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.

COVID-19-The Shift of Homeostasis into Oncopathology or Chronic Fibrosis in Terms of Female Reproductive System Involvement.

The COVID-19 pandemic caused by the SARS-CoV-2 coronavirus remains a global public health concern due to the systemic nature of the infection and its long-term consequences, many of which remain to be elucidated. SARS-CoV-2 targets endothelial cells and blood vessels, altering the tissue microenvironment, its secretion, immune-cell subpopulations, the extracellular matrix, and the molecular composition and mechanical properties. The female reproductive system has high regenerative potential, but can accumulate damage, including due to SARS-CoV-2. COVID-19 is profibrotic and can change the tissue microenvironment toward an oncogenic niche. This makes COVID-19 and its consequences one of the potential regulators of a homeostasis shift toward oncopathology and fibrosis in the tissues of the female reproductive system. We are looking at SARS-CoV-2-induced changes at all levels in the female reproductive system.

Comment on "Oestrogen-induced angiogenesis and implantation contribute to the development of parasitic myomas after laparoscopic morcellation".

BACKGROUND: The cause of contamination and dissemination of leiomyoma tissue particles and cells in the peritoneal cavity during myomectomy is a challenging issue for both clinicians and researchers. Therefore, the article by Huang et al. recently published in your journal is the subject of this letter. MAIN BODY: We comment on the role of laparoscopic condition in xenograft implantation and also highlighted the shortcomings of this study. The surgical technique of intramural fibroid enucleation, cell spillage during morcellation and postsurgical hormonal impact on the development of parasitic myomas become evident, while the contribution of CO2 insufflation, the fibroid's nature, mutations and pseudocapsule impacts on angiogenesis are not clear. In addition, an exploration of the exact origin of implanted fragments harvested from the fibroid tissue and their nature might play a significant role in the implantation and the angiogenesis induction ability of xenografts. CONCLUSION: Taking into account the current literature in the scope of this study, we suggest that the factors involved in development of parasitic myomas can be classified as confirmed and doubtful contributions.

Naive Treg-like CCR7(+) mononuclear cells indicate unfavorable prognosis in hepatocellular carcinoma.

Chemokine receptor-like 1 (CCRL1) has the potential in creating a low level of CCL19 and CCL21 to hinder CCR7(+) cell tracking to tumor tissue. Previously, we found a tumor suppressive role of CCRL1 by impairing CCR7-related chemotaxis of tumor cells in human hepatocellular carcinoma (HCC). Here, we reported a contribution of CCR7(+) mononuclear cells in the tumor microenvironment to the progression of disease. Immunohistochemistry was used to investigate the distribution and clinical significance of CCR7(+) cells in a cohort of 240 HCC patients. Furthermore, the phenotype, composition, and functional status of CCR7(+) cells were determined by flow cytometry, immunofluorescence, and in vitro co-culture assays. We found that CCR7(+) mononuclear cells were dispersed around tumor tissue and negatively related to tumoral expression of CCRL1 (P < 0.001, r = 0.391). High density of CCR7(+) mononuclear cells positively correlated with the absence of tumor capsule, vascular invasion, and poor differentiation (P < 0.05). Survival analyses revealed that increased number of CCR7(+) mononuclear cells was significantly associated with worse survival and increased recurrence. We found that CCR7(+) mononuclear cells featured a naive Treg-like phenotype (CD45RA(+)CD25(+)FOXP3(+)) and possessed tumor-promoting potential by producing TGF-ß1. Moreover, CCR7(+) cells were also composed of several immunocytes, a third of which were CD8(+) T cells. CCR7(+) Treg-like cells facilitate tumor growth and indicate unfavorable prognosis in HCC patients, but fortunately, their tracking to tumor tissue is under the control of CCRL1.

Mother-to-child transmission of HBV: review of current clinical management and prevention strategies.

