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Vacuum extraction is the most common choice to assist vaginal delivery, but there are still concerns regarding the neonatal injuries it may cause. This study aimed to evaluate the rate of intracranial injuries assessed by cranial ultrasound (cUS) among infants born by vacuum extraction, and the relationship with maternal and perinatal factors.This was a single-center retrospective study carried out in a level-3 neonatal unit. A total of 593 term and late preterm infants born by vacuum-assisted delivery were examined with a cUS scan within 3 days after birth.Major head injuries were clinically silent and occurred in 2% of the infants, with a rate of intracranial haemorrhage of 1.7%. Regardless of obstetric factors, the risk of cranial injury was increased in infants requiring resuscitation at birth (p = 0.04, OR 4.1), admitted to NICU (p = 0.01, OR 5.5) or with perinatal asphyxia (p 0.01, OR 21.3). Maternal age ≥40 years correlated both with adverse perinatal outcomes (p 0.05) and the occurrence of major injury (p = 0.02, OR 4.6).Overall, vacuum extraction is a safe procedure for neonates. Head injuries are usually mild and asymptomatic, and with spontaneous recovery. However, the rate of major cranial injuries in our cohort warrants further investigation to support a cUS screening, particularly for infants requiring respiratory support at birth. Also, maternal age might be taken into account when evaluating the risk for neonatal complications after vacuum application.

Surgery is the mainstay of treatment in the management of early-stage cervical cancer. Until the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial, minimally invasive radical hysterectomy was the recommended approach to treat patients with early-stage disease. The results of the LACC trial questioned the adoption of minimally invasive surgery in cervical cancer. In comparison with the open approach, minimally invasive surgery correlated with worse disease-free and cancer-specific survival. Similarly, other retrospective studies highlighted this correlation, thus corroborating the results of the LACC trials. In the present review, we evaluated current evidence and further prospective of the adoption of minimally invasive radical hysterectomy in cervical cancer. Moreover, we sought to assess some unsolved issues regarding the role of minimally invasive surgery in early-stage cervical cancer patients.

To compare scar quality associated with metal staples or tissue adhesive for closure of the skin incision at repeat cesarean delivery (CD).Single-center Randomized Controlled Trial (ClinicalTrial.gov ID: NCT04302597), including women undergoing repeat CD using metal staples or 2- octylcyanoacrylate for closure of the skin incision. Patients were randomized to have skin closure following CD with either staples or tissue adhesive. Scar quality was evaluated 2 and 6 months postoperatively using the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale.Of the 66 patients who were recruited, 55 successfully completed the study. The duration of surgery was comparable in both groups. A partial wound dehiscence occurred in one patient who had tissue adhesive closure. No difference in subjective and objective scar cosmesis rating was found between tissue adhesive and staples groups at either 2 months or 6 months.In women undergoing CD, stapled wounds and those closed with tissue adhesive result in equivalent cosmetic appearance of the scar.

Study objective: There is great consensus that the implementation of ERAS approach is beneficial for surgical patients, but there is paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The present survey was aimed at gathering detailed information on perioperative management of DE patients undergoing sigmoid/rectal (discoid or segmental) resection within SEGI group. Design: Baseline survey. Setting: National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). Patients: The study did not involve patients. Interventions: A 63-item questionnaire, covering ERAS items for gynecologic/elective colorectal surgery, was sent to SEGI centres. Only questionnaires from centres reporting to perform ≥10 sigmoid/rectal resections per year were considered for the present analysis. Measurements and main results: Thirty-three/38 (86.8%) questionnaireswere analysed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 56.6%. Pre-operative diet, fasting and bowel preparation, correction of anaemia, avoidance of peritoneal drains, post-operative feeding and early mobilization were the most controversial. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p=0.044 and p=0.003, respectively) and gynecologist's/surgeon's experience (p=0.042 and p=0.022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centres reporting ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p=0.081) and gynecologist's/surgeon's experience (p=0.294). Conclusion: This is the first study conducted on a national scale for DE. The present survey reveals a sub-optimal compliance to the ERAS recommendations, and underline the need for improving the quality of peri-operative care in DE patients undergoing sigmoid/rectal resection. The present study is a first step to build a consistent structured reporting platform for the SEGI units and facilitate a wide implementation and standardization of ERAS protocol for DE patients in Italy.

OBJECTIVE To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer. METHODS This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting. RESULTS Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p��

Objective To assess characteristics, incidence, risk factors, and reporting rate of needlestick injuries (NSIs) among Obstetrics and Gynecology trainees. Study design We performed a nationwide cross-sectional survey study. The 40-items survey Obstetrics Needlestick Injury Questionnaire (ONSI-Q) was used to investigate the prevalence of NSIs, participant attitudes, associated factors, and the NSI reporting rate among trainees in Obstetrics and Gynecology. The target responders were all trainees of Obstetrics and Gynecology training programs in Italy. The trainees were invited between September 2018 and December 2018 via a web-based platform. Results Among 1049 trainees, 1041 (99.2%) completed the survey. Out of 1041 trainees, 639 (61.4%) had at least one NSI, and 90.9% (581/639) experienced at least one during obstetric surgery. The number of NSIs increased with the year of training, with 2.48 NSIs per trainee in the fifth year. 90.6% (579/639) reported details about the most recent NSI, which was during obstetric surgery in 95.3% (552/579) of cases. 57.1% (315/552) experienced the most recent NSI during cesarean section, which was mainly inflicted by someone else (72.4%; 228/315). 42.9% (237/552) of NSIs were during perineal suture, and 84% (199/237) of them were self-inflicted. 77.9% (417/535) of trainees did not report the NSI. Associated factors were non-high-risk patients, self-inflicted NSI, and the first NSI. Conclusions NSIs are frequent among Obstetrics and Gynecology trainees but not reported, and obstetric surgery is the primary source. These data support the European efforts to improve working practices' safety. The education about protective strategies and reporting should be a priority.

In high income setting, the massive implementation of screening programs has reduced the incidence of cervical cancer, dramatically. However, cervical cancer still remains a major health concern, being one of the most common cause of death for cancer among women. The adoption of primary prevention through vaccination against HPV aims to reduce the prevalence of HPV-related lesions and cervical cancer. Accumulating data highlighted the cost-effectiveness of introducing HPV vaccination for adolescent and young adults. In the present review, we critically evaluated the role of vaccination against HPV, focusing much more on the role of vaccination in specific cluster of subjects (eg, post-treatment and older adults). Additionally, we evaluated the available evidence on the role of vaccination in HIV-positive subjects and in women receiving solid organs transplantation. We observed that although vaccination might be considered effective in those cluster of subjects; further evidence is needed to assess the cost-effectiveness of vaccination in these settings.

