish to preserve the fertility, there is a wide variety of surgical alternatives.

The potential pathogenic role of gut microbiota in rheumatic diseases: a human-centred narrative review.

A growing amount of evidence suggests that gut microbiota plays an important role in human health, including a possible role in the pathogenesis of rheumatic and musculoskeletal diseases (RMD). We analysed the current evidence about the role of microbiota in rheumatoid arthritis (RA), spondyloarthritis (SpA), systemic lupus erythematosus (SLE) and systemic sclerosis (SSc). In RA, we found a general consensus regarding a reduction of diversity and a specific bacterial signature, with consistent changes according to the different ethnic and geographical areas. The major pathogenetic role in RA is recognised for P. copri, L. salivarius and Collinsella, even if findings become more heterogeneous when considering established disease. In SpA, we found a relative gut abundance of Akkermansia, Coprococcus, Ruminoccocus and a relative reduction in Bacterioides and Firmicutes spp. Human and preclinical data suggest loss of mucosal barrier, increased permeability and Th1- and Th17-mediated inflammation. Additionally, HLA-B27 seems to play a role in shaping the intestinal microbiota and the consequent inflammation. In SLE, the typical gut microbiota signature was characterised by a reduction in the Firmicutes/Bacteroidetes ratio and by enrichment of Rhodococcus, Eggerthella, Klebsiella, Prevotella, Eubacterium and Flavonifractor, even if their real pathogenic impact remains unclear. In SSc, gastrointestinal dysbiosis is well documented with an increase of pro-inflammatory species (Fusobacterium, Prevotella, Ruminococcus, Akkermansia, γ-Proteobacteria, Erwinia, Trabsulsiella, Bifidobacterium, Lactobacillus, Firmicutes and Actinobacteria) and a reduction of species as Faecalibacterium, Clostridium, Bacteroidetes and Rikenella. In conclusion, seems possible to recognise a distinct gut microbiota profile for each RMD, even if significant differences in bacterial species do exist between different studies and there is a high risk of bias due to the cross-sectional nature of such studies. Therefore longitudinal studies are needed, especially on patients with preclinical and early disease, to investigate the real role of gut microbiota in the pathogenesis of RMD.