Mother-to-child transmission (MTCT) of HBV is responsible for approximately half of the HBV transmission routes and continues to be a challenging problem worldwide. Even after the development of effective vaccines and clear World Health Organization guidelines toward HBV several decades ago, 1-9% newborns of HBV-carrying mothers still acquire HBV in early life as a result of in utero infection. The prevention of MTCT is of high importance, because chronically infected individuals function as a reserve for sustained HBV transmission, and 25% of them can develop asymptomatic liver cirrhosis and hepatocellular carcinoma. In this article, we review the canonical and novel HBV infection routes/mechanisms, influencing factors, diagnostic criteria, and interruption strategies for HBV MTCT. The preventative strategy of HBV MTCT has evolved from routine postpartum HB immune globulin (HBIG) plus HB vaccine schedules to administration of HBIG or nucleoside analogs during pregnancy and minimizing the exposure of maternal body fluids to the newborn during delivery.

Impact of surgical approach on blood loss during intracapsular myomectomy.

BACKGROUND: Myomectomy is one of the most common surgical procedures in gynecology and has implications on fertility and subsequent pregnancies. We compared the impact of surgical approach on blood loss during laparoscopic and abdominal intracapsular myomectomy. MATERIAL AND METHODS: The evaluation comprised 124 fertile women with subserous or intramural myomas: 66 patients treated by laparoscopy and 58 patients treated by laparotomy. The intracapsular myoma enucleation technique was similar for both approaches. All procedures were analyzed for the evaluation of intra- and post-surgical blood loss and intra- and short-term post-operative surgical outcomes. RESULTS: The operating time for laparoscopic intracapsular myomectomy was longer (95 ± 7.2 min vs. 63 ± 5.6, p < 0.0001), but was associated with reduced intra- (65 ± ml vs. 105 ± 5, p < 0.0001) and post-surgical blood loss (30 ± 5 vs. 60 ± 5 ml, p < 0.0001), as well as diminished application of pain relief medication (8 patients vs. 17, p < 0.05), compared to open intracapsular myomectomy. CONCLUSIONS: The surgical approach did not substantially affect the technique of intracapsular myomectomy; however, laparoscopy significantly reduced intra- and postoperative blood loss and resulted in better short-term outcomes than after open surgery. Our results underscore the advantages of trying to reduce the rate of laparotomic myomectomy, one of the leading surgical interventions associated with infertility and sterility.

Lymphocele prevention after pelvic laparoscopic lymphadenectomy by a collagen patch coated with human coagulation factors: a matched case-control study.

OBJECTIVE: Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy. MATERIALS AND METHODS: The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration. RESULTS: The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request. CONCLUSIONS: In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

The opioid neuropeptides in uterine fibroid pseudocapsules: a putative association with cervical integrity in human reproduction.

The myoma pseudocapsule (MP) is a fibro-vascular network rich of neurotransmitters, as a neurovascular bundle, surrounding fibroid and separating myoma from myometrium. We investigated the distribution of the opioid neuropeptides, as enkephalin (ENK) and oxytocin (OXT), in the nerve fibers within MP and their possible influence in human reproduction in 57 women. An histological and immunofluorescent staining of OXT and ENK was performed on nerve fibers of MP samples from the fundus, corpus and isthmian-cervical regions, with a successive morphometric quantification of OXT and ENK. None of the nerve fibers in the uterine fundus and corpus MPs contained ENK and the nerve fibers in the isthmian-cervical region demonstrated an ENK value of up to 94 ± 0.7 CU. A comparatively lower number of OXT-positive nerve fibers were found in the fundal MP (6.3 ± 0.8 CU). OXT-positive nerve fibers with OXT were marginally increased in corporal MP (15.0 ± 1.4 CU) and were substantially higher in the isthmian-cervical region MP (72.1 ± 5.1 CU) (p < 0.01). The distribution of OXY neurofibers showed a slight into the uterine corpus, while are highly present into the cervico-isthmic area, with influence on reproductive system and sexual disorders manifesting after surgical procedures on the cervix.

Erroneous presentation of respiratory-hemodynamic disturbances and postsurgical inflammatory responses in patients having undergone abdominal cavity cancer surgery.

In this letter to the editor, the authors discuss the findings and shortcomings of a published retrospective study, including 120 patients undergoing surgery for gastric or colon cancer under general anesthesia. The study focused on perioperative dynamic respiratory and hemodynamic disturbances and early postsurgical inflammatory responses.

Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation.