The major causes of IVF failure in women with endometriosis have been attributed to decreased ovarian reserve, low embryo quality and impaired receptivity of the endometrium. Dienogest (DNG) has anti-inflammatory and anti-angiogenic activity and so may theoretically improve IVF outcomes in women with endometriosis. This study aimed to evaluate the administration of DNG before IVF in women with endometriosis who had previously failed one IVF cycle.This study was based on the retrospective analysis of a prospectively collected database, including 151 women who had failed a previous IVF cycle and all subsequent embryo transfers and had an imaging diagnosis of endometriosis. Patients either directly underwent IVF without receiving hormonal treatment or received 3 months of treatment with DNG (2 mg/daily) before IVF.Eighty-eight (58.3%) patients underwent IVF without previous hormonal treatment, and 63 (41.7%) received pretreatment with DNG. The cumulative implantation, clinical pregnancy and live birth rates were significantly higher in the DNG-treated group (39.7%, 33.3% and 28.6%) than in the non-treated group (23.9%, 18.2% and 14.8%; P = 0.049, 0.037 and 0.043, respectively). The largest diameter of endometriomas significantly decreased after DNG pretreatment (P 0.001). The use of DNG increased significantly the number of oocytes retrieved (P = 0.031), two-pronuclear embryos (P = 0.039) and blastocysts (P = 0.005) in women with endometriomas of diameter ≥4 cm.This study suggest that in patients with endometriosis, IVF outcomes can be improved by pretreatment with DNG. In particular, the use of DNG allows for better oocyte retrieval and blastocysts in patients with large endometriomas.

Study Objective: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire. Design: Secondary analysis of a prospective randomized controlled trial. Setting: Three academic research centers. Patients: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included. Interventions: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications. Measurements and Main Results: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (

Study Objective Sentinel node mapping (SNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate the long-term survival of three different approaches of nodal assessment. Design A retrospective study evaluating long-term outcomes (at least 3 years of follow-up). Setting Multi-institutional study. Patients or Participants EC patients having nodal assessment between 2006 and 2016. In order to reduce possible confounding factors, we applied a propensity-matched algorithm. Interventions Laparoscopic hysterectomy plus sentinel node mapping and/or lymphadenectomy Measurements and Main Results Charts of 940 patients were evaluated: 174 (18.5%), 187 (19.9%), and 579 (61.6%) having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Applying a propensity score matching algorithm (1:1:2) we selected 500 patients: 125 SNM vs. 125 SNM plus backup lymphadenectomy vs. 250 lymphadenectomy. Baseline characteristics of the study population were similar between groups. The prevalence of nodal disease was 14%, 16%, and 12% in patients having SNM, SNM followed by backup lymphadenectomy and lymphadenectomy, respectively. Overall, 19 (7.6%) patients were diagnosed with low volume nodal disease (7 and 12 patients with micrometastasis and isolated tumor cells). The mean (SD) follow-up time was 62 (±11) months. The survival analysis comparing the three techniques did not show statistical differences in terms of disease-free (p=0.750) and overall survival (p=0.899). Similarly, the type of nodal assessment did not impact survival outcomes after stratification on the basis of uterine risk factors. Conclusion Our study highlighted that SNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultrastaging and the role of molecular/genomic profiling.

Myo-inositol (MI) and D-chiro-inositol (DCI) are insulin second messengers, and MI is involved in follicular gonadotropin pathways which orchestrate ovulation. The tissue-specific MI/DCI ratio is modulated by insulin through aromatase and is altered in insulin resistance (IR), with reduced epimerization of MI to DCI in insulin-sensitive tissues. In ovaries, the MI/DCI ratio is 100:1, but is dramatically reduced by insulin-stimulated epimerase in hyperinsulinemic women with polycystic ovary syndrome (PCOS). Inositols have proved to be effective in PCOS, improving metabolic and hormonal state, and restoring spontaneous ovulation. In assisted reproductive technology, inositol improved ovarian stimulation parameters, although data concerning fertility outcomes are conflicting. Given their functions, inositols are an attractive treatment option for PCOS, although well-designed studies on spontaneous and non-spontaneous fertility are needed.

Background Inside-out transobturator tape (tension-free vaginal tape–obturator [TVT-O]) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI). However, data reporting long-term outcomes are lacking. Objective To assess the efficacy and safety of TVT-O 10 yr after implantation for the treatment of female pure SUI. Design, setting, and participants A multicenter, prospective study was conducted in five tertiary referral centers in three countries. All consecutive women with urodynamically proven pure SUI treated by TVT-O were included. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. Intervention TVT-O implantation. Outcome measurements and statistical analysis Data regarding subjective outcomes (International Consultation on Incontinence Questionnaire–Short Form, Patient Global Impression of Improvement, and patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Univariable analysis was performed to investigate outcomes. Results and limitations One hundred sixty-eight women had TVT-O implantation. At 10-yr follow-up, 160 patients (95%) were available for the evaluation. We did not find any significant change of the surgical outcomes during this time. At 10 yr after surgery, 155 of 160 patients (97%) declared themselves cured ( p =0.7). Similarly, at 10-yr evaluation, 148 of 160 patients (92%) were objectively cured. No significant deterioration of objective cure rates was observed over time ( p =0.4). The history of failure of previous anti-incontinence procedures (hazard ratio: 5.34; 95% CI, 2.61–11.9; p =0.009) was the only predictor of recurrence of SUI. The onset of de novo overactive bladder was reported by 23 of 160 patients (14%) at 10-yr follow-up. No other late complications were reported. Conclusions The 10-yr results of this study showed that TVT-O is a highly effective and safe option for the treatment of SUI. Patient summary At long-term follow up, tension-free vaginal tape-obturator is highly effective and safe for the treatment of stress urinary incontinence.

Study Objective Sentinel node mapping (SLNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate long-term survival of two different approaches of nodal assessment in EC. Design This is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years) of EC patients having SLNM alone and SLNM followed by lymphadenectomy. In order to reduce possible confounding factors we applied a propensity-matched algorithm. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard models. Setting Three oncologic referral centers. Patients or Participants Consecutive EC patients having minimally invasive surgical staging. Interventions Laparoscopic hysterectomy plus SLNM with or without backup lymphadenectomy. Measurements and Main Results Applying a propensity score matching algorithm we selected 180 patients having SLNM (90 SLNM vs. 90 SLNM followed by lymphadenectomy). Median follow-up time was 69 months. Overall, 10% of patients were diagnosed with positive nodes. Low volume disease was observed in 16 cases (5 micrometastasis and 11 isolated tumor cells). Patients having SLNM followed by lymphadenectomy had not a higher possibility to be diagnosed with a stage IIIC disease in comparison to SLNM alone (p=0.389). The survival analysis comparing did not show statistical differences in terms of disease-free (p=0.570, log-rank test) and overall survival (p=0.911, log-rank test) were similar between groups. No survival differences were observed also after stratification in low, intermediate and high-risk patients (p>0.20). Conclusion Our study highlighted that laparoscopic staging is safe and effective in EC. SLNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultra staging in patients following SLNM.

