Coexisting overactive-underactive bladder and detrusor overactivity-underactivity in pelvic organ prolapse

OBJECTIVE

The coexisting overactive-underactive bladder (COUB) syndrome could be related to the increased urethral resistance caused by severe pelvic organ prolapse (POP). We aimed to evaluate the clinical and urodynamic findings of patients with COUB and/or detrusor overactivity-underactivity (DOU) in a cohort of patients scheduled for POP surgery and the possible risk factors of COUB after surgery.

METHODS

This retrospective study analyzed all patients who underwent POP repair between 2008 and 2013, excluding women with a history of pelvic floor surgery. Patients were divided into COUB and non-COUB according to baseline symptoms and into DOU and non-DOU based on urodynamic findings. A multivariate model was performed to identify risk factors for COUB symptoms after surgery.

RESULTS

A total of 533 women underwent POP surgery. Preoperatively, patients with COUB had more severe anterior compartment prolapse (Pelvic Organ Prolapse Quantification staging system Aa point, P = 0.008) and more frequently had overactive bladder compared with controls (P = 0.023). The rate of COUB decreased significantly after surgery. Preoperative opening detrusor pressure resulted as the only independent predictor of postoperative COUB symptoms (P = 0.034).

CONCLUSION

POP is a valid pathogenetic model for COUB development. POP repair induced a significant decrease in COUB symptoms with low opening detrusor pressure resulting as the only independent predictor of postoperative COUB.

Native-tissue prolapse repair: efficacy and adverse effects of uterosacral ligaments suspension at 10-year follow up

Objective

To evaluate the 10‐year outcomes of high uterosacral ligaments suspension as a primary repair for apical prolapse and to evaluate the long‐term impact of prognostic factors.

Methods

A retrospective study analyzed 10‐year follow up after repair of primary apical prolapse through high uterosacral ligament suspension. Bulging symptoms and postoperative prolapse stage II or above were considered subjective and objective recurrences, respectively. Patient Global Impression of Improvement score was used to evaluate subjective satisfaction after surgery.

Results

A total of 287 women were analyzed. Ten‐year recurrence rates were 19.1% for objective recurrence and 6.3% for subjective recurrence; surgical retreatment rate was 2.1%. Premenopausal status was related to 15‐fold increased risk of developing either objective or subjective recurrence. Conversely, anterior and posterior repair were protective factors against reoperation.

Conclusion

High uterosacral ligaments suspension is a safe and long‐lasting effective procedure for the treatment of uterovaginal prolapse even 10 years after index surgery. Premenopausal status and lack of anterior and posterior repair represented long‐term risk factors for surgical failure.

Transvaginal primary layered repair of postsurgical urethrovaginal fistula

INTRODUCTION AND HYPOTHESIS

Urethrovaginal fistula (UVF) is a rare disorder, which implies the presence of an abnormal communication between the urethra and the vagina.

METHODS

Surgical repair options include transurethral, transabdominal and transvaginal procedures, either with or without tissue interposition. The vaginal route is considered a safe and effective option to correct UVF. This video is aimed to present a case of direct transvaginal layered repair of urethrovaginal fistula, without the use of tissue interposition. The featured patient is a 66-year-old woman who developed a symptomatic UVF after a complicated laparoscopic hysterectomy for endometrial cancer 3 years before. Cystoscopy demonstrated the presence of a 7 mm urethral orifice a few millimeters caudal from the bladder neck. After proper informed consent, the patient was admitted to transvaginal primary layered repair, according to the technique demonstrated in the video. The featured procedure was completed in 60 min and blood loss was < 100 ml. No surgical complications were observed.

RESULTS

The procedure was successful in restoring the anatomy and relieving the symptoms.

CONCLUSION

Transvaginal layered repair without tissue interposition represents a safe and effective procedure for the surgical management of postsurgical urethrovaginal fistula.

Inability to walk and persistent thigh pain after transobturator tape procedure for stress urinary incontinence: surgical management

INTRODUCTION AND HYPOTHESIS

Groin pain after transobturator tape is often a self-limiting situation, but can occasionally persist and be associated with serious neurological sequelae. The video is aimed at presenting the surgical management of persistent groin pain and inability to walk after transobturator sling placement and subsequent partial removal.

METHODS

The featured patient is a 31-year-old woman unable to walk after transobturator sling implantation 2 years before. She reported left thigh pain immediately after surgery that was not responsive to postoperative medication. Six months later, suburethral portion excision was performed but no pain relief was obtained. She was unable to walk, and needed a wheelchair. Electromyography showed axonal injury of the left obturator nerve. After providing proper informed consent, the patient was admitted for combined transvaginal and transcutaneous transobturator tape arm removal.

RESULTS

The featured procedure was completed in 120 min and blood loss was <100 ml. No surgical complications were observed. The patient is currently doing left leg rehabilitation, has regained the ability to walk with the aid of a crutch, and the need for chronic pain control medication is greatly reduced.

