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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��

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.

OBJECTIVE To investigate whether primary conization might overcome the risk of local dissemination in patients undergoing laparoscopic radical hysterectomy. METHODS Consecutive data of 262 patients with early stage cervical cancer were retrieved: 88 women had conization followed by radical hysterectomy. A propensity-matched comparison (1:1) was carried out in order to compare laparoscopy and open surgery. Accumulating data highlighted that minimally invasive surgery has been associated with higher recurrence rates and worse overall survival than open surgery in women with early stage cervical cancer. RESULTS Data of 35 paired patients (total 70 patients) were analyzed. No between-group differences in baseline, disease, and pathological variables were observed. Patients undergoing laparoscopy correlated with lower blood loss (50 [range 30-100] vs 150 [range 50-500] mL; P

Objective To evaluate long-term outcomes after surgery for apparent early-stage ovarian cancer (OC). Methods Retrospective analysis of women who underwent staging surgery for apparent early-stage OC at a single center in Milan, Italy, from 1990 to 2008, and had a follow-up longer than 10 years (living women with no recurrence). Univariate and multivariate analyses and propensity score matching were carried out. Results Overall, 182 women underwent radical (n=148, 81.3%) or conservative (n=34, 18.7%) procedures for early-stage OC. Ten-year disease-free and overall survival were 82.9% (n=151) and 87.9% (n=160), respectively. Conservative or radical surgery had similar disease-free (log-rank test, P=0.783) and overall (log-rank test, P=0.783) survival. These data were confirmed after the application of propensity score matching. High-risk features correlated with non-significant worse disease-free survival (P=0.080). In the high-risk group (≥Grade 3 or ≥ Stage IC), type of surgical approach (conservative vs radical) did not affect survival (hazard ratio, 0.81; 95% confidence interval, 0.18-3.56; P=0.781). Conclusion Women with early-stage OC had encouraging long-term survival. The presence of high-risk disease had detrimental effects on survival, regardless of surgical approach. High-risk disease should not be considered a contraindication to conservative surgery.

OBJECTIVE Sentinel node mapping (SLN) has replaced lymphadenectomy for staging surgery in apparent early-stage low and intermediate risk endometrial cancer (EC). Only limited data about the adoption of SNM in high risk EC is still available. Here, we evaluate the outcomes of high-risk EC undergoing SNM (with or without back-up lymphadenectomy). METHODS This is a multi-institutional international retrospective study, evaluating data of high-risk (FIGO grade 3 endometrioid EC with myometrial invasion >50% and non-endometrioid histology) EC patients undergoing SNM followed by back-up lymphadenectomy and SNM alone. RESULTS Chart of consecutive 196 patients were evaluated. The study population included 83 and 113 patients with endometrioid and non-endometrioid EC, respectively. SNM alone and SNM followed by back-up lymphadenectomy were performed in 50 and 146 patients, respectively. Among patients having SNM alone, 14 (28%) were diagnosed with nodal disease. In the group of patients undergoing SNM plus back-up lymphadenectomy 34 (23.2%) were diagnosed with nodal disease via SNM. Back-up lymphadenectomy identified 2 (1%) additional patients with nodal disease (in the para-aortic area). Back-up lymphadenectomy allowed to remove adjunctive positive nodes in 16 (11%) patients. After the adoption of propensity-matched algorithm, we observed that patients undergoing SNM plus back-up lymphadenectomy experienced similar disease-free survival (p��=��0.416, log-rank test) and overall survival (p��=��0.940, log-rank test) than patients undergoing SLN alone. CONCLUSIONS Although the small sample size, and the retrospective study design this study highlighted that type of nodal assessment did not impact survival outcomes in high-risk EC. Theoretically, back-up lymphadenectomy would be useful in improving the removal of positive nodes, but its therapeutic value remains controversial. Further prospective evidence is needed.

Objective: To evaluate the outcomes of high-risk (HR) HPV-positive and -negative women affected by high-grade cervical dysplasia. Methods: This is a retrospective multi-institutional study. Medical records of consecutive patients with high-grade cervical dysplasia undergoing conization between 2010 and 2014 were retrieved. All patients included had at least 5 years of follow-up. A propensity-score matching was adopted in order to reduce the presence of confounding factors between groups. Kaplan-Meir and Cox hazard models were used to estimate 5-year outcomes. Results: Overall, data of 2966 women, affected by high-grade cervical dysplasia were reviewed. The study population included 1478 (85%) and 260 (15%) women affected by HR-HPV-positive and HR-HPV-negative high-grade cervical dysplasia. The prevalence of CIN2 and CIN3 among the HR-HPV-positive and -negative cohort was similar (p = 0.315). Patients with HR-HPV-positive high-grade cervical dysplasia were at higher risk of 5-year recurrence (after primary conization) that HR-HPV-negative patients (p < 0.001, log-rank test). Via multivariate analysis, HR-HPV-negative women were at low risk of recurrence (HR: 1.69 (95%CI: 1.05, 4.80); p = 0.018, Cox Hazard model). A propensity-score matched comparison was carried out in order to reduce biases that are related to the retrospective study design. In comparison to HR-HPV-negative patients, thosewith HR-HPV-positive CIN3 was associate with a 8-fold increase in the risk of recurrence (p < 0.001, log-rank test). Conclusions: HR-HPV-negative high-grade cervical dysplasia is not uncommon, accounting for 15% of our study population. Those patients experience more favorable outcomes than patients with documented HR-HPV infection(s). Further prospective studies are needed to corroborate our data.

STUDY OBJECTIVE To investigate the factors associated with poorer oncologic outcomes in patients undergoing laparoscopic radical hysterectomy (LRH) for early stage cervical cancer. DESIGN Multicenter retrospective study. SETTING Three gynecologic oncology referral centers. PATIENTS Patients with International Federation of Gynecology and Obstetrics 2009 stage IA (positive lymphovascular space invasion)-IB1 cervical cancer between January 2006 and June 2018. INTERVENTIONS LRH (Piver type II-III hysterectomies). Lymph-node dissection was accomplished according to the tumor characteristics. MEASUREMENTS AND MAIN RESULTS Surgical and oncologic outcomes were analyzed. Overall, 186 patients met the inclusion criteria, 16 (8.6%) experienced a recurrence, and 9 (4.8%) died of the disease (median follow-up period 37.9 months). Surgery-related complications did not influence disease-free survival. All the recurrences (16/16; 100%) occurred in patients with stage IB1 disease (p = .02), and 15 (93.7%) in cases involving tumors ≥2 cm. No association between positive lymph node and recurrence was detected (p =.82). Patients who had a preoperative diagnosis through conization (93; 50%) had a significantly lower rate of recurrence than those who underwent cervical biopsy (93; 50%): 1/93 (1.1%) vs 15/93 (16.1%); p