Objective To summarize available evidence on clitoral reconstruction after Female genital mutilations/cut (FGM/C). Study design Systematic review of the literature to identify studies on clitoral reconstruction after previous FGM/C with at least 6 months of follow-up. The literature search was performed in the following databases: PubMed, EMBASE, Web of Science, and the Cochrane Library. The period considered was from the database inception to June 30th, 2020. Main outcome measures Post-operative vulvar pain or dyspareunia, changes in sexual activity or orgasm, and the impact on self-image. Results We identified 8 studies; four used the same “Foldes technique”, and four adopted similar techniques based on the downward mobilization of the clitoral stump, with different reconstructions of glans and prepuce. The postoperative complication rate was reported at 5.3%. Sexual function is the only outcome investigated by all studies, which consistently suggest that clitoral reconstruction appear effective to improve clitoral pleasure/orgasm. Almost all studies assessed self-image, which appears improved. Only 2 studies provided data about pain and/or dyspareunia, which were improved by clitoral reconstruction. However, the risk of bias is high. Most patients were lost at follow-up, and validated instruments to assess outcomes were used only in a minority of studies. Conclusions Although clitoral reconstructive surgery for FGM/C appears safe and effective, caution is required to interpret available evidence due to significant limitations. Further studies are required to compare the proposed techniques and to confirm the effectiveness in terms of vulvar pain and/or dyspareunia, sexual activity and/or orgasm, and self-image improvement.

Study Objective To investigate the feasibility and safety of laparoscopic cytoreduction in ovarian cancer patients with localized carcinomatosis or lymph node involvement. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Multi-institutional study performed in 6 referral gynecologic oncology units. Patients Between June 2005 and December 2014, preoperatively presumed early-stage ovarian cancer patients, who accidentally revealed localized carcinomatosis or lymph node involvement at laparoscopic evaluation or at postoperative pathological examination managed by the laparoscopic approach. Interventions All patients with limited carcinomatosis and/or lymph node metastases underwent complete laparoscopic cytoreduction. Measurements and results Sixty-nine patients were included in the analysis. Twenty-eight (40.6%) patients were staged III C because they had lymph node metastases. Pelvic lymphadenectomy was performed in 75.4% of cases, whereas aortic lymphadenectomy was performed in 79.7% of cases. Lymph node metastases were found in pelvic and aortic regions in 11 and 13 patients, respectively, whereas 4 patients had lymph node metastases in both regions. Twelve (17.4%) patients underwent complete pelvic peritonectomy because of the presence of nodules localized in several pelvic region sites. As of May 2015, the median follow-up was 35 months, and the median disease-free survival was 29 months. The 2-year disease-free survival rate was 77.1%, whereas the 2-year overall survival rate was 90.6%. The median time to recurrence was 26 months (range, 6 -55 months); 15 (21.7%) patients developed recurrence. Conclusion The present study shows the technical and clinical feasibility of laparoscopic cytoreduction in ovarian cancer patients with limited carcinomatosis or lymph node involvement.

Objective To investigate in depth the effect of increasing age on the peri-operative outcomes of laparoscopic treatment for endometrial cancer, compared to open surgery, with stratification of patients according to the different definitions of elderly age used in the literature. METHODS: Data of consecutive patients who underwent surgery for endometrial cancer staging at six centers were reviewed and analyzed according to surgical approach (laparoscopic or open), different definitions of elderly and very elderly age (≥65years, ≥75years, ≥80years), and class of age (0.05). The same tendency was observed among very-elderly patients (≥80years). Multivariable and propensity score-matched analysis confirmed these findings. CONCLUSIONS: Laparoscopy for staging endometrial cancer retains its advantages over open surgery even in elderly and very-elderly patients. Our data strongly suggest that minimally-invasive surgery is advantageous even among subjects ≥80years.

Study Objective To identify different patterns of recurrence after laparoscopic and open abdominal radical hysterectomy for cervical cancer. Design This a retrospective multi-institutional study evaluating patients with recurrent cervical cancer after laparoscopic and open abdominal surgery. In order to reduce possible confounding factors, we applied a propensity-matching algorithm. Setting Two oncologic referral centers. Patients or Participants Consecutive cervical cancer patients who developed recurrence after surgical treatments. Interventions Laparoscopic and open abdominal radical hysterectomy. Measurements and Main Results Chart of 1,058 cervical cancer patients were retrieved. The study population included 117 (14.2%) and 35 (14.9%) patients with recurrent cervical cancer who had had open abdominal and laparoscopic surgery, respectively. Applying a propensity matched comparison (1:2) we reduced the study population to 105 patients (35 vs. 70 patients having recurrence after laparoscopic and open abdominal radical hysterectomy). The groups had similar baseline characteristics. Patients having laparoscopic radical hysterectomy experienced shorter progression-free survival than patients having open abdominal procedures (median progression-free survival: 8.0 vs. 15.8 months; HR: 1.98 (95%CI: 1.32 to 2.97); p=0.005). Site specific progression-free survival for vaginal, lymphatic and distant recurrences was similar between groups. However, patients having laparoscopy are at high risk of developing intra-pelvic recurrences and peritoneal carcinomatosis (HR: 17.9 (95%CI: 3.42 to 93.7); p=0.0006 log-rank test). Conclusion Patients having laparoscopy are at high risk of developing intra-pelvic recurrences and peritoneal carcinomatosis, due to unknown reasons (possibly due to a contamination of the pelvic area during colpotomy). Further evidence is needed in order to identify the best surgical treatment modality for cervical cancer patients.

Objective To present three different subtypes of T-shaped uterus with the use of three-dimensional (3D) ultrasound imaging and hysteroscopy. Design Video article. Setting Fertility center. Patient(s) Three cases showing the different subtypes of T-shaped uterus. Intervention(s) 3D ultrasound imaging and hysteroscopy. Main Outcome Measure(s) Distance between the interostial line and external uterine profile at the midcoronal plane of the uterus obtained with the use of transvaginal 3D ultrasound; delineation of the external uterine contour and the length of any existing internal indentation (defined as the distance between the interostial line and the indentation's edge at the cavity). Result(s) It is possible to identify three different subtypes of T-shaped uterus: the most common type of T-shaped uterus, with thick lateral walls and normal fundus (without septum or subseptum appereance) and interostial distance; the Y-shaped uterus, with thick lateral walls, fundal septum or subseptum, and reduced interostial distance; and the I-shaped uterus, with very thick lateral walls (even above the isthmus) and severe reduction of the interostial distance (tubular appearance of the whole uterus). Conclusion(s) We solicit to investigate the occurrence of different T-shaped uterus subtypes in large cohorts, to evaluate whether they may have different reproductive outcomes and whether they may need different approaches for surgical correction through hysteroscopic metroplasty.

Growing evidence suggests that the level of pneumoperitoneal pressure is directly correlated with postoperative pain in patients undergoing laparoscopic procedures. However, only limited evidence is available in the field of gynaecologic surgery. Therefore, this study aimed to compare the effects of low (8mmHg), standard (12mmHg) and high (15mmHg) pneumoperitoneal pressures (LPP

Bulking agents provide an alternative option in the management of women with stress urinary incontinence and they seem to have an important role in the management flow chart of SUI. However, evidence on this issue is scanty. The most important aspect is to understand whether bulking agents are comparable with the other first-line anti-incontinence surgical procedure (MUS, Burch colposuspension and pubovaginal slings). Hence, the primary aim of the current review was to assess the objective and subjective outcomes of bulking agents in comparison with the other surgical procedures for the treatment of SUI. PubMed and Medline were systematically searched and we included studies evaluating the use of bulking agents in comparison with other surgical approaches for either primary or recurrent treatment of female SUI. Three studies meeting the inclusion criteria were identified. Two of these studies were RCTs evaluating the use of bulking agents versus other surgical procedures for the treatment of primary female SUI; the remnant article was a retrospective cohort study that compared the effectiveness and safety of repeat midurethral sling with urethral bulking after failed midurethral sling. The combined results of all analyses showed that the objective recurrence rate of peri- or trans-urethral injections is significantly higher in comparison with the other surgical procedures. Similar findings were observed when considering separately the treatment for primary or recurrent SUI. Furthermore, lower subjective recurrence rate was observed among patients undergoing other surgical treatment in comparison with those undergoing bulking agents; however, this trend was not statistically significant. Moreover, patients undergoing injection of bulking agents experienced a lower rate of voiding dysfunctions in comparison to the control group. According to current evidence, bulking agents should not be proposed as first-line treatment in those women seeking permanent cure for both primary and recurrent SUI. However, the effectiveness of a procedure should be balanced with its invasiveness and patients’ expectations. Bulking agents are a minimally invasive approach to treat SUI and their use should be considered as an alternative strategy particularly in special conditions: patients who are fragile, in those who do not wish to have surgery, or in whom surgical options are restricted (postoperatively, after irradiation).

Objective To determine if breastfeeding outcomes differ between mothers who conceived spontaneously compared with those who conceived with assisted reproductive technology (ART). Design Matched case-control study. Setting Teaching hospital. Patient(s) Ninety-four women having a singleton baby conceived with ART, matched by maternal age, parity, mode of delivery, and gestational age to controls who conceived spontaneously. Intervention(s) Cases and controls were interviewed using a standardized, structured questionnaire, to obtain information on lactation. Exposure to maternity care practices contributing to breastfeeding success was investigated. Main Outcome Measure(s) Initiation, exclusivity, and continuation of breastfeeding. Result(s) Cases were as likely as controls to initiate breastfeeding (89.4% vs. 90.4%), but by 6 weeks postpartum, a greater proportion of mothers who conceived through ART has ceased breastfeeding (20.2% vs. 5.3%). The percentage of mothers who exclusively breastfed their child for 6 months was similar among the 2 groups. On univariate conditional logistic regression, a history of using ART was the only predictor of early breastfeeding cessation (odds ratio=65.3 [95% confidence interval: 1.5–2889.3]). Conclusion(s) Women who have conceived with ART should be regarded as being at higher risk for early breastfeeding cessation. This study serves as a first step in the investigation of potential modifiable factors that contribute to breastfeeding failure among women who give birth after using ART, and may help in efforts to customize breastfeeding support strategies.

To compare surgery-related outcomes of electric motorized morcellator (EMM) and transvaginal extraction (TVE) for myoma retrieval after laparoscopic myomectomy.A retrospective propensity-matched analysis of prospectively collected data (Canadian Task Force classification II-2).A university teaching hospital.One hundred women undergoing laparoscopic myomectomy.Laparoscopic myomectomy followed by myoma retrieval via TVE or EMM.Fifty propensity-matched patient pairs (100 patients) undergoing laparoscopic myomectomy followed by myoma retrieval via TVE or EMM were studied. No significant differences were observed in baseline patient characteristics. Operative times were similar between groups (66 vs 73 minutes in the TVE and EMM group, respectively, p = .19). However, patients undergoing TVE experienced lower specimen retrieval time than patients undergoing extraction via EMM (5 [3-30] vs 7 [3-35] minutes, p.001). Blood loss, transfusion, and complication rates were similar between groups. One retrieval-related complication occurred in the EMM group (bleeding from an incision using a morcellator requiring resuture). The need for an analgesic rescue dose was lower in the TVE group compared with patients in the EMM group (p = .03). Although overall satisfaction levels were similar between groups, TVE is related to higher cosmetic outcomes compared with EMM (9.5 [±0.6] vs 8.5 [±1], p.001).TVE upholds the effectiveness of EMM, minimizing the operative time and potentially postoperative pain. Further large prospective studies are needed.

Surgery represents the mainstay of treatment for pelvic organ prolapse (POP). Among different surgical procedures, abdominal sacrocolpopexy (SC) is the gold standard for apical or multicompartmental POP. Research has recently focused on the role of robot-assisted sacrocolpopexy (RASC).To conduct a systematic review on the outcomes of RASC.PubMed, Scopus, and Web of Science databases as well as ClinicalTrials.gov were searched for English-language literature on RASC. A total of 509 articles were screened; 50 (10%) were selected, and 27 (5%) were included. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation system and the European Association of Urology guidelines.Overall, data on 1488 RASCs were collected from 27 studies, published from 2006 to 2013. Objective and subjective cures ranged from 84% to 100% and from 92% to 95%, respectively. Conversion rate to open surgery was1% (range: 0-5%). Intraoperative, severe postoperative complications, and mesh erosion rates were 3% (range: 0-19%), 2% (range: 0-8%), and 2% (range: 0-8%), respectively. Surgical-related outcomes have improved with increased experience, with an estimated learning curve of about 10-20 procedures. Laparoscopic SC is less costly than RASC, although the latter has lower costs than abdominal SC.RASC is a safe and feasible procedure for POP; it allows the execution of complex surgical steps via minimally invasive surgery without medium- and long-term anatomic detriments. Further prospective studies are needed to confirm these findings.We looked at the outcomes of robotic sacrocolpopexy for prolapse. We found that the use of robotic technology is safe and effective for the treatment of prolapse in women.

Study Objective To present our experience with laparoscopic hysterectomy (LH) for uteri weighing 1 kilogram or more and to provide a systematic review of the available English literature. Design Retrospective analysis and review of the literature (Canadian Task Force Classification II-2). Setting Department of Obstetrics and Gynecology, University of Insubria, Varese, Italy. Patients All women in whom LH was attempted at the Department of Obstetrics and Gynecology, University of Insubria for uteri weighing ≥1 kg were included in the present study. Demographic characteristics and perioperative details of patients were prospectively recorded in our institutional surgical database. We also performed a systematic review of the English literature to identify studies including at least 1 case of LH for uteri weighing ≥1 kg. Interventions Hysterectomy for uteri ≥1 kg was performed through a total laparoscopic approach with vaginal morcellation of the uterus in the majority of patients and transvaginal closure of the vaginal vault in all cases. Measurements and Main Results LH was attempted in a total of 71 women. The median uterine weight was 1120 g (1000–2860 g). Three (4.2%) conversions to open surgery were needed. The median operative time and blood loss were 120 minutes (55–360 minutes) and 200 mL (10–1000 mL), respectively. No intraoperative and 2 (2.8%) postoperative complications occurred. Our review identified 6 studies reporting details of LH for uteri weighing ≥1 kg for a total of 62 patients; conversion to open surgery was necessary in 6 (9.7%) patients, and an additional 13 (21%) received a minilaparotomic incision to extract the uterus. The overall complication rate reported in the literature was 11.4%. Conclusion LH represents a possibility even in cases of uteri weighing ≥1 kg. In a dedicated setting with high endoscopic experience, conversion and complication rates appear acceptable.

Study Objective To compare the use of low pneumoperitoneum pressure (LPP; 8 mm Hg) vs standard pneumoperitoneum pressure (SPP; 12 mm Hg) during mini-laparoscopic hysterectomy (MLH). Design Randomized controlled trial (Canadian Task Force classification I). Setting Tertiary care center. Patients Forty-two consecutive women scheduled to undergo MLH to treat benign uterine disease. Interventions Women were randomly selected to undergo MLH using LPP (n = 20) or SPP (n = 22). MLH was performed via 3-mm ancillary ports. Measurements and Main Results The primary outcome was to evaluate changes in abdominal and shoulder-tip pain via a 100-mm visual analog scale at 1, 3, and 24 hours postoperatively. All procedures were completed via mini-laparoscopy without the need to increase intra-abdominal pressure or convert to conventional laparoscopy or open surgery. Intraoperatively, 1 episode of severe bradycardia occurred in the LPP group, whereas no intraoperative complications were recorded in the SPP group (p = .47). No postoperative complications were recorded (p > .99). Abdominal pain was similar between groups at each time point. Incidence and intensity of shoulder-tip pain at 1 and 3 hours postoperatively was lower in the LPP group than in the SPP group (p .05). Rescue analgesic requirement did not differ statistically between the LPP and SPP groups (20% vs 41%, respectively; p = .19; odds ratio, 2.7; 95% confidence interval, 0.69–11.08). Conclusion In experienced hands, use of LPP is safe and feasible. During performance of MLH, compared with SPP, LPP is a simple method that offers advantages of less shoulder-tip pain.

Objective To evaluate the outcomes of women treated with Solifenacin 5 mg once a day for overactive bladder (OAB) to identify the factors associated with the risk of treatment failure. Methods Women with OAB symptoms for at least 3 months were considered for this study. At visit 0, patients received a 3-day voiding diary. Eligibility was determined at visit 1, 2 weeks later, on the basis of the results recorded in the 3-day voiding diary. To be included, patients had to have experienced at least 3 episodes of urgency during the 3-day voiding diary period. Eligible women received a 12-week antimuscarinic therapy with oral Solifenacin 5 mg once a day. At the follow-up examination, objective outcomes included changes from baseline in the 3-day voiding diary data. Subjective efficacy was evaluated using the Overactive Bladder Questionnaire Short Form (OABq-SF), the Indevus urgency severity scale (USS) questionnaire, and the Patient Global Impression of Improvement. Results A total of 675 (69.3%) women met the inclusion criteria and were directed to Solifenacin therapy. After a 12-week treatment, 632 (93.6%) women were assessed for office evaluation, and 101 (16%) patients were considered as nonresponders. The antimuscarinics were effective both in terms of improvement of questionnaires scores and in terms of reduction of episodes of urgency/24 hour (P

Objective To evaluate the risk factors potentially involved in the development of cervical intraepithelial neoplasia (CIN) recurrence after cervical conization in a long-term follow-up period. Study design Consecutive patients with histologically proven CIN who had undergone either cold knife conization or a loop electrosurgical excision procedure were enrolled and scheduled for serial follow-up examinations over a 10-year period. Data were stored in a digital database. Multivariate analysis was performed to identify factors for recurrence. Results Between January 1999 and December 2009, 282 patients fulfilled the inclusion criteria and were included in the final statistical analysis. After a median follow-up of 26.7 months (range 6–100), 64 (22.7%) women developed histologically confirmed recurrence. The 2-year recurrence-free survival was 83.7% and 66.7% for women with negative and positive margins, respectively ( p = 0.008). The 5-year recurrence-free survival was 75.4% and 50.3% for patients with negative and positive margins, respectively ( p = 0.0004). Positive surgical margin was the most important independent predictor of recurrence [HR 2.5 (95%CI 1.5–4.5), p = 0.0007; Wald 11.338]. After multinomial logistic regression the indication for conization based on persistent CIN1 was the only independent predictor for negative margin [OR 0.3 (95%CI 0.1–0.7), p = 0.008]. Conclusions Our study demonstrated that the surgical margin status represents the most important predictor for CIN recurrence after conization. After excisional therapy, close follow-up is mandatory for the early detection of recurrent disease. The identification of risk factors for recurrence may guide clinical decision-making on expectant management versus re-intervention.

Study Objective To compare operative outcomes and postoperative pain of laparoscopic hysterectomy (LH) versus minilaparoscopic hysterectomy (MLH). Design Randomized controlled trial (Canadian Task Force Classification I). Setting Tertiary care center. Patients Seventy-six women scheduled to undergo a hysterectomy for a supposed benign gynecologic condition. Interventions Participants were randomly assigned to LH (n = 38) or MLH (n = 38). MLH was performed with use of 3-mm ports. Both patients and assessors of the postoperative outcomes were blinded to the size of port used, and patients’ wounds were concealed by standard-size nontransparent dressings. Measurements Primary outcome was postoperative pain (both rest and incident on coughing and abdominal pain, as well as shoulder pain) by use of a 100-mm visual analogue scale. Main Results The two groups were similar in terms of operative outcomes. No intraoperative conversion from MLH to both LH and open surgery occurred. No significant difference in pain scores at 1, 3, 8, and 24 hours after surgery between groups was found. Rescue analgesic requirement was similar in the MLH and LH groups (21.1% vs 13.2%, p =.54). Conclusions Ports can safely be reduced in size without a negative impact on the surgeon’s ability to perform LH. MLH appears to have no advantage over LH in terms of postoperative pain.

Summary Introduction Bowel resection is now considered the “gold standard” treatment for severe endometriosis infiltrating the bowel. Laparoscopic colorectal resection can be considered a safe option in order to reduce surgical trauma and complications as well as to improve cosmetics. Transvaginal approach, used for several years to remove large specimens, can be an interesting approach also in case of colorectal resections. Aim of the study To present our experience on laparoscopic colorectal resection and transvaginal specimen extraction as treatment of severe endometriosis. Results Eleven patients (mean age 45±12 years) have been operated by a combined team of gynecologist and colorectal surgeons. There were no intra- or post-operative complications. In all cases, the transvaginal route was used to remove the specimen and prepare the bowel for anastomosis. Patients were allowed to free light diet on post-operative day 3±1 and discharged on day 5±2. The mean follow-up was 4±2 months and all patients are well with normal bowel function and symptoms free. Conclusions Our preliminary experience demonstrates such approach is safe and feasible with excellent results in term of post-operative course.

OBJECTIVE: To evaluate whether intra- and post-operative morbidity varies according to the method used for female sterilization. STUDY DESIGN: The database of the Swiss obstetric study group was analyzed for a period of 9 years. After the exclusion of cases with extraneous factors that may have influenced the operative outcome, three groups of patients were identified: (1) interval laparoscopic sterilization unrelated to pregnancy (n=20,325); (2) postpartum laparoscopic sterilization (n=2233); (3) postpartum sterilization by minilaparotomy (n=5095). Intra-operative and post-operative complications were compared according to the surgical approach. RESULTS: A total of 27,653 patients were included in the study. The proportion of major complications was higher in group 3 than in group 1 (0.39% versus 0.10%, odds ratio 4.0, 95% CI 2.15-7.44, p

Summary. Background: Information on the incidence of venous thromboembolism (VTE) following laparoscopic procedures is inadequate and there is currently no solid evidence to guide the use of thromboprophylaxis in this setting. Gynecologic laparoscopy is a common procedure, and is frequently performed in low-risk patients. To our knowledge, there are no clinical studies specifically designed to assess the incidence of VTE in this setting. Methods: In a prospective cohort study, consecutive patients undergoing gynecologic laparoscopy underwent compression ultrasonography (CUS) and clinical assessment to evaluate the incidence of clinically relevant VTE. CUS was performed 7 ± 1 and 14 ± 1 days postoperatively. A subsequent telephone contact was scheduled at 30 and 90 days. No patient received pharmacologic or mechanical prophylaxis. Patients with malignancy or previous VTE were excluded from the study. Results: We enrolled 266 consecutive patients; mean age was 36.3 years, range: 18–72. The most common indications for laparoscopy were ovarian cysts in 25.6% of patients, endometriosis in 21.0% of patients, unexplained adnexal masses in 12.4% of patients, and infertility in 7.5% of patients. The mean duration of the procedure was 60.5 min (range: 10–300 min). In particular, in 55.6% of patients the duration exceeded 45 min. There were neither episodes of CUS detected DVT (0/247; 0%, 95% CI 0–1.51%) or clinically relevant VTE after follow-up (0/256; 0%, 95% CI 0–1.48%). No patient died of fatal pulmonary embolism (0/266; 0%, 95% CI 0–1.42%). Conclusions: Gynecologic laparoscopy in non-cancer patients is a low-risk procedure for postoperative VTE.

Objective To evaluate the adequacy of laparoscopic ureterolysis as a primary treatment option for ureteral endometriosis. Design Prospective collaborative cohort study. Setting Gynecologic departments of three university hospitals. Patient(s) Women with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis on preoperative intravenous pyelography. Intervention(s) Laparoscopic ureterolysis. Main Outcome Measure(s) Cure rate, disesase recurrence. Result(s) Thirty-three patients underwent laparoscopic ureterolysis during the study period. Bilateral involvement of ureters was found in 4 (12.1%) cases. In women with unilateral lesions the left ureter was more frequently affected (24/29 vs. 5/29). Ureteral involvement was associated with uterosacral ligaments endometriosis in 65.5% (22/34) of cases. No inadvertent ureteral injuries occurred during ureterolysis. A partial wall resection of the ureter was necessary in one case and a segmental ureteral resection with vescicopsoas hitch was required in a women with intrinsic ureteral endometriosis. The median (range) follow-up time was 16 months (range: 3–53 months). Thirty-two patients (96.7%) had a patent ureter on the 3-month postoperative intravenous pyelography. The recurrence rate of ureteral lesions was 12.1% (4/33). Conclusion(s) Our findings suggest that a conservative laparoscopic approach is an effective treatment option in most patients with ureteral endometriosis exhibiting moderate-to-severe hydronephrosis.

Study objective To assess the technical feasibility and surgical outcome of a 5 mm-ports technique in a consecutive series of women with endometrial cancer laparoscopically managed. Design Prospective collaborative cohort study (Canadian Task Force classification II-2). Setting Two gynecologic oncology units of university hospitals. Patients A series of consecutive patients undergoing laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy for the treatment of endometrial cancer. Interventions A 10-mm zero-degree umbilical operative laparoscope and three 5-mm suprapubic trocars were used. The lymph nodes were removed with the use of a specimen bag through the umbilical port. Intraoperative and postoperative details and complications were prospectively collected. Measurements and main results A total of 101 patients were enrolled. Twenty-two (21.8%) had a body mass index (BMI) of 30 kg/m 2 or higher, and nine (8.9%) were severely obese (BMI ≥35 kg/m 2 ). One hundred procedures (99%) were carried out entirely with only three 5-mm ancillary trocars. In one patient, a 5-mm trocar was replaced with a 10-mm trocar because of a lesion of the external iliac vein requiring the placement of vascular clips. One procedure needed to be converted to laparotomy. Intraoperative complications occurred in three patients (one bladder injury and one iliac vein injury, both managed laparoscopically, and one subcutaneous emphysema). Postoperative complications occurred in 10 (10%) patients. The only complication requiring a subsequent intervention was a symptomatic pelvic lymphocyst. No difference was found in surgical outcomes between obese women and those of ideal BMI. Conclusion The use of only 5-mm ancillary trocars for the laparoscopic treatment of endometrial cancer can further minimize surgical invasiveness without compromising surgical efficacy and safety in patients with high BMI as well as for women with ideal BMI.

Background Dialysis and kidney transplantation represent two effective strategies in treating chronic uremia, albeit with different results. Our study compared the psychological aspects of two categories of patients: patients who faced kidney transplantation and have been on dialysis, and noncompliant patients treated with these therapies. Materials and Methods On 170 patients (120 hemodialysis and 50 peritoneal dialysis) we used a personality analysis (MMPI2) and the COPE, which assessed the ability of patients to cope under certain conditions that can be perceived as stressful or, in any case, unusual. The screening succeeded in 11 cases among the first group and 9 in the second. Three of the 20 patients were considered to be partially noncompliant: 1 on peritoneal and the other 2 on hemodialysis. We also tested a control group of 300 people of different ages, sexes, social and cultural status, dates and kinds of transplantation (cadaveric or living donors). Of the 36 feedbacks received, only 30 were considered valuable. Results The results of the research showed that patients with less than 2 years of dialysis treatment and patients with more than 2 years survival after transplantation time were inclined to deny their disease and the possible emotions about their clinical status, drawing an inadequate attention to the difficulties. This behavior was clearer among noncompliant patients. Family problems and couple malaise in everyday life can push more and more of these patients to be noncompliant with therapeutic prescriptions, as they do not feel adequate support. The result is an excessive foreboding, poor disposition, and nervousness. Conclusions Screening of patients’ social and psychological status is useful as is psychological intervention for those who miss emotional support from the family. This psychological support is advisable for uremics who have to enter a waiting list and for those who are subject to postoperative treatment in order to promote compliant behavior.

Study objective To evaluate the feasibility, safety, and effect on postoperative pain of laparoscopy for the management of adnexal masses by downsizing ancillary trocars from 5- to 3-mm. Design Randomized, controlled trial (Canadian Task Force classification I). Setting Gynecologic department of a university hospital Patients A total of 102 women with an adnexal mass scheduled for gynecologic laparoscopic procedures were randomized to undergo laparoscopy using either conventional 5-mm ancillary trocars (n = 52) or 3-mm instruments (n = 50). Preoperative suspicion of malignancy, deep infiltrating endometriosis, and indications for hysterectomy or myomectomy were considered as exclusion criteria. Interventions Laparoscopic procedures for the treatment of benign adnexal masses. Measurements and main results Both groups were similar in patient age, body mass index, history of abdominal surgery, and type of procedures. Intraoperative complications occurred in no patient (0%) in the 3-mm group and in two patients (3.8%) in the 5-mm group (p = .49). Conversion from 3- to 5-mm instrumentation was necessary in one procedure. No difference was found in the operative time between the 3-mm and the 5-mm groups (54 min [range 15–175 min] vs 50 min [range 20–150 min], p = .89). The severity of incisional pain was evaluated with a 100-mm visual analog scale at 1, 3, and 24 hours after surgery. Postoperative pain was significantly lower in the 3-mm than in the 5-mm group 1 hour after laparoscopy (20 [range 0–60] vs 32.5 [range 0–80], p = .04). The proportion of women requiring analgesia before discharge, the timing of analgesic requirement, and the total amount of medication in the first 24 hours after surgery were similar in the two groups. Conclusion Three-millimeter ancillary trocars can safely replace traditional-size equipment for the management of adnexal masses without a negative impact on the surgeon’s ability to perform gynecologic laparoscopy and are associated with less immediate postoperative pain.

Objective The purpose of this study was to evaluate the feasibility and efficacy of laparoscopic radiofrequency ablation of uterine fibroids. Study design Eighteen women with symptomatic intramural uterine myomas underwent radiofrequency ablation under laparoscopic guidance. Postoperative sonographic evaluations of the fibroids size were scheduled at 1, 3, 6 ,9, and 12 months. The impact of myoma-related symptoms on quality of life (QOL) was assessed using a validated questionnaire. Results The median number of myomas treated per patient was 1 (1-3). The median baseline volume of the dominant myoma was 67.2 cm 3 (14.8-332.8). No intraoperative or postoperative complications occurred. The median reductions in myomas volume were 41.5%, 59%, and 77% at 1, 3, and 6-months, follow-up evaluation, respectively. No further change in fibroid size was observed at 9 months and 1 year. A significant improvement in the symptoms score and QOL score was observed at 3 and 6 months, follow-up. Conclusion In this pilot study, laparoscopic radiofrequency ablation successfully reduced fibroid symptoms and fibroid volume in short-term follow-up. Additional studies are needed before its efficacy and safety can be confirmed.

Objective To evaluate whether the presence of kissing ovaries at ultrasound is a marker for endometriosis and whether it correlates with the severity of the disease. Design Prospective observational study. Setting Gynecologic departments of two university hospitals. Patient(s) A total of 722 consecutive premenopausal women who had laparoscopic surgery for an adnexal mass or suspected pelvic endometriosis. Intervention(s) Preoperative ultrasound evaluation and laparoscopic surgery. Main outcome measure(s) Diagnostic and predictive value of ultrasound identification of kissing ovaries in the detection of endometriosis. Result(s) Kissing ovaries were diagnosed at ultrasound and confirmed laparoscopically in 32 patients. Of these, 27 had moderate to severe endometriosis and five others had benign adnexal masses. Bowel (18.5% vs. 2.5%) and fallopian tube (92.6% vs. 33%) endometriosis were significantly more frequent in patients with kissing ovaries than in patients without kissing ovaries. In infertile patients (n = 145), kissing ovaries were associated with a higher proportion of women with fallopian tube obstruction (80% vs. 8.6%). Considering patients with moderate to severe endometriosis (n = 189), the median (range) revised American Fertility Society score (74 [32–148] vs. 35 [16–146]) and the operative time (115 minutes [65–245 minutes] vs. 50 [15–180 minutes]) were significantly higher in patients with than in those without kissing ovaries. Conclusion(s) The detection of kissing ovaries at ultrasound is strongly associated with the presence of endometriosis and is a marker of the most severe form of this disease.

Objective To evaluate whether the serum concentrations of novel placental markers and nonplacental markers differ in ectopic pregnancy when compared with normal intrauterine pregnancy. Design Prospective clinical study. Setting University hospital. Patient(s) Patients with confirmed ectopic pregnancy (EP) and control population with normal intrauterine pregnancy (IUP). Intervention(s) Laparoscopy. Main outcome measure(s) Serum concentrations of placental markers: pregnancy-associated plasma protein A (PAPP-A), pregnancy-specific β1-glycoprotein (SP1), human placental lactogen (HPL), and HCG; and nonplacental markers: glycodelin, vascular endothelial growth factor (VEGF), and P. Result(s) The multiples of median of all markers (except VEGF) were decreased in EP when compared with the control group. Conversely, the serum values of VEGF were significantly increased in EP. VEGF showed a negative correlation with HCG and SP1, but not with PAPP-A, P, or the nonplacental markers. HCG, PAPP-A, SP1, and HPL strongly correlated with each other. But, in contrast to the above, P only correlated with HCG and, in contrast to the controls, with glycodelin. The combination of three independent markers in the formula VEGF/(PAPP-A × P) was found to be largely superior to the measure of any single marker. Conclusion(s) The “triple marker analysis” [VEGF/(PAPP-A × P] allows a clear discrimination between normal IUP and EP.

To explore the sonographic vascular architecture and the hyaluronan amount and distribution of umbilical cords of healthy and trisomy 21 fetuses in early gestation.Umbilical cord sonographic morphology and morphometry of 112 consecutive normal fetuses and 11 trisomy 21 fetuses were assessed between 10 and 15 weeks of gestation. The umbilical coiling index was defined as the reciprocal of the length of one complete coil measured in a longitudinal section of the umbilical cord. The umbilical coiling angle was defined as the maximum angle between the long axis of the umbilical cord and that of the umbilical arteries. Three umbilical cord samples obtained from Down syndrome fetuses and one from a healthy fetus after voluntary termination of pregnancy at 13 weeks of gestation were used for biochemical analysis. Quantitative hyualuronan content and tissue distribution was studied using fluorophore-assisted carbohydrate electrophoresis (FACE) analysis and staining methods using biotin-labeled hyaluronan-binding protein (bHABP), respectively.A significant correlation was present between gestational age and both the umbilical coiling index (r=-0.56, p0.001) and the umbilical coiling angle (r=-0.43, p0.001). The proportion of uncoiled umbilical cords was significantly higher in Down syndrome fetuses than in healthy fetuses [8/112 (7.1%) vs. 4/11 (36.4%), p0.05]. Biochemical analysis demonstrated a higher amount and a different distribution of hyaluronan in trisomy 21 umbilical cords compared to healthy fetuses.The umbilical cord of Down syndrome fetuses in early gestation shows peculiar sonographic vascular features and quantitative alterations of the Wharton's jelly hyaluronan.

Objective To compare 3-mm minilaparoscopy and standard 5-mm laparoscopy for sentinel lymph node (SLN) detection in apparent early-stage endometrial cancer (EC). Design Retrospective study (Canadian Task Force classification II-2). Setting Two academic research centers. Patients Consecutive women with apparent early-stage EC who underwent surgical staging with SLN detection between November 2015 and April 2016. Interventions The surgical approach was a total laparoscopic extrafascial hysterectomy plus bilateral salpingo-oophorectomy and SLN detection. Systematic lymphadenectomy was performed in selected cases. In all patients, SLN detection was performed with cervical injection of indocyanine green and the use of an optical camera with a near-infrared high-intensity light source for detection of fluorescence imaging. All patients who underwent a minilaparoscopic approach (using one 5-mm scope and three 3-mm ancillary trocars) have been enrolled at the University of Insubria, whereas at the San Gerardo Hospital, standard laparoscopy was performed with one 10-mm scope and three 5-mm ancillary trocars. Measurements ad Main Results A total of 38 patients were enrolled, including 15 (39.5%) in the 3-mm group and 23 (60.5%) in the 5-mm group. No between-group differences were found in terms of demographic and tumor characteristics. Bilateral SLNs were detected in 73.3% of the patients in the 3-mm group and in 73.9% in the 5-mm group. Operative time, blood loss, hemoglobin drop, hospital stay, and the incidence and severity of complications were similar in the 2 groups. One patient (4.3%) in the standard 5-mm group had a positive SLN result (a micrometastasis in the left external iliac SLN). No positive SLNs were detected in the 3-mm group. Conclusion Minilaparoscopic SLN biopsy appears to be a promising and feasible technique for EC staging. Further research is warranted to investigate the possible benefits of 3-mm instruments in this specific setting.

A pre-existing intrauterine inflammation in the first half of gestation has been proposed as a possible condition that leads to preterm delivery. Indeed, elevated levels of inflammatory mediators (eg, interleukin-6, tumor necrosis factor) in midtrimester amniotic fluid have been found in cases of preterm delivery and/or spontaneous abortion. The objective of this study was to investigate whether the amniotic fluid C-reactive protein level at the time of genetic amniocentesis is a marker for spontaneous preterm delivery before 34 and 37 weeks of gestation.Women who underwent genetic amniocentesis between 15 and 18 weeks of gestation with (1) singleton gestation, (2) uneventful pregnancy course before the amniocentesis, and (3) absence of fetal abnormalities were included in the study. Patients with abnormal karyotype were excluded. C-reactive protein concentration was measured in amniotic fluid and in maternal blood immediately after genetic amniocentesis. All patients were followed until delivery for the occurrence of pregnancy complications. Nonparametric tests and receiver-operating characteristic curve analysis were used for statistical purposes.The prevalence of spontaneous preterm delivery before 34 and 37 weeks was 3.3% (10 of 306 pregnancies) and 8.5% (26 of 306 pregnancies), respectively. Women with preterm delivery at37 weeks had a higher median (range) of amniotic fluid C-reactive protein concentration than those women who delivered at term (median, 113.3 ng/mL [range, 16-623 ng/mL] vs median, 57.8 ng/mL [range, 0-808.9 ng/mL]; P.005). Women with preterm delivery at34 weeks had a higher median (range) amniotic fluid C-reactive protein concentration than those women who delivered at term (median, 183.8 ng/mL [range, 46.5-447 ng/mL] vs median, 57.8 ng/mL [range, 0-808.9 ng/mL]; P.005]. No correlation was found between amniotic fluid C-reactive protein and maternal blood C-reactive protein concentrations. No relationship was found between maternal blood C-reactive protein concentration and preterm delivery before either 34 or 37 weeks. Amniotic fluid C-reactive protein concentration of110 ng/mL had a sensitivity of 80.8% and a specificity of 69.5% in the prediction of spontaneous preterm delivery at34 weeks.This study supports the theory that a subclinical intrauterine/fetal inflammatory process early in gestation may be important for the occurrence of preterm delivery in the second half of gestation.

A rare case of prelabor uterine rupture in a primigravida was reported. A woman with a history of uterine perforation during hysteroscopy became pregnant after donor oocyte in vitro fertilization. To provide more insight into the possible risk factors for prelabor uterine rupture in primigravidae, a literature review was performed.

This study evaluated the efficacy of intravaginal prostaglandin E(2) gel in comparison with that of a Foley catheter for cervical ripening and induction of labor.Consecutive patients with unfavorable cervix requiring preinduction cervical ripening and induction of labor at term gestation were asked to participate in the study. One hundred and two patients were assigned to treatment with intravaginal prostaglandin E(2) gel (group 1) and 122 patients underwent the placement of an intracervical Foley catheter (group 2). After a maximum of three applications of intravaginal prostaglandin E(2) gel (18h) or after 18h from Foley catheter insertion oxytocin was administered to patients not in active labor. Labor profiles and pregnancy and neonatal outcome were compared between groups.The groups were comparable in term of demographic characteristics, indications for induction of labor, Bishop score at admission. The induction to labor time and the induction to delivery time were similar between groups. The cesarean sections rate was higher in group 1 than in group 2 (26.5 versus 14.7%, P0.05). This remained significant when the analysis was restricted to nulliparous patients (32.3 versus 14.2%). The incidence of urinary tract infections, chorioamnionitis, and febrile morbidity was similar between groups.For preinduction cervical ripening, the Foley catheter is a valid alternative to the application of intravaginal prostaglandin E(2) gel and it is associated with a lower cesarean rate in nulliparous women.