CONCLUSION

This represents a valid surgical approach for the late management of this mesh-related complication.

Single-incision slings for the treatment of stress urinary incontinence: efficacy and adverse effects at 10-year follow-up

INTRODUCTION AND HYPOTHESIS

Single-incision slings are not considered a first-choice surgical treatment owing to a lack of data about long-term outcomes. We aimed to assess the long-term results of urinary incontinence treatment after single-incision sling implantation at 10 years' follow-up and to investigate possible deterioration over time.

METHODS

This retrospective study analyzed women with subjective and urodynamically proven stress urinary incontinence who underwent single-incision sling procedure. The objective cure rate was assessed with a 300-ml stress test. The subjective cure rate was determined by the Patient Global Impression of Improvement (PGI-I) questionnaire. International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) questionnaire scores and self-answered patient-satisfaction scales were collected to assess symptom severity. Findings were compared with short-term outcomes in the same patients, available through our previous database, in order to detect possible outcome deterioration over time.

RESULTS

The records of 60 patients were analyzed. Nine patients (15%) were lost to follow-up. A total of 51 patients completed the evaluation, with a mean follow-up of 10.3 ± 0.7 years. Objective and subjective cure resulted 86.3% and 88.2% respectively. Mean PGI-I scores and ICIQ-SF were 1.5 ± 1.0 and 3.2 ± 4.8 respectively. Patients' satisfaction scored 8.6 ± 2.6 out of 10. No long-term complications occurred. Comparison of short-term (2.6 ± 1.4 years after surgery) and long-term follow-up did not show a significant deterioration of outcome over time.

CONCLUSIONS

Single-incision slings were shown to be a procedure with a great efficacy and safety profile at very long-term follow-up. Cure rates and functional outcomes did not show any deterioration over time compared with short-term results.

Surgical management of bladder erosion and pelvic pain after laparoscopic lateral suspension for pelvic organ prolapse

INTRODUCTION AND HYPOTHESIS

Mesh-augmented lateral suspension for prolapse repair seems to be associated with few complications. However, mesh-related complications can negatively affect the quality of life and may be challenging to manage. This video is aimed at presenting the surgical management of a case of severe pelvic pain and dyspareunia after lateral laparoscopic suspension associated with mesh erosion in the bladder.

METHODS

A 46-year-old woman was referred to our Unit for severe pelvic pain and inability to have sexual intercourses since undergoing a uterus-sparing laparoscopic lateral suspension procedure for genital prolapse 2 years before in another hospital. Moreover, she reported bladder pain and recurrent urinary tract infections. Cystoscopy showed mesh erosion in the bladder. She was admitted to laparoscopic hysterectomy plus subtotal mesh excision and bladder reconstruction (video).

RESULTS

No surgical complications were observed. The postoperative course was uneventful. At the current follow-up, the patient reported complete resolution of her symptoms.

CONCLUSION

The featured video shows laparoscopic subtotal mesh excision, concomitant hysterectomy and bladder repair for pelvic pain, dyspareunia and bladder erosion after lateral suspension. This video may be useful in providing anatomical views and surgical steps necessary for achieving successful surgical management of this mesh-related complication.

Surgical excision of paraurethral cyst

Purpose

Patients with paraurethral cyst may be asymptomatic or bothered by sensation of a mass, pain, distorted urinary outflow, dyspareunia, and dysuria (1). Differential diagnosis includes ectopic ureterocele, pelvic organ prolapse, and urethral diverticulum. At present, the management of paraurethral cysts is unclear, but surgical excision appears as the best treatment option (1-3). Alternative methods include waiting for spontaneous rupture, needle aspiration and marsupialization (4). The aim of the video-tutorial is to provide anatomic views and surgical steps necessary to achieve a successful complete excision of a paraurethral cyst.

Materials and methods

A 54-year-old woman with a 2cm paraurethral cyst bothered by intermittent sensation of an introital mass, dyspareunia, and dysuria was admitted to surgical excision according to the described technique. Urethrocystoscopy and ultrasonography were preoperatively performed to confirm the diagnosis and rule out an urethral diverticulum. Surgical steps included: cyst exposure; vaginal mucosa incision; adequate dissection (needle injection of saline solution inside the cyst can be performed to inflate the cyst) with scissors and swab, isolation and excision of paraurethral cyst, layered reconstruction with avoidance of suture layers overlapping.

Results

Surgical procedure was successfully achieved without complications. The postoperative course was uneventful. No recurrence was observed and the patient reported complete resolution of her symptoms.

Conclusions

The featured video showed complete excision of a paraurethral cyst successfully achieved without complications. Surgical excision represents a safe and effective procedure to manage paraurethral cysts. This step-by-step video-tutorial may represent an important tool to improve surgical know-how.