Background: Primary prevention through vaccination is a prophylactic approach aiming to reduce the risk of developing human papillomavirus (HPV)-related lesions. No mature and long-term data supported the adoption of vaccination in women undergoing conization. Methods: This is a retrospective multi-institutional study. Charts of consecutive patients undergoing conization between 2010 and 2014 were collected. All patients included had at least 5 years of follow-up. We compared outcomes of patients undergoing conization plus vaccination and conization alone. A propensity-score matching algorithm was applied in order to reduce allocation biases. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models. Results: Overall, charts of 1914 women were analyzed. The study group included 116 (6.1%) and 1798 (93.9%) women undergoing conization plus vaccination and conization alone, respectively. Five-year recurrence rate was 1.7% (n = 2) and 5.7% (n = 102) after conization plus vaccination and conization alone, respectively (p = 0.068). After the application of a propensity-score matching, we selected 100 patients undergoing conization plus vaccination and 200 patients undergoing conization alone. The crude number of recurrences was 2 (2%) and 11 (5.5%) for patients undergoing conization plus vaccination and conization alone, respectively (p = 0.231). Vaccination had no impact on persistent lesions (no negative examination between conization and new cervical dysplasia, p = 0.603), but reduced the risk of recurrent disease (patients who had at least one negative examination between conization and the diagnosis of recurrent cervical dysplasia, p = 0.031). Conclusions: Patients having vaccination experience a slightly lower risk of recurrence than women who had not, although not statistically significantly different. Further evidence is needed to assess the cost effectiveness of adopting vaccination in this setting.

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 three different approaches of nodal assessment in EC. Methods This is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years) of patients having lymphadenectomy, SLNM followed by lymphadenectomy and SLNM alone. We applied a propensity-matched algorithm. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard models Results Applying a propensity score matching algorithm we selected 180 patients having SLNM (90 SLNM vs. 90 SLNM followed by lymphadenectomy). Additionally, a control group of 180 patients having lymphadenectomy was selected. 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 a higher possibility to be diagnosed with a stage IIIC disease in comparison to lymphadenectomy alone (p=0.02); while we did not observe a difference in the diagnostic value of SLNM followed by lymphadenectomy and SLNM (p=0.389). Median follow-up time was 69 (7–206) months. There were no statistical differences in terms of disease-free (p=0.570, log-rank test) and overall survival (p=0.911, log-rank test); Similarly, they did not impact on survival outcomes after stratification by low, intermediate and high-risk patients. Conclusions Our study highlighted that SLNM provides similar long-term oncologic outcomes than lymphadenectomy, even in high-risk patients. Further evidence is warranted to assess the prognostic value of low volume disease detected by ultrastaging in patients following SLNM.

To investigate trends in prevalence of various human papillomavirus types in order to assess the unmet clinical needs for women affected by human papillomavirus-related disease. Data of consecutive 15 138 patients undergoing human papillomavirus DNA testing from 1998 to 2018 were retrospectively identified. Human papillomavirus types were classified at high-risk according to the classification of the International Agency for Research on Cancer. The International Agency for Research on Cancer included seven human papillomavirus types covered by nine-valent vaccine and five not yet covered by any available vaccines. Overall, 4159 (65.3%), 1500 (23.5%) and 714 (11.2%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. At least one high-risk human papillomavirus type(s) was detected in 1241 patients with genital dysplasia: 832 (67.1%), 291 (23.4%) and 118 (9.5%) women had human papillomavirus types covered by nine-valent vaccination, not covered by nine-valent vaccination and co-infections of human papillomavirus types of both groups. Over the twenty-year study period, the number of human papillomavirus types not covered by nine-valent vaccine increased dramatically (from 4 to 16%; P < 0.001, P for trend). Similarly, looking at patients with genital dysplasia, high-risk human papillomavirus types not covered by nine-valent vaccine increased from 3 to 13% (P < 0.001, P for trend). Our data highlight that human papillomavirus types covered by nine-valent vaccine represent are the main types associated with genital dysplasia. However, over the study period, we observed an increasing prevalence of confections and high-risk human papillomavirus types not covered by the nine-valent vaccine, thus suggesting the need of developing more complete vaccines against human papillomavirus.

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and surgery represents the pivotal part of treatment. Hysterectomy and salpingo-oophorectomy allow removing the primary tumor and defining patients at higher risk, who might benefit from adjuvant therapies. Minimally invasive surgery is associated with superior postoperative outcomes and represents a safe and effective approach for surgical staging of EC. The lymph node status evaluation in EC is still a matter of debate. Over the last twenty years much has changed, moving from a full systematic pelvic and paraaortic lymphadenectomy for staging purpose to the removal of the pelvic (with or without paraaortic) lymph nodes only in selected EC classes of risk. Two randomized trials failed to demonstrate survival benefits of lymphadenectomy in case of apparent early stage EC; however, its prognostic role has never been questioned. At present, with the aim of reducing the surgical-related morbidity, sentinel node mapping is emerging as a safe and valid alternative to lymphadenectomy for EC staging, demonstrating high accuracy and an increased detection of lymph nodes metastasis. Here, we performed a review of the most significant studies, which supported the changes in the lymph node status evaluation for EC over the last two decades.

ObjectiveRecent evidence has suggested that laparoscopic radical hysterectomy is associated with an increased risk of recurrence in comparison with open abdominal radical hysterectomy. The aim of our study was to identify patterns of recurrence after laparoscopic and open abdominal radical hysterectomy for cervical cancer.MethodsThis a retrospective multi-institutional study evaluating patients with recurrent cervical cancer after laparoscopic and open abdominal surgery performed between January 1990 and December 2018. Inclusion criteria were: age ≥18 years old, radical hysterectomy (type B or type C), no recurrent disease, and clinical follow-up >30 days. The primary endpoint was to evaluate patterns of first recurrence following laparoscopic and open abdominal radical hysterectomy. The secondary endpoint was to estimate the effect of the primary surgical approach (laparoscopy and open surgery) in post-recurrence survival outcomes (event-free survival and overall survival). In order to reduce possible confounding factors, we applied a propensity-matching algorithm. Survival outcomes were estimated using the Kaplan-Meier model.ResultsA total of 1058 patients were included in the analysis (823 underwent open abdominal radical hysterectomy and 235 patients underwent laparoscopic radical hysterectomy). The study included 117 (14.2%) and 35 (14.9%) patients who developed recurrent cervical cancer after open or laparoscopic surgery, respectively. Applying a propensity matched comparison (1:2), we reduced the population to 105 patients (35 vs 70 patients with recurrence after laparoscopic and open radical hysterectomy). Median follow-up time was 39.1 (range 4–221) months and 32.3 (range 4–124) months for patients undergoing open and laparoscopic surgery, respectively. Patients undergoing laparoscopic radical hysterectomy had shorter progression-free survival than patients undergoing open abdominal surgery (HR 1.98, 95% CI 1.32 to 2.97; p=0.005). Patients undergoing laparoscopic radical hysterectomy were more likely to develop intrapelvic recurrences (74% vs 34%; pConclusionsPatients undergoing laparoscopic radical hysterectomy are at higher risk of developing intrapelvic recurrences and peritoneal carcinomatosis. Further evidence is needed in order to corroborate our findings.