BACKGROUND: Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions. METHODS: A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests. RESULTS: More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01--120th and p < 0.001--168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group. CONCLUSIONS: MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.

The impact of cervical conization size with subsequent cervical length changes on preterm birth rates in asymptomatic singleton pregnancies.

The study aimed to explore the impact of cervical conization size (CCS) with subsequent cervical length (USCL) changes on preterm birth (PTB) rates in asymptomatic singleton pregnancies as compared to pregnancy outcomes in healthy women with an intact cervix (ICG), and to estimate PTB prevention efficiency in patients with a short cervix. Pregnancy outcomes in populations of similar age, ethnicity, residency, education and harmful habits having undergone cervical conization (CCG) were retrospectively analyzed and compared to ICG and cervical conization sub-populations adjusted by USCL during pregnancy (adequate cervical length vs. a short cervix) and a progesterone-only group (POG) vs. a progesterone-pessary group (PPG). Cervical conization was not associated with an increased PTB risk (CCG vs. ICG) when parameters of CCS and USCL were not adjusted (p = NS). A significantly higher proportion of parous women was observed in the CCG population than in the ICG (p = 0.0019). CCS turned out to be a key PTB risk during pregnancy, the larger CCS being associated with a short cervix (p = 0.0001) and higher PTB risks (p = 0.0001) with a notably increased PTB rate (p = 0.0001) in nulliparous women (p = 0.0022), whereas smaller CCS with adequate cervical length and a lower PTB rate was predominantly observed in women with prior parity. An initial equal USCL size was to be considerably elongated in women with adequate cervical length (p < 0.0001), and shortened in those with a short cervix (p < 0.0001). USCL assessment during pregnancy proved to be the PTB risk-predicting tool, with CCS supplementation apt to increase its diagnostic value. No substantial impact on pregnancy outcomes could be linked to any particular PTB prevention mode (POG or PPV). However, during pregnancy, the USCL changes relating to CCS proved to be more critical in pregnancy outcomes.

Laparoscopic Intracapsular Myomectomy in Women 40 Years Old and Over with Symptomatic Uterine Fibroids. A Pilot Study.

Authors evaluated the impact of laparoscopic intracapsular myomectomy (LIM) in women 40 years of age and over with desire of future fertility compared with medical management of symptomatic fibroids, by a prospective cohort study in University affiliated Hospitals. This study includes a cohort of women 40 years of age and older with symptomatic intramural fibroids with desire of future fertility. Women with symptomatic fibroid uterus were offered to undergo LIM or medical management. They were encouraged to attempt conception either spontaneously or by assisted reproductive technology (ART) according to their individual preference. All women were followed for 2 years. Fibroid characteristics, pre- and post-surgical variables, including surgical complications, days of hospitalization, pregnancy rate, and obstetrical outcomes were collected. A total of 100 patient were included in the analysis. Fifty patients were assigned to the LIM group and 50 to the medical treatment group (MT). Groups were similar regarding age (43.5 ± 2.4 and 43.5 ± 2.4, p = 0.99), body mass index (23.8 ± 3.1 and 24.2 ± 3.1, p = 0.54), parity (0.46 ± 0.09 and 0.58 ± 0.09, p = 0.37), fibroid number (1.38 ± 0.6 and 1.46 ± 0.6, p = 0.53), and fibroid size (5.92 ± 1.62 cm vs. 5.94 ± 1.49 cm, p = 0.949). Of the patients who underwent LIM, 62% conceived within the study period compared with 56% in the control group ( p = 0.54). Pregnancy was achieved by ART in 44% of the patients of the LIM group and 30% in control group. There was no significant difference in pregnancy rates among the two groups regarding spontaneous pregnancy rate ( p = 0.332), nor in pregnancies obtained by ART with own eggs ( p = 0.146) and oocyte or embryo donation ( p = 0.821). The take home baby rate was 65% (20/31) in the LIM group and 61% (17/28) in the control group ( p = 0.7851). Both groups had similar rate of miscarriage ( p = 0.748). Patients 40 years old and over with symptomatic fibroid uterus who undergo LIM have similar subsequent fertility and obstetrical outcomes than women treated with medical management. LIM has no detrimental impact on future fertility in women 40 years old and over.