Long-term outcomes and five-year recurrence-free survival curves after native-tissue prolapse repair

OBJECTIVE

To evaluate the long-term objective and subjective outcomes to build recurrence-free survival curves after mesh-free uterosacral ligament suspension and to evaluate the long-term impact of prognostic factors on outcome measures.

METHODS

A retrospective study analyzed 5-year follow-up after repair of primary prolapse through high uterosacral ligament suspension. Bulging symptoms and post-operative prolapse stage II or above were considered subjective and objective recurrences, respectively. The cumulative proportion of relapse-free patients in time was analyzed by Kaplan-Meier curves.

RESULTS

A total of 353 women were analyzed. Five-year recurrence rates were 15.0% for objective recurrence, 13.0% for subjective recurrence, and 4.0% for the combined objective and subjective recurrences. Premenopausal status was shown to be a risk factor for anatomic (P=0.022), symptomatic (P=0.001), and combined (P=0.047) recurrence. Conversely, anterior repair was shown to be a protective factor for symptomatic (P=0.012) and combined (P=0.002) recurrence. Most of the recurrences occurred within 2 years after surgery.

CONCLUSION

Long-term outcomes after high uterosacral ligament suspension were satisfactory. Premenopausal status and lack of anterior repair represented risk factors for recurrence in the long term.

Efficacy of needle retractor device in single-incision slings for treatment of stress urinary incontinence

BACKGROUND

Single-incision slings demonstrated overall similar effectiveness and less pain and recovery time compared to standard tapes. Efficacy rates vary widely among different commercial kits and may be affected by device characteristics. The aim was to evaluate the impact needle removal device of single-incision sling on objective, subjective and functional outcomes.

METHODS

This was a retrospective study. Single-incision sling without needle removal device (Group A) were compared to same single-incision sling with needle removal device (Group B) in terms of complications, objective, subjective and functional outcomes.

RESULTS

A total of 191 patients were analyzed: 51 in group A and 140 in group B. Estimated blood loss, operative time and overall complications were not different. No bladder perforation or other intraoperative complications were observed. At 12-month follow-up visit, objective cure rate was similar irrespective of the presence of the needle retractor lever (Group A: 84.3%, Group B: 87.1%; P=0.61). Subjective outcomes evaluated as International Consultation on Incontinence Questionnaire-Short Form (ICIQ-SF) score, ICIQ-SF score improvement and Patient Global Impression of Improvement score were similar between groups. De-novo onset of overactive bladder syndrome resulted more frequent in Group A (Group A: 19.6%, Group: B 7.9%; P=0.02) while voiding symptoms were reported without differences between groups.

CONCLUSIONS

The current study showed that the presence of a needle retractor device to avoid unintentional tip displacement for single-incision sling had no impact on objective and subjective postoperative continence. However, a reduced rate of de-novo overactive bladder syndrome was observed after implantation of single-incision sling with needle retractor.

Transvaginal native-tissue repair of vaginal vault prolapse

BACKGROUND

Posthysterectomy vaginal vault prolapse repair is a challenge for pelvic floor surgeons. Native-tissue repair procedures imply lower costs and reduced morbidity. Our study aims to evaluate operative data, complications, objective, subjective and functional outcomes of transvaginal native-tissue repair for posthysterectomy vaginal vault prolapse. We also investigated differences among available techniques.

METHODS

Retrospective study including patients with symptomatic vaginal vault prolapse (≥stage 2), previously treated with transvaginal vault suspension through native-tissue repair. Objective recurrence was defined as the descent of at least one compartment ≥II stage according to Pelvic Organ Prolapse Quantification (POP-Q) system or need of reoperation. Subjective recurrence was defined as the presence of bulging symptoms. Patients satisfaction was evaluated with PGI-I Score.

RESULTS

The study included 111 patients. Apical suspension was achieved either by uterosacral ligament suspension (16), levator myorrhaphy (17), iliococcygeus fascia fixation (65) or sacrospinous ligament fixation (13). No intraoperative complications were observed. Perioperative/postoperative complications occurred in 8 patients (7.2%). Mean follow-up was 24.5±12.1 months. Objective recurrence was observed in 28 patients (25.2%). Reintervention was required by 3 patients (2.7%). Subjective recurrence was referred by 6 patients (5.4%). Mean satisfaction evaluated with PGI-I Score was 1.2±0.6. No differences in terms of operative data, overall complications, objective, subjective cure rate and perceived satisfaction were found among different techniques.

CONCLUSIONS

Transvaginal repair with native-tissue procedures is safe and effective in correcting posthysterectomy vaginal vault prolapse and represents a valid alternative to prosthetic procedures for vaginal vault prolapse treatment.

Transvaginal native-tissue repair of enterocele

INTRODUCTION AND HYPOTHESIS

Enterocele repair represents a challenge for pelvic surgeons. Surgical management implies enterocele sac removal. Subsequently, hernial port closure and adequate suspension may be achieved with Shull uterosacral ligament suspension (ULS).

METHODS

A 55-year-old woman with symptomatic stage 3 enterocele was admitted for transvaginal uterosacral ligaments suspension according to the described technique.

RESULTS

Surgical procedure was successfully achieved without complications. Final examination revealed excellent pelvic supports and preservation of vaginal length. This step-by-step video tutorial may represent an important tool to improve surgical know-how.

CONCLUSIONS

Transvaginal uterosacral ligaments suspension provides a safe and effective technique for enterocele repair without the use of prosthetic materials. Identifying uterosacral ligaments, proper suture placement, and reapproximation of pubocervical and rectovaginal fascias with closure of the hernial port are the key points to achieve surgical success.

Risk factors for stress urinary incontinence after native-tissue vaginal repair of pelvic organ prolapse

OBJECTIVE

To identify risk factors for postoperative stress urinary incontinence (POSUI) after native-tissue prolapse repair without a concomitant anti-incontinence procedure.

METHODS

The present single-center retrospective study included women with genital prolapse who underwent high uterosacral ligament suspension without a concomitant anti-incontinence procedure during 2008-2013. Univariate and multivariate analyses were performed to identify risk factors for POSUI (identified through clinical interview and International Consultation on Incontinence Modular Questionnaire-Short Form [ICIQ-SF] self-administration) at 6 months.

RESULTS

In total, 87 (20.9%) of 417 women developed POSUI. Preoperative stress urinary incontinence (SUI) and urodynamically diagnosed SUI were significantly associated with POSUI; moreover, women with POSUI had a higher preoperative ICIQ-SF score, a lower opening detrusor pressure, and a lower detrusor pressure at maximum flow than did women without POSUI (P<0.05 for all comparisons). In the multivariate analysis, preoperative SUI (odds ratio 3.11), a detrusor pressure at maximum flow of less than 30 cm H₂ O (odds ratio 2.93), and urodynamically diagnosed SUI (odds ratio 2.26) were independent risk factors for POSUI.

CONCLUSION

Preoperative urodynamic parameters, obtained before prolapse repair surgery, were associated with POSUI and could be useful in providing adequate counseling to facilitate decision making on whether to add a concomitant anti-incontinence procedure.

Incidence and risk factors of third- and fourth-degree perineal tears in a single Italian scenario

OBJECTIVE

This study aimed to evaluate III and IV degree tears rates and related risk factors in a single Italian centre. The secondary goal was to build a predictive model based on identified risk factors.

STUDY DESIGN

This was a retrospective cohort study. All vaginal deliveries from 2011 to 2015 in a single Italian University Hospital were analysed. Univariate analysis was applied to evaluate the overall association between each factor and severe tear. Multivariate logistic regression was used to build a predictive model for the absolute risk of severe tear. We computed a resampling validated measure (AUC) of the predictive accuracy of the model and we provided a nomogram for the risk calculation in clinical practice.

RESULTS

62 out of 10133 patients (0.61%) had a severe perineal tear. Univariate analysis identified gestational age >40 weeks, nulliparity, moderate/severe obesity, oxytocin use in pushing stage, sinciput presentation, instrumental delivery, shoulder dystocia, pushing stage ≥90 min, lithotomy position, birth weight >4 kg, head circumference at birth >34 cm and length at birth >50 cm as risk factors. Multivariate analysis identify moderate/severe obesity (OR = 2.8), instrumental delivery (OR = 2.6) and birth weight (OR = 1.1/hg) as independent risk factors. Using the predicted risk score from the final model (bootstrap-validated AUC 70%), we designed a nomogram for severe perineal tears absolute risk calculation.

CONCLUSION

Moderate/severe obesity, instrumental delivery and foetal weight resulted as independent risk factors for severe obstetrical tears.

Repair of a vesicouterine fistula following cesarean section

INTRODUCTION AND HYPOTHESIS

Vesicouterine fistula is a rare complication of cesarean section. The aim of this video is to present a case report and to provide a tutorial on the surgical technique of delayed transvaginal repair of a high vesicouterine fistula that developed after cesarean section with manual removal of a morbidly adherent placenta.

METHODS

A 43-year-old woman was referred to our unit for continuous urinary leakage 3 months after undergoing a cesarean section with manual removal of a morbidly adherent placenta. A vesicouterine fistula starting from the posterior bladder wall was identified. The surgical repair consisted of a transvaginal layered repair as shown in the video.

RESULTS

No surgical complications were observed postoperatively. Two months after surgery the fistula had not recurred and the patient reported no urinary leakage.

CONCLUSIONS

Transvaginal layered primary repair of vesicouterine fistula was shown to be a safe and effective procedure for restoring continence. The vaginal route can be particularly attractive for urogynecological surgeons.

Risk factors for recurrence after hysterectomy plus native-tissue repair as primary treatment for genital prolapse

INTRODUCTION AND HYPOTHESIS

Identification of risk factors for pelvic organ prolapse (POP) recurrence is crucial to provide adequate preoperative counselling and tailor surgical treatment. The aim of this retrospective study was to identify risk factors for recurrence in a large series of patients with POP treated with primary transvaginal native-tissue repair involving high uterosacral ligament suspension.

METHODS

Postoperative descent of POP-Q stage 2 or higher in any compartment was considered as recurrence. Global recurrence (GR) was defined as any recurrence in any compartment irrespective of the surgical procedures performed during primary prolapse surgery. True recurrence (TR) was defined as recurrence in a compartment repaired during primary prolapse surgery.

RESULTS

Of a total of 533 eligible women, 519 were available for follow-up. Univariate analysis showed that age ≤50 years, premenopausal status, obesity (BMI >30 kg/m²), history of severe macrosomia (>4,500 g), preoperative POP stage 3 or higher and absence of anterior repair at the time of POP surgery were risk factors for GR. Multivariate analysis confirmed lack of posterior repair (odds ratio, OR, 1.8), severe macrosomia (OR 2.7), premenopausal status (OR 3.9), obesity (OR 2.2) and preoperative stage 3 or higher (OR  2.6) as risk factors for GR. Univariate analysis showed that premenopausal status and preoperative POP stage 3 or higher were risk factors for TR. Multivariate analysis confirmed premenopausal status (OR 4.0) and preoperative stage 3 or higher (OR 4.5) as risk factors for TR.

CONCLUSIONS

This study confirmed preoperative stage 3 or higher as a risk factor for prolapse recurrence. The study also identified additional risk factors for surgical failure including lack of posterior repair, severe macrosomia, premenopausal status and obesity.

Mini-sling efficacy in obese versus non-obese patients for treatment of stress urinary incontinence

BACKGROUND

The impact of obesity on single-incision has been object of concerns. The aim of the study was to compare the outcomes of MiniArc single-incision sling in normal weight, overweight and obese patients.

METHODS

This retrospective study analyzed women with proven stress urinary incontinence (SUI). Patients were divided into three groups according to BMI: normal weight (group A), overweight (group B) and obese (group C). Objective cure rate was assessed with stress test and subjective cure rate was determined by ICIQ-SF and PGI-I scores. Postoperative overactive bladder syndrome and voiding symptoms were recorded.

RESULTS

One hundred ninety-two patients were analyzed (A=97; B=68; C=27). Mean follow-up was 23.2 months without differences among groups. Estimated blood loss and operative time were not influenced by BMI. No bladder perforation were observed. Objective cure rate (A=87.6%; B=86.8%; C=81.5%) and subjective outcomes resulted similar irrespective of BMI class. De novo onset of overactive bladder syndrome and voiding symptoms were reported without significant differences among groups.

CONCLUSIONS

The current study showed that single-incision sling Miniarc seems to be an effective treatment irrespective of BMI. Operative data, complications, objective and subjective outcomes were similar for normal weight, overweight and obese women.

Randomized study between radical surgery and radiotherapy for the treatment of stage IB-IIA cervical cancer: 20-year update

OBJECTIVE

Stage IB-IIA cervical carcinoma can be equally cured either by radical surgery or radiotherapy (RT). Albeit such policies show the same efficacy, they carry a different morbidity. This is an update after 20 years of a previously published randomized trial of RT vs. surgery in the treatment of stage IB-IIA cervical cancers to assess long-term survival and morbidity and the different pattern of relapse between the 2 modalities.

METHODS

Between September 1986 and December 1991, women referred for a newly diagnosed stage IB and IIA cervical carcinoma were randomized to radical surgery or RT. The primary outcome measures were long-term survival and complications rate. The secondary outcome was recurrence of the disease.

RESULTS

Three-hundred forty-three eligible women were randomized: 172 to radical surgery and 171 to external RT. Minimum follow-up was 19 years. Thirty-three patients (10%) died of intercurrent disease (31 cases) or fatal complications (2 cases). Twenty-year overall survival is 72% and 77% in the 2 treatment groups (p=0.280), respectively. As a whole, 94 recurrences (28%) were observed. Median time to relapse was 13.5 (surgery group) and 11.5 months (radiotherapy group) (p=0.100), respectively. Multivariate analysis confirms that risk factors for survival are histotype (p=0.020), tumor diameter (p=0.008), and lymph node status (p<0.001).

CONCLUSION

The results of the present study seem to suggest that there is no treatment of choice for early stage cervical carcinoma in terms of survival. Long term follow-up confirms that the best treatment for the individual patient should take into account clinical factors such as menopausal status, comorbidities, histological type, and tumor diameter.

Potential role of BCL2 in the recurrence of uterine smooth muscle tumors of uncertain malignant potential

Uterine smooth muscle tumors are the most common female genital tract neoplasms. While leiomyosarcoma has been studied at length, smooth muscle tumors of uncertain malignant potential (STUMPs) still have ambiguous and unresolved issues, with a risk of relapse and evolution largely undefined. We performed an array comparative genomic hybridization analysis on a primitive STUMP and its local recurrence, histologically diagnosed as undifferentiated sarcoma. To the best of our knowledge, our report is the first genomic study on primitive STUMPs and the different relapsed tumors. The results showed few copy number alterations shared between both samples and the high heterogeneity in the STUMP was apparently lost in the sarcoma. Surprisingly the STUMP presented an amplification of the BCL2 gene, not observed in the relapsed tumor. Additionally, fluorescence in situ hybridization and immunohistochemical staining were performed to confirm BCL2 amplification and expression in these samples and in two other cases of primitive STUMPs and their corresponding relapsed tumors. The presence of BCL2 in multiple copies and expression in the two primitive STUMPs and two relapsed tumors was confirmed. The marked amplification of the BCL2 gene present in the primitive STUMP and the multiple copies also observed in other cases, suggest its potential role as a marker of STUMP malignant potential and recurrence.

Reproductive prognosis in women with endometriosis after conservative surgery: a single-center experience

BACKGROUND

To evaluate the reproductive prognosis in women subjected to conservative surgical treatment for endometriosis seeking pregnancy during the first three years after surgery. We tried to identify operative findings which negative influences prognosis.

METHODS

A total of 140 patients were retrospectively analyzed, who had a diagnosis of endometriosis, based on surgical and histological criteria and without other male or female infertility factors who underwent surgery between 01/2002 and 01/2012. For each patient, anatomic and surgical data, stage according to the revised classification of American Fertility Society (AFS), months of pregnancy research and the use of assisted reproductive technology (ART) after surgery were collected. A total of 109 patients had been diagnosed preoperatively as being infertile (group 1), 31 cases tried to conceive only after surgery (group 2). The study was approved by the Ethics Committee of San Gerardo Hospital, Monza.

RESULTS

The pregnancy rate among infertile women (group 1) was 53% (58/109, 48 occurring naturally and 10 with ART), and 71% (22/31, 3 with ART) in patients of group 2. The overall cumulative probability of pregnancy at 3 years was 60% for group 1 and 76% for group 2. The prognosis was independent by the stage, presence of monolateral or bilateral endometriomas, tubal adhesions or superficial lesions while it is inversely correlated to Douglas' pouch obliteration (DPO) (P=0.05).

CONCLUSIONS

Surgery improves the reproductive prognosis in infertile women with endometriosis. In the studied population DPO obliteration had a high prevalence and it influenced negatively the pregnancy outcome.

Voiding disorders as etiologic cofeature of overactive bladder syndrome. An observational study

BACKGROUND

Overactive bladder (OAB) is very common in the urological and gynecological practice. It is well known that the correlation between clinical features and urodynamics findings is often poor. In this observational study urodynamic findings of an OAB population have been retrospectively analyzed with the aim to identify a possible role of voiding disorders in the pathophysiology of OAB syndrome.

METHODS

Urodynamics executed between January 2005 and December 2010 have been analyzed. Female patients presenting characteristics of OAB syndrome according to International Continence Society definition were identified. Urodynamic investigations have been carried out according to the good practice guidelines for urodynamics. The Blaivas-Groutz cut off for female urinary obstruction was to detect voiding disorders.

RESULTS

According to the selection criteria 258 patients presenting OAB syndrome have been considered eligible to join the study. Eighty-one patients (30%) showed voiding difficulties: in 21 of them pressure-flow study was diagnostic for frank outlet obstruction, in 47 a mild form and 13 bladder sphincter pseudo-dyssynergia.

CONCLUSIONS

OAB syndrome can be related to voiding disorders mostly represented by a mild degree of obstruction. Such condition could trigger irritative symptoms. These clinical findings require an instrumental assessment represented by a pressure-flow analysis. This approach seems to be mandatory in patients refractory to drug therapy.

Histologic and metabolic assessment in a cohort of patients with genital prolapse: preoperative stage and recurrence investigations

BACKGROUND

Biological basis of prolapse development and recurrence are still unclear. Aim of this observational and prospective study is to correlate clinical stage of anterior vaginal wall prolapse and anatomical recurrence to histological and metabolic characteristics of vaginal tissue.

METHODS

Patients undergoing surgery were divided into two groups according to anterior stage ≤II (group A) and ≥III (group B). Full-thickness excisional biopsies of the anterior vaginal wall were obtained after hysterectomy. Hystological characteristics and metalloproteinases activity (MMP-2) were analyzed.

RESULTS

Sixty-nine patients (35 group A; 34 group B) completed evaluation. Mean follow-up was 35 months. Collagen amount and organization were significantly higher in group B both in lamina propria and fascia specimens, but MMP-2 activity was significantly lower in this group. Recurrence rate of anterior compartment was 10.1%. Collagen cellularity of fascia was higher in recurrence groups. On the contrary MMP-2 activity showed a close to significant correlation to surgical success (P=0.07).

CONCLUSIONS

Patients with advanced stages of prolapse have increased collagen amount associated to decreased MMP-2 activity. This suggests that connective tissue is more abundant but less metabolically active in patients with severe prolapse. A similar trend can be found in recurrences.

Long-term results of fertility-sparing treatment compared with standard radical surgery for early-stage epithelial ovarian cancer

BACKGROUND

The objective of this study is to evaluate the safety of fertility-sparing surgery (FSS) for early-stage epithelial ovarian cancer (EOC).

METHODS

A retrospective analysis was performed to identify patients treated for early-stage EOC and to compare the clinical outcomes of patients treated with FSS and radical surgery (RS).

RESULTS

A total of 1031 patients were treated at two Institutions, 242 with FSS (group A) and 789 with RS (group B). Median duration of follow-up was 11.9 years. At univariate analyses, FSS was associated with decreased risk of relapse (P=0.002) and of tumour-related death (P=0.001). Multivariate analysis did not confirm the independent positive role of FSS neither on relapse-free interval (RFI) nor on cancer-specific survival (CSS). Tumour grade was associated with shorter RFI (P<0.001) and shorter CSS (P=0.001). The type of treatment did not influence CSS or RFI in any grade group. We also found a significant association between low-grade tumours and younger age.

CONCLUSIONS

Fertility-sparing surgery is an adequate treatment for patients with stage I EOC. The clinical outcome of patients with G3 tumours, which is confirmed to be the most important prognostic factor, is not determined by the type of treatment received.

A prognostic regulatory pathway in stage I epithelial ovarian cancer: new hints for the poor prognosis assessment

BACKGROUND

Clinical and pathological parameters of patients with epithelial ovarian cancer (EOC) do not thoroughly predict patients' outcome. Despite the good outcome of stage I EOC compared with that of stages III and IV, the risk assessment and treatments are almost the same. However, only 20% of stage I EOC cases relapse and die, meaning that only a proportion of patients need intensive treatment and closer follow-up. Thus, the identification of cell mechanisms that could improve outcome prediction and rationalize therapeutic options is an urgent need in the clinical practice.

PATIENTS AND METHODS

We have gathered together 203 patients with stage I EOC diagnosis, from whom snap-frozen tumor biopsies were available at the time of primary surgery before any treatment. Patients, with a median follow-up of 7 years, were stratified into a training set and a validation set.

RESULTS AND CONCLUSIONS

Integrated analysis of miRNA and gene expression profiles allowed to identify a prognostic cell pathway, composed of 16 miRNAs and 10 genes, wiring the cell cycle, 'Activins/Inhibins' and 'Hedgehog' signaling pathways. Once validated by an independent technique, all the elements of the circuit resulted associated with overall survival (OS) and progression-free survival (PFS), in both univariate and multivariate models. For each patient, the circuit expressions have been translated into an activation state index (integrated signature classifier, ISC), used to stratify patients into classes of risk. This prediction reaches the 89.7% of sensitivity and 96.6% of specificity for the detection of PFS events. The prognostic value was then confirmed in the external independent validation set in which the PFS events are predicted with 75% sensitivity and 94.7% specificity. Moreover, the ISC shows higher classification performance than conventional clinical classifiers. Thus, the identified circuit enhances the understanding of the molecular mechanisms lagging behind stage I EOC and the ISC improves our capabilities to assess, at the time of diagnosis, the patient risk of relapse.

Near-Infrared Sentinel Lymph Node Mapping With Indocyanine Green Using the VITOM II ICG Exoscope for Open Surgery for Gynecologic Malignancies

Sentinel lymph node (SLN) mapping is emerging as an effective method for surgical staging of different gynecologic malignancies. Near-infrared (NIR) technology using a fluorescent dye such as indocyanine green (ICG) represents an interesting and feasible method for SLN mapping even in traditional open surgeries by applying video telescope operating microscope (VITOM) system technology. We report our preliminary experience in 12 women who underwent surgical nodal staging for early-stage vulvar and uterine or cervical cancer. Surgical and pathological outcomes are described, and the VITOM II ICG system's intraoperative image quality, handling and docking, and teaching value are assessed. The general impression of the surgical staff was that the VITOM II system is easy to use, and that the image quality of the anatomic structures is impressive. Traditional open SLN mapping with ICG appears to be easy to perform and reproducible, providing a new tool in the management of patients with gynecologic malignancies. Moreover, we believe that this technology has great potential as an operative teaching and learning modality for trainers for open surgical cases. Additional studies involving the VITOM system with a large sample size of patients are needed to confirm these promising results.

Impact of Indocyanine Green for Sentinel Lymph Node Mapping in Early Stage Endometrial and Cervical Cancer: Comparison with Conventional Radiotracer (99m)Tc and/or Blue Dye

Purpose

To compare the detection rate (DR) and bilateral optimal mapping (OM) of sentinel lymph nodes (SLNs) in women with endometrial and cervical cancer using indocyanine green (ICG) versus the standard technetium-99m radiocolloid (^99mTc) radiotracer plus methylene or isosulfan blue, or blue dye alone.

Methods

From October 2010 to May 2015, 163 women with stage I endometrial or cervical cancer (118 endometrial and 45 cervical cancer) underwent SLN mapping with ^99mTc with blue dye, blue dye alone, or ICG. DR and bilateral OM of ICG were compared respectively with the results obtained using the standard ^99mTc radiotracer with blue dye, or blue dye alone.

Results

SLN mapping with ^99mTc radiotracer with blue dye was performed on 77 of 163 women, 38 with blue dye only and 48 with ICG. The overall DR of SLN mapping was 97, 89, and 100 % for ^99mTc with blue dye, blue dye alone, and ICG, respectively. The bilateral OM rate for ICG was 85 %—significantly higher than the 58 % obtained with ^99mTc with blue dye (p = 0.003) and the 54 % for blue dye (p = 0.001). Thirty-one women (19 %) had positive SLNs. Sensitivity and negative predictive value of SLN were 100 % for all techniques.

Conclusions

SLNs mapping using ICG demonstrated higher DR compared to other modalities. In addition, ICG was significantly superior to ^99mTc with blue dye in terms of bilateral OM in women with early stage endometrial and cervical cancer. The higher number of bilateral OM may consequently reduce the overall number of complete lymphadenectomies, reducing the duration and additional costs of surgical treatment.

The contribution of a collagen-fibrin patch (Tachosil) to prevent the postoperative lymphatic complications after groin lymphadenectomy: a double institution observational study

OBJECTIVE

Postoperative morbidity associated with groin lymphadenectomy remain high and still represents a major concern for this patients. The aim of this study was to confirm the efficacy of TachoSil(®) in preventing postoperative complications after inguinofemoral lymphadenectomy for gynecological malignancy.

STUDY DESIGN

An observational study was conducted to evaluate the incidence of postoperative complications among 49 patients (TachoSil(®) group=24; control group=25) underwent groin dissection enrolled in two Italian Department of Gynecology Oncology from 2011 to 2014.

RESULTS

A total of 74 inguinal dissections were performed. Bilateral groin dissection was performed in 25 patients (Tachosil group=10; group 2=15). Patients in TachoSil(®) group showed a lower daily drainage volume with a mean volume of 84 ml (range 30-465) vs. 143 ml (range -72 to 413) in the control group (p=.004), and a lower total drainage volume with a mean of 540 ml (range 90-930) vs. 900 ml (range 200-3270) for Tachosil and control group, respectively. A lower incidence of lymphocyst required drainage, cellulitis, wound infection and late lymphedema was observed in TachoSil group even without reaching statistical significance.

CONCLUSIONS

This observational study confirmed that the use of TachoSil(®) seems to be highly effective in reducing the rate of postoperative lymphorrea and postoperative complications after groin dissection in case of gynecological malignancies. Larger multicenter prospective study is advisable to validate our preliminary results.

Repair of a traumatic cloaca after obstetric anal sphincter injury

INTRODUCTION AND HYPOTHESIS

Unsuccessful primary repair of fourth-degree obstetric trauma can lead to permanent communication between the rectum and the vagina, which, in association with full-thickness anal sphincter defects, is characterized by complete fecal incontinence and severe impairment of quality of life. The aim of this video is to serve as a tutorial for repair.

METHODS

A 27-year-old woman who developed a full-thickness recto-vaginal defect extended from the perineum to the upper third of the vagina has been managed through layered surgical repair without flaps.

RESULTS

Anatomy and fecal continence have been completely restored by a follow-up of 24 months.

CONCLUSION

The procedure described in this video has been shown to be effective and safe.

Sentinel Lymph Node Mapping With Near-Infrared Fluorescent Imaging Using Indocyanine Green: A New Tool for Laparoscopic Platform in Patients With Endometrial and Cervical Cancer

Indocyanine green (ICG) represents a feasible alternative to the more traditional methods of sentinel lymph node (SLN) mapping, and interest in this promising tracer is growing. This report outlines our experience with ICG in a minimally invasive laparoscopic approach in women with endometrial cancer and cervical cancer using the Storz SPIES ICG near-infrared fluorescence imaging technology. A total of 49 patients with clinical stage I endometrial cancer (n = 40) or stage I cervical cancer (n = 9) were retrospectively reviewed. All patients had undergone simple or radical laparoscopic hysterectomy with pelvic and/or aortic lymphadenectomy and SLN mapping by means of an intracervical injection of ICG dye at the 3 o'clock and 9 o'clock locations after the induction of general anesthesia. The detection rate of ICG was 100% (49 of 49). The rate of bilateral SLN detection was 86% (42 of 49). Positive lymph nodes were found