At the beginning of 2020, coronavirus disease 2019 (COVID‐19) spreads worldwide. Patients with ovarian cancer should be considered at high‐risk of developing severe morbidity related to COVID‐19. Most of them are diagnosed in advanced stages of disease, and they are fragile. Here, we evaluated the major impact of COVID‐19 on patients with ovarian cancer, discussing the effect of the outbreak on medical and surgical treatment.

To investigate oncological outcomes and patterns of recurrence of patients undergoing adjuvant “sandwich” chemo-radio-chemotherapy for locally advanced endometrial cancer. This is a multi-institutional retrospective study evaluating chart of consecutive patients undergoing chemo-radio-chemotherapy for FIGO stage III–IVA endometrial caner. The study population included 45 patients who had adjuvant sandwich regimen. Median age of the study population was 66 years. The majority of patients were diagnosed with endometrioid histology and with stage III disease. After a median follow-up of 35 months, 15 patients developed recurrent disease. Three-year disease-free and overall survivals was 45% and 81%, respectively. Three-years site-specific disease-free survival was 85%, 92% and 48% for local, loco-regional, and distant recurrence, respectively. All patients included in the study had nodal dissection. Nodal assessment included: sentinel node mapping, sentinel node mapping plus backup lymphadenectomy and lymphadenectomy in 15, 6 and 24 patients, respectively. The latter group included four patients detected by suspected enlarged nodes, intraoperatively. Even after the exclusion of patients with enlarged nodes, the type of nodal assessment did not impact on survival outcomes (p > 0.2). Positive peritoneal cytology was the only factor associated with an increased risk of developing (any site) recurrence and distant-specific recurrence, independently. No factor predicted for overall survival. Adjuvant “sandwich” chemo-radio-chemotherapy for locally advanced endometrial cancer guarantee promising local and loco-regional controls, but distant failure rate is high, thus suggesting the need for applying other systemic treatment strategies for these patients.

BACKGROUND Elderly ovarian cancer (OC) patients are more likely to be managed suboptimally, with worse clinical outcomes as a result. Strategies to decrease morbidity are lacking.Methodology: Consecutive patients with advanced stage OC (IIIC-IV) who were managed in our center between January 2016 and July 2018 were retrospectively analyzed. All patients underwent neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) according to our institution protocol. We divided patients into two groups: Group 1 (age ≥ 70 years) and Group 2 (age < 70 years). The primary outcome of the study was assessment of peri-operative morbidity amongst two groups. RESULTS A total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS compared to younger patients (39% vs. 19%, p = 0.03). Elderly patients were more frequently subjected to Cardiopulmonary Exercise Testing (CPET) as pre-operative assessment (63% vs. 27%, p = 0.002). Optimal/complete resection was achieved in all patients in Group 1 (100%) and in 97% of patients in Group 2. With the exception of higher postoperative cardiac arrhythmias in Group 1 (11% vs. 1%, p = 0.04), no significant differences in 30-day morbidity were observed. No 90-day death in both groups was registered. CONCLUSION Older age should not preclude clinicians from offering ultra-radical resection to patients with advanced OC after NACT. In our series, elderly patients received the same treatment with similar outcomes to the younger group. Clinicians should be encouraged to use CPET for patients' selection following NACT.

Objective Uterine serous carcinoma (USC) is a rare highly aggressive disease. In the present study, we aimed to investigate the survival implication of the systematic lymphadenectomy in patients who underwent surgery for apparent early-stage USC. Methods Consecutive patients with apparent early-stage USC surgically treated at six Italian referral cancer centers were analyzed. A comparison was made between patients who underwent retroperitoneal staging including at least pelvic lymphadenectomy “LND” vs. those who underwent hysterectomy alone “NO-LND”. Baseline, surgical and oncological outcomes were analyzed. Kaplan- Meier curves were calculated for disease-free survival (DFS) and disease-specific survival (DSS). Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). Results One hundred forty patients were analyzed, 106 LND and 34 NO-LND. NO-LND group (compared to LND group) included older patients (median age, 73 vs.67 years) and with higher comorbidities (median Charlson Comorbidity Index, 6 vs. 5) (p

Objective Coronavirus disease 2019 (COVID-19) has caused rapid and drastic changes in cancer management. The Italian Society of Gynecology and Obstetrics (SIGO), and the Multicenter Italian Trials in Ovarian cancer and gynecologic malignancies (MITO) promoted a national survey aiming to evaluate the impact of COVID-19 on clinical activity of gynecologist oncologists and to assess the implementation of containment measures against COVID-19 diffusion. Methods The survey consisted of a self-administered, anonymous, online questionnaire. The survey was sent via email to all the members of the SIGO, and MITO groups on April 7, 2020, and was closed on April 20, 2020. Results Overall, 604 participants completed the questionnaire with a response-rate of 70%. The results of this survey suggest that gynecologic oncology units had set a proactive approach to COVID-19 outbreak. Triage methods were adopted in order to minimize in-hospital diffusion of COVID-19. Only 38% of gynecologic surgeons were concerned about COVID-19 outbreak. Although 73% of the participants stated that COVID-19 has not significantly modified their everyday practice, 21% declared a decrease of the use of laparoscopy in favor of open surgery (19%). However, less than 50% of surgeons adopted specific protection against COVID-19. Additionally, responders suggested to delay cancer treatment (10%-15%), and to perform less radical surgical procedures (20%-25%) during COVID-19 pandemic. Conclusions National guidelines should be implemented to further promote the safety of patients and health care providers. International cooperation is of paramount importance, as heavily affected nations can serve as an example to find out ways to safely preserve clinical activity during the COVID-19 outbreak.

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 three different approaches of nodal assessment in EC. Methods This is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years) of EC patients having lymphadenectomy, SLNM followed by lymphadenectomy and SLNM alone. 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. Results Applying a propensity score matching algorithm we selected 180 patients having SLNM (90 SLNM vs. 90 SLNM followed by lymphadenectomy). Additionally, a control group of 180 patients having lymphadenectomy was selected using the same criteria. 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 a higher possibility to be diagnosed with a stage IIIC disease in comparison to lymphadenectomy alone (p=0.02); while we did not observe difference in the diagnostic value of SLNM followed by lymphadenectomy and SLNM (p=0.389). Median follow-up time was 69 months (range, 7–206). The survival analysis comparing the three techniques 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); Similarly, they did not impact on survival outcomes after stratification by low, intermediate and high risk patients. Conclusions Our study highlighted that SLNM provides similar long-term oncologic outcomes than lymphadenectomy. Further evidence is warranted to assess the prognostic value of low-volume disease detected by ultrastaging in patients following SLNM.

Objective This study aimed to identify predictors of recurrence/persistence of cervical intraepithelial neoplasia grade 2+ (CIN2+) lesion (r-CIN2+) after primary conization. Methods Retrospective analysis involving all consecutive women having conization for CIN2+ between 1998 and 2018. The risk of r-CIN2+ was assessed using Kaplan-Meier and Cox models. Results Data of 3,212 women were retrospectively identified. After a mean follow-up of 47 (±22.2) months, 112 (3.5%) patients developed r-CIN2+. Mean time interval between prior conization and diagnosis of r-CIN2+ was 26.2 (±13.2) months. Via multivariate analysis, presence of high-risk human papillomavirus (HPV) types at the time of CIN2+ diagnosis, hazard ratio (HR)=3.40 (95% confidence interval [CI]=1.66-6.95) for HPV16/18 and HR=2.59 (95% CI=1.21-5.55) for HPV types other than 16/18, positive margins at primary conization, HR=4.11 (95% CI=2.04-8.26) and HPV persistence after conization, HR=16.69 (95% CI=8.20-33.9), correlated with r-CIN2+, independently. Considering age-specific HPV types distribution, we observed that HPV16/18 infection correlated to an increased risk of r-CIN2+ only in young women (aged ≤25 years; p=0.031, log-rank test); while in the older population (>25 years) HPV type(s) involved had not impact on r-CIN2+ risk (p>0.200, log-rank test). Conclusion HPV persistence is the main factor predicting r-CIN2+. Infection from HPV16/18 has a detrimental effect in young women, thus highlighting the need of implementing vaccination against HPV in this population. Further prospective studies are warranted for tailoring clinical decision-making for post-conization follow-up on the basis of risk factors.

Objective: Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+). Methods: This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models. Results: Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001). Conclusions: HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.

Aim During the last years, the role of sentinel lymph node mapping (SLNM) for endometrial cancer (EC) surgical treatment has increased in popularity. However, several controversies remain about different technical steps of SLNM. Thus, a randomised control trial was designed to compare cervical (CI) and hysteroscopic (HI) indocyanine green (ICG) injection for SLNM of newly diagnosed EC undergoing surgical staging. The primary end-point of the study was to compare these two techniques in terms of para-aortic detection rate. Methods Patients with apparent stage I or II histologically confirmed EC undergoing surgery were included in the study. This randomised trial distinguished patients in two study groups according to two different techniques of ICG SLNM: CI versus HI injection. Patients who met the inclusion criteria were randomly assigned to CI or HI injection in a 1:1 ratio. The central randomisation system allocated patient randomisation numbers sequentially in the order in which the patients were enrolled. This randomised trial was not blinded for either patients or the surgeons. Results From March 2017 until April 2019, a total of 165 patients were randomised in this study: 85 (51.5%) in the CI group and 80 (48.5%) in the HI group. After randomisation, 14 (8.5%) patients were excluded from the study. Finally, 151 patients were included in the analysis: 82 (54.3%) in the CI group and 69 (45.7%) in the HI group. Hysteroscopy injection shows an ability to detect Sentinel nodes (SNLs) in the para-aortic area of about 10% greater compared with CI injection, although this difference did not reach statistical significance. The HI technique was superior in detecting isolated para-aortic SLNs (5.8% Versus 0%). The CI injection was correlated with higher SLN detection rates at the pelvic level compared with HI injection. Pelvic and overall detection was higher in the CI group. Conclusions The present study supports the adoption of CI instead of HI injection because the former allows better identification of sentinel nodes (especially in the pelvic area). Detection of SLN in the para-aortic area was slightly higher in patients receiving a HI injection, but the difference with the CI route was not statistically significant.

Objective To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC). Methods This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored. Results 428 patients were included in the analysis. With a median follow-up of 56 months (1–162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01–1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34–20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11–0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01–1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58–24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12–0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13–0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39–17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS. Conclusions In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role.

We present the first case of minilaparoscopic single-site bilateral salpingo-oophorectomy (BSO) performed as a risk-reducing procedure in a 39-year-old woman presenting with BRCA-1 mutation. Surgery was performed using only minilaparoscopic instruments inserted alternatively through two 3-mm umbilical trocars placed one next to the other. Following the BSO, specimens were retrieved within an endobag through the posterior vaginal fornix. No intraoperative or postoperative complications occurred. The patient was discharged home on the day of surgery. Thirty-day postoperative clinical evaluation was uneventful. In selected patients, the minilaparoscopic single-site approach might represent an alternative technique to minimize surgical trauma and morbidity in patients undergoing risk-reducing BSO.

To evaluate the impact of various HPV types on the risk of developing lesions of the uterus (either uterine cervix and endometrium) in women diagnosed with "atypical glandular cells" (AGC) at Pap smear.This is a multi-institutional retrospective study. Data of women diagnosed with AGC were retrospectively reviewed. All patients included had data about HPV DNA testing and 1-year clinical follow-up.Overall, chart of 480 patients were evaluated. After the exclusion of 286 patients, data of 194 patients were available for the analysis. Mean age was 43.9 (±6.0) years. HPV infection was documented in 136 women (70.1 %). Among HPV positive patients the risk of having/developing a lesion was 33.8 % (n = 46). Lesions included low- (L-SIL) and high- (H-SIL) squamous intraepithelial lesions, in situ adenocarcinoma of the uterine cervix, invasive cancer of the uterine cervix, endometrial hyperplasia and endometrial cancer in 16 (11.7 %), 18 (13.2 %), 6 (4.4 %), 3 (2.2 %), 2 (1.5 %) and 1 (1%), respectively. Among HPV negative patients the risk of having/developing a lesion was 15.5 %. They included l-SIL, H-SIL, in situ adenocarcinoma, endometrial hyperplasia and endometrial cancer in 1 (1.7 %), 1 (1.7 %), 1 (1.7 %), 3 (5.1 %) and 3 (5.1 %), respectively. Patients diagnosed with HPV16 were at higher risk of having/developing cervical lesions in comparison to patients with other HPV infections (p 0.01). In comparison to other HPV types, the presence of HPV 18, 31, 33, and 45 did not increase the risk of developing a lesion over the time (p 0.2). HPV positive patients were at higher risk of being diagnosed with a cervical lesion within 6 months from detection of AGC.Patients diagnosed with AGC are at risk to have / developing cervical and uterine lesions. Further prospective evidence is needed.

The role of adjuvant chemotherapy in surgically staged stage I clear cell ovarian cancer (OCCC) is unclear. Here, we performed a systematic review and meta-analysis in order to evaluate the role of chemotherapy vs. observation in stage I OCCC. This systematic review was registered in the International Prospective Register of Systematic Reviews (PROSPERO; ID: #129628). A protocol was defined prior to the search include the population criteria, description of interventions, comparisons, and the outcomes of interest, according to the PRIMA guidelines. Overall, the study population included 5073 women. Stage I OCCC experienced a 5-year disease-free survival and a 5-year overall survival of 83.7% and 86.9%, respectively. Pooled data suggested that in the overall population adjuvant chemotherapy did not impact on 5-year disease free survival (test for overall effect, Z = 0.18; p = 0.86) and 5-year overall survival (test for overall effect, Z = 0.62; p = 0.53). Focusing on 2264 stage IC OCCC we observed that adjuvant correlated with an improvement in overall survival (OR: 0.70 (95%CI: 0.52 to 0.93); Z = 2.44; p = 0.01). In conclusion our study underlines that adjuvant chemotherapy could be reserved for patients with stage IC OCCC; while in stage IA and IB it could be safely omitted. Owing to the inherent biases of the studies included in the meta-analysis further prospective evidences are needed.

Introduction/Background Several studies have demonstrated the feasibility and role of cardiophrenic lymph nodes (CPLNs) resection during primary debulking surgery (PDS) for stage IV ovarian cancer (OC). However, no studies, to date, investigated the role of CPLNs removal during interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT). Methodology A retrospective analysis of consecutive stage IV OC patients who underwent NACT followed by IDS with CPLNs resection from July 2017 to June 2018. CPLNs sized >7 mm on the short axis at pre-operative CT-scan were considered for excision if optimal complete resection could be achieved. Results A total of 21 ovarian cancer stage IV patients treated with NACT followed by IDS were identified. Seven (33.3%) patients underwent CPLNs resection. A partial response to NACT by RECIST criteria was observed in 5 of 7 patients (71%) while 2 cases had stable disease (29%). Complete cytoreduction without residual disease was achieved in 5 cases (71%) while in two cases (29%) optimal cytoreduction was performed. All patients underwent full-thickness right diaphragmatic resection and pleurectomy. All excised CPLNs were found in the right side of the lower anterior mediastinum. Intra-operative surgical complications occurred in one patient. One patient (14%) had a major postoperative complication (Clavien-Dindo 3). Two cases of postoperative cardiac arrhythmia were observed. The final histological examination of the CPLNs revealed metastatic disease in 4 (57%) of 7 patients. Conclusion CPLNs removal after NACT for stage IV OC is safe and necessary to achieve a complete resection in the context of IDS after NACT. Disclosure Nothing to disclose.

Introduction/Background Elderly ovarian cancer (OC) patients are more likely to be managed suboptimally and experience worse clinical outcomes as a result. Strategies to improve outcomes in this patients are lacking. Methodology Retrospective analysis for consecutive patients with advanced stage OC (IIIC–IV) who were managed in Oxford University Hospital between January 2016 and July 2018 were analysed. All patients underwent neoadjuvant chemotherapy (NACT) and interval debulking surgery (IDS) according to our institution protocol. We divided the patients into two groups: an ‘older group’ (age ≥70 years) (Group 1) and a ‘younger group’ (age Results A total of 153 patients were referred during the study period. 114 patients underwent IDS after NACT (74.5%), of which 46 in Group 1 and 68 in Group 2. Elderly patients were more likely to receive more than three cycles of NACT prior to IDS when compared to younger patients (39% vs. 19%, p=0.03). Elderly patients were more frequently subjected to Cardiopulmonary Exercise Testing (CPET) as part of their pre-operative assessment (63% vs. 27%, p=0.002). For those who underwent IDS; optimal/complete resection was achieved in all patients in Group 1 (100%) and in 97% of patients in Group 2. With the exception of higher postoperative cardiac arrhythmias in Group 1 (11% vs. 1%, p=0.04), no significant differences in 30-day morbidity were observed. No 90-day death in both groups was registered. Conclusion Older age should not preclude clinicians from offering ultra-radical resection, for patients with advanced OC who underwent careful preoperative assessment. In our series, elderly patients received the same treatment with similar outcomes to the younger group. CPET has an important role and clinicians should be encouraged to use it more frequently especially when ultraradical surgery is postponed. Disclosure Nothing to disclose.

Introduction/Background Following the results of LACC trial, laparoscopic treatment for early stage cervical cancer has become matter of debate. In the present investigation we aimed to evaluate predictors of recurrence after laparoscopic surgery for early stage cervical cancer (CC). Methodology A multi-centre retrospective study was conducted among patients who underwent laparoscopic radical surgery for FIGO 2009 stage IA (positive LVSI) - IB1 at three referral gynecologic oncology centers, between January 2006 and June 2018. All patients had radical hysterectomy (B-C1) with or without lymph node dissection according with tumour characteristics. Surgical and oncological outcomes were analysed. Results Among 186 patients who met the inclusion criteria, 16 (8,6%) experienced recurrence (6 vault, 9 pelvis, 5 abdominal, 3 distant, 7 multiple), and 9 (4.8%) died of disease over the follow-up period (median follow-up 38.0 months). Surgical-related complications did not influence survival outcomes. All the recurrences occurred in stage Ib1 disease, which has been found to be the main predictor of recurrence (p=0.02), while no association between positive lymph node and relapse was detected. Patients who had preoperative conization (93, 50%) had a significant lower rate of recurrence compared to those who had biopsy (93, 50%) (1/93, 1,1% vs. 15/93: 16,1% p=0.0003). After stratification by FIGO stage, patients with Ib1 tumor undergoing conization had significant favourable DFS compared to those who had only biopsy (p=0.012). Conclusion Preoperative conization might play a crucial role in patients undergoing laparoscopic treatment for early stage CC. Further studies are warranted to strength our finding. Disclosure Nothing to disclose.

Introduction: In the present study, perioperative outcomes of laparoscopy (LPS) were compared to open surgery (OS) for the treatment of large adnexal masses (AM).Material and methods: Retrospective...

We investigated the correlation between glandular cells (GC) detected at preoperative cervical-smear and the histologic findings and oncologic outcomes in patients undergoing surgery for endometrial cancer (EC). We retrospectively analyzed data of all consecutive EC patients who underwent surgery between January 1, 1990 and December 31, 2012 with preoperative cervical smear performed within 3 mo from the EC diagnosis. Basic descriptive, logistic regression and artificial neural network analyses were used. Five-year disease-free survival and overall survival were assessed using Kaplan-Meier and Cox hazard models. The study included 229 (89%) and 29 (11%) patients with normal cytology (control group) and GC (GC group), respectively. A higher proportion of elderly patients with nonendometrioid and FIGO grade 3 EC was observed in the GC group compared with the control group (P

Several studies have demonstrated the feasibility and role of bulky cardiophrenic lymph nodes (CPLNs) resection during primary debulking surgery (PDS) for stage IV ovarian cancer (OC). However, no studies, to date, investigated the accuracy and feasibility of CPLNs assessment and removal during interval debulking surgery (IDS) after neoadjuvant chemotherapy (NACT).A retrospective analysis of consecutive stage IV OC patients who underwent NACT followed by IDS with CPLNs assessment and/or resection from July 2017 to June 2018. Bulky CPLNs were considered for excision when a full-thickness diaphragmatic resection was required in order to achieve complete tumour resection.A total of 21 ovarian cancer stage IV patients treated with NACT followed by IDS were identified. Seven (33.3%) patients underwent CPLNs resection due to bulky appearance of the CPLNs at the intraoperative palpation. The final histological examination of the CPLNs reported metastatic disease in four (57%) of seven patients. Complete cytoreduction without residual disease was achieved in five cases (71.4%) while in two case (28.6%) optimal cytoreduction was performed. Intra-operative surgical complications occurred in one patient. One patient had a major postoperative complication (Clavien-Dindo 3). Two cases of postoperative cardiac arrhythmia were observed.CPLNs intraoperative assessment is less accurate during IDS compared to previous PDS studies. CPLNs removal during IDS after NACT for stage IV OC could be safely performed to achieve a complete resection.

We evaluated fertility rates, pregnancy course and maternal/neonatal outcomes following laparoscopic ureterolysis for deep endometriosis. Data about women who underwent laparoscopic excision of ureteral endometriosis were analysed. After exclusion of women who underwent hysterectomy/bilateral adnexectomy at initial surgery, and those lost-to-follow-up or with follow-up1 year, a total of 61 patients were included. Of them, 36 (59%) wished to conceive after surgery. Twenty women became pregnant: nine (45%) of them after assisted reproductive technologies. Twenty-six pregnancies were observed with four (15.6%) miscarriages. Median gestational week at delivery was 38 weeks + 2 days (range, 33 + 1-41 + 6), with three (13.6%) and two (9%) deliveries before 37 and 34 weeks, respectively. Nine caesarean sections were performed (40.9%). Fertility rates after laparoscopic ureterolysis are comparable to those of other women operated for other forms of deep endometriosis. Apart from a higher risk of caesarean and preterm birth, the course of pregnancy and peripartum outcomes appear encouraging.

OBJECTIVE To assess whether risk of severe maternal morbidity at delivery differs for women who conceived using assisted reproductive technology (ART), compared with those with a spontaneous conception. DESIGN A cohort study using a prospectively maintained institutional database. SETTING A tertiary university maternity hospital. POPULATION All women delivering at Del Ponte Hospital, Italy, between 2005 and 2016. METHODS Data from 650 ART-conceived pregnancies were compared with 22 803 spontaneously conceived pregnancies. We used multivariable analysis to estimate the odds of severe maternal morbidity at delivery associated with ART conception, adjusting for maternal demographic and health factors, gestational age, and mode of delivery. MAIN OUTCOME MEASURES The World Health Organization criteria for potentially life-threatening conditions and near-miss maternal mortality were used. RESULTS The incidence of near-miss in the entire cohort was 3.3 cases per 1000 births (95% confidence interval, 95% CI, 2.6-4.1). The crude prevalences of potentially life-threatening conditions and maternal near-miss were higher among ART than among non-ART deliveries (27.1 versus 5.7% and 2.6 versus 0.3%, respectively). The three most common causes of maternal near-miss cases were peripartum hysterectomy, transfusion of ≥5 units of red blood cells, and cardiovascular dysfunction requiring vasoactive drugs. The odds of a maternal near-miss at delivery were increased for ART-conceived pregnancies compared with non-ART-conceived pregnancies (adjusted odds ratio, aOR 3.61, 95% CI 1.61-8.09, for ART-conceived pregnancies with autologous oocytes; aOR 13.57, 95% CI 5.45-33.77, for ART pregnancies conceived with donor oocytes). CONCLUSION Although we cannot exclude unmeasured confounding, we found that pregnancies conceived via ART, especially those conceived with donor oocytes, are at increased risk of maternal potentially life-threatening conditions and near-miss at delivery. FUNDING This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. TWEETABLE ABSTRACT Conceiving through assisted reproductive technology increases the likelihood of maternal near miss.

Objective To investigate survival outcomes in endometrioid endometrial cancer (EEC) patients with single vs. multiple positive pelvic lymph nodes. Methods We performed a retrospective evaluation of all consecutive patients with histologically proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 EEC who underwent primary surgical treatment between 2004 and 2014 at seven Italian gynecologic oncology referral centers. Patients with pre- or intra-operative evidence of extra-uterine disease (including the presence of bulky nodes) and patients with stage IIIC2 disease were excluded, in order to obtain a homogeneous population. Results Overall 140 patients met the inclusion criteria. The presence of >1 metastatic pelvic node was significantly associated with an increased risk of recurrence and mortality, compared to only 1 metastatic node, at both univariate (recurrence: hazard ratio [HR]=2.19; 95% confidence interval [CI]=1.2-3.99; p=0.01; mortality: HR=2.8; 95% CI=1.24-6.29; p=0.01) and multivariable analysis (recurrence: HR=1.91; 95% CI=1.02-3.56; p=0.04; mortality: HR=2.62; 95% CI=1.13-6.05; p=0.02) and it was the only independent predictor of prognosis in this subset of patients. Disease-free survival (DFS) and disease-specific survival (DSS) were significantly longer in patients with only 1 metastatic node compared to those with more than 1 metastatic node (p=0.008 and 0.009, respectively). Conclusion The presence of multiple metastatic nodes in stage IIIC1 EEC represents an independent predictor of worse survival, compared to only one positive node. Our data suggest that EEC patients may be categorized according to the number of positive nodes.

OBJECTIVE The present study aimed to evaluate surgical operation-related outcomes of laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for the treatment of benign uterine diseases, other than pelvic organ prolapse, in women aged 65 years or older. METHODS Data of women who underwent LH and VH between 2000 and 2013 were compared using propensity-matched analysis. Postoperative complications were graded according to the Accordion Severity Grading. Martin criteria were applied to improve the quality of complications reporting. RESULTS The study group included 40 propensity-matched participant pairs (80 women) who underwent VH and LH. No significant differences in baseline characteristics were observed between groups. A trend toward longer median operative time was observed in the LH group, in comparison with the VH group (75 [range, 20-340] vs 60 [range, 30-140] min; P = 0.09), whereas LH correlated with shorter hospital stay and lower blood loss in comparison with VH (P < 0.05). One intraoperative complication occurred during VH (bladder injury); no intraoperative complications were recorded in the LH group. No differences in Accordion grade 2 (or worse) postoperative complications were observed (1 of 40 [2.5%] in the LH group vs 3 of 40 [7.5%] in the VH group; P = 0.61; odds ratio, 3.1; 95% CI, 0.3-31.8), and no postoperative deaths occurred. CONCLUSIONS Our findings suggest the noninferiority of LH to VH. LH improves the postoperative course of older women undergoing surgical operation for benign uterine diseases. If an appropriate indication exists, LH should not be denied based on mere chronological age.

To present a large single-center series of hysterectomies for uteri ≥1 kg and to compare the laparoscopic and open abdominal approach in terms of perioperative outcomes and complications.A retrospective analysis of prospectively collected data (Canadian Task Force classification II-2).An academic research center.Consecutive women who underwent hysterectomy for uteri ≥1 kg between January 2000 and December 2016. Patients with a preoperative diagnosis of uterine malignancy or suspected uterine malignancy were excluded. The subjects were divided according to the intended initial surgical approach (i.e., open or laparoscopic). The 2 groups were compared in terms of intraoperative data and postoperative outcomes. Multivariable analysis was performed to identify possible independent predictors of overall complications. A subanalysis including only obese women was accomplished.Total laparoscopic versus abdominal hysterectomy (±bilateral adnexectomy).Intra- and postoperative surgical outcomes. A total of 258 patients were included; 55 (21.3%) women were initially approached by open surgery and 203 (78.7%) by laparoscopy. Nine (4.4%) conversions from laparoscopic to open surgery were registered. The median operative time was longer in the laparoscopic group (120 [range, 50-360] vs 85 [range, 35-240] minutes, p = .014). The estimated blood loss (150 [range, 0-1700] vs 200 [50-3000] mL, p = .04), postoperative hemoglobin drop, and hospital stay (1 [range, 1-8] vs 3 [range, 1-8] days, p .001) were lower among patients operated by laparoscopy. No difference was found between groups in terms of intra- and postoperative complications. However, the overall rate of complications (10.8% vs. 27.2%, p = .015) and the incidence of significant complications (defined as intraoperative adverse events or postoperative Clavien-Dindo ≥2 events, 4.4% vs 10.9%, p = .04) were significantly higher among patients who initially received open surgery. The laparoscopic approach was found to be the only independent predictor of a lower incidence of overall complications (odds ratio = 0.42; 95% confidence interval, 0.19-0.9). The overall morbidity of minimally invasive hysterectomy was lower also in the subanalysis concerning only obese patients.In experienced hands and in dedicated centers, laparoscopic hysterectomy for uteri weighing ≥1 kg is feasible and safe. Minimally invasive surgery retains its well-known advantages over open surgery even in patients with extremely enlarged uteri.

ObjectiveThe objective of this study was to determinate whether the introduction of nerve-sparing (NS) procedure influences surgical and survival outcomes of cervical cancer patients undergoing laparoscopic radical hysterectomy (LRH).MethodsData of consecutive patients undergoing minimally invasive radical with or without NS surgery for cervical cancer were enrolled in the study.ResultsSixty-three patients (66%) who had LRH were compared with 33 women (34%) undergoing NS-LRH. Among the NS group, 19 patients (57.6%) had surgery via minilaparoscopy (using 3-mm instruments). Baseline characteristics were similar between groups. Patients undergoing NS-LRH had shorter operative time (210 vs 257 minutes; P = 0.005) and higher number of pelvic lymph nodes yielded (29 [26–38] vs 22 [8–49]; P < 0.001) than patient in the control group. No differences in blood loss, complications, and parametrial width were observed. Patients were catheterized with an indwelling Foley catheter for a median of 3.5 days (2–7 days) and 5.5 days (4–7 days) in NS and non-NS groups, respectively (P = 0.01). Voiding dysfunctions occurred in 1 patient (3%) and 12 patients (19%) who underwent NS-LRH and standard LRH, respectively (P = 0.03). No differences in 3-year disease-free survival (P = 0.72) and overall survival (P = 0.71) were recorded.ConclusionsThe beneficial effects (in terms of operative time and number of nodes harvested) of NS-LRH are likely determined by the expertise of the surgeon because NS approach was introduced after having acquired adequate background in conventional LRH. Our data show that in experienced hands NS-LRH is safe and feasible. Moreover, NS technique reduces catheterization time and the rate of postoperative urinary dysfunction.

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.

STUDYTo evaluate perioperative outcomes and complications of laparoscopic hysterectomy (LH) in women with giant uteri (≥1.5 kg) compared with open abdominal hysterectomy (AH), which is considered the reference.A retrospective analysis of prospectively collected data (Canadian Task Force Classification II-2).An academic research center.All consecutive women who underwent hysterectomy for uteri weighing ≥1500 g (total = 51) between 2000 and 2015 were analyzed. Twenty-seven (53%) patients had been scheduled for the laparoscopic approach (LH), whereas 24 (48%) had been scheduled for AH.Hysterectomy ± mono/bilateral salpingo-oophorectomy.Perioperative details, incidence, severity, and type of complications were analyzed according to surgical approach (AH vs LH). We also evaluated the trends over time in terms of perioperative outcomes.AH was associated with a shorter operative time (97.5 vs 160 minutes, p = .004) compared with LH. Blood loss (200 vs 225 mL, p = .21) and the decrease in postoperative hemoglobin (-1.2 vs -1.1, p = .89) were similar between AH and LH. Intra- and postoperative complications were similar between the 2 groups; however, hospital stay was significantly shorter in the LH group (median = 3 days vs 1 day, p .001). A significant trend toward a progressive increase in the use of the minimally invasive approach was registered through the years (p = .001). Parallel to this increase, we observed a significant reduction in terms of length of stay. Moreover, a decrease in the total number of complications, mainly because of a decrease in the rate of early minor events, was observed through the years.Our experience shows that LH can be considered a feasible procedure, even in cases of uteri ≥1.5 kg, with significant advantages over open surgery in terms of postoperative hospital stay.

ObjectiveThis study aimed to evaluate the impact on perioperative and medium-term oncologic outcomes of the implementation of laparoscopy into a preexisting oncologic setting.MethodsData from consecutive 736 patients undergoing surgery for apparent early stage gynecological malignancies (endometrial, cervical, and adnexal cancers) between 2000 and 2011 were reviewed. Complications were graded per the Accordion classification. Survival outcomes within the first 5 years were analyzed using Kaplan-Meier method.ResultsOverall, 493 (67%), 162 (22%), and 81 (11%) had surgery for apparent early stage endometrial, cervical, and adnexal cancer. We assisted at an increase of the number of patients undergoing surgery via laparoscopy through the years (from 10% in the years 2000-2003 to 82% in years 2008-2011; P < 0.001 for trend); while the need to perform open surgery decreased dramatically (from 83% to 10%; P < 0.001). Vaginal approach was nearly stable over the years (from 7% to 8%; P = 0.76). A marked reduction in estimated blood loss, length of hospital stay, blood transfusions as well as grade greater than or equal to 3 postoperative complications over the years was observed (P < 0.001). Surgical radicality assessed lymph nodes count was not influenced by the introduction of laparoscopic approach (P > 0.05). The introduction of laparoscopy did not adversely affect medium-term (within 5 years) survival outcomes of patients undergoing surgery for apparent early stage cancers of the endometrium, uterine cervix, and adnexa (P > 0.05 log-rank test).ConclusionsThe introduction of laparoscopy into a preexisting oncologic service allows an improvement of standard of care due to a gain in perioperative results, without detriments of medium-term oncologic outcomes.

Objective To evaluate surgery-related outcomes of laparoscopic (LH) and vaginal hysterectomy (VH) in patients with a history of previous cesarean section (CS). Study design Data on 289 consecutive patients with a history of CS undergoing VH (n = 49, 17%) and LH (n = 219, 76%) were collected. Basic descriptive statistics, univariate and multivariate analyses were performed to evaluate surgery-related outcomes. A propensity-matched algorithm was applied in order to reduce allocation biases between groups. Results Patients undergoing LH were more likely to have a history of multiple cesarean sections (44% vs. 18%; p = 0.001). Additionally, uterine weight was greater among patients undergoing LH than VH (median weight: 235 (range, 45–2830) vs. 150 (range, 40–710) g; p

Hysterectomy for enlarged uteri is a surgical challenge. Our aim was to compare perioperative outcomes, cosmesis, and postoperative quality of life following laparoscopic hysterectomy for large uteri using minilaparoscopic 3-mm versus conventional laparoscopic 5-mm instruments.We prospectively enrolled women with a uterus between 16 and 20 weeks of gestation at the preoperative examination. These patients underwent laparoscopic procedures using either 3-mm (minilaparoscopy group) or 5-mm (standard laparoscopy group) instruments. Five months after surgery, patients were called back to fill out the validated Italian translation of the Short Form 12-item Health Survey. Data about the cosmetic outcome of the procedure were also collected, using a Numeric Rating Scale (NRS) from 0 to 10.Seventy-eight women were included (27 in the 3-mm and 51 in the 5-mm groups). Perioperative characteristics were comparable between groups. The median uterus weight was 575 (range, 440-1050) g and 550 (400-1000) g in the 3-mm and 5-mm groups, respectively. No minilaparoscopic procedure was converted to standard 5-mm or to an open approach. One (2%) conversion to open abdominal surgery was needed in the conventional laparoscopy group. A better subjective cosmetic outcome was found in the 3-mm (NRS, 9.7 ± 0.4) versus the 5-mm (NRS, 8.9 ± 1.2) group (P=.01). Postoperative quality of life was comparable between groups.Minilaparoscopic hysterectomy is feasible, even in the case of an enlarged-size uterus. Moreover, it is associated with a better cosmetic outcome, compared with conventional laparoscopy.

The aim of the study was to compare surgery-related outcomes between laparoscopic (LH) and vaginal (VH) hysterectomy, performed for benign uterine disease (other than pelvic organs prolapse) in obese women.Data of consecutive obese (BMI≥30) patients undergoing LH and VH, between 2000 and 2013, were compared using a propensity-matched analysis. One hundred propensity-matched patient pairs (200 patients) undergoing LH (n=100) and VH (n=100) represented the study group.Baseline demographic characteristics were similar between groups. Patients undergoing LH experienced similar operative time (87.5 (25-360) vs. 85 (25-240)min; p=0.28), slightly lower blood loss (100 (10-3200) vs. 150 (10-800)ml; p=0.006) and shorter length of hospital stay (1 (1-5) vs. 2 (1-5) days; p0.001) than women undergoing VH. There was no statistically significant difference between LH and VH in complication rate (3% for VH vs. 10% for LH; OR: 3.4; 95%CI: 0.95-13.5; p=0.08). At multivariable analysis complication rates increased as BMI increase (OR: 1.01 (1.00-1.02) for 1-unit increase in BMI; p=0.05). Independently, LH correlated with reduced hospital stay (OR: 0.63 (95%CI: 0.49-0.82); p=0.001) and complication rates (OR: 0.91 (95%CI: 0.85-0.97); p=0.01).In obese women affected by benign uterine disease LH and VH should not be denied on the basis of the mere BMI, per se. In this setting, LH upholds effectiveness of VH, improving postoperative outcomes. However, complication rate increases as BMI increase, regardless surgical route.

ObjectivesThe aim of this study was to analyze perioperative and long-term survival outcomes after either laparoscopic or open abdominal staging for apparent early-stage ovarian cancer.MethodsData of consecutive women with early-stage ovarian cancer undergoing comprehensive laparoscopic staging between 2003 and 2010 were matched with a historical cohort of patients undergoing open surgery. Five-year survival outcomes were analyzed using the Kaplan-Meier method. In addition, a systematic review of the literature and meta-analysis of comparative studies was performedResultsA total of 35 women undergoing staging via laparoscopy were compared with a cohort of 32 patients undergoing open surgery. Baseline characteristics were similar between groups. Spillage occurred in 6 and 4 patients in laparoscopic and open group, respectively (P = 0.59). Patients undergoing laparoscopy experienced longer operative time (P < 0.001), shorter hospital stay (P = 0.03), and lower postoperative complication rate (3% vs 28%; P = 0.005) than patients undergoing staging via open surgery. The median (range) follow-up period was 64 (37–106) and 100 (61–278) months for case and control, respectively (P < 0.001). Five-year disease-free survival (P = 0.12, log-rank test) and overall survival (P = 0.26, log-rank test) were not influenced by surgical approach. Pooled analyses of the literature results corroborate our results suggesting an improvement of perioperative results in the laparoscopic group in comparison with the open abdominal one. In comparison with open surgery, laparoscopy did not influenced spillage (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.35–1.73) and upstaging rate (OR, 0.7; 95% CI, 0.38–1.27). No between-group differences in survival were observed (OR, 0.5; 95% CI, 0.21–1.21).ConclusionsLaparoscopy upholds open surgery in long-term oncologic control, reducing morbidity.

To investigate if low-dose aspirin influences the risk of bleeding and hemorrhagic complications during minimally invasive surgical staging for endometrial cancer.Retrospective study (Canadian Task Force classification II-2.)University teaching hospital.Three hundred seventeen endometrial cancer patients undergoing laparoscopic staging.Laparoscopic surgical staging included total laparoscopic hysterectomy plus bilateral salpingo-oophorectomy ± retroperitoneal staging.Forty-three (14%) low-dose aspirin users were compared with 274 (86%) nonaspirin users. Aspirin-treated patients were older than patients in the control group (71 [range, 50-85] vs. 64 [range, 27-92] years old, p.001). No between-group differences in intraoperative bleeding (p = .32), hemoglobin drop (p = .91), transfusions (p = .09), and hemorrhagic complications rate (p = .58) were recorded. Aspirin users had a lower lymphadenectomy rate in comparison with patients in the control group (p = .001). However, according to a subanalysis of patients undergoing retroperitoneal staging (20 aspirin users vs. 200 patients in the control group), no differences in bleeding (p = .53), hemorrhagic complications (p = 1.0), or transfusion rate (p = .25) were observed.Low-dose aspirin does not influence the risk of bleeding and hemorrhagic complications in endometrial cancer patients undergoing minimally invasive staging. Hence, the choice to continue or cease the use of low-dose aspirin should be guided only by perioperative cardiovascular risk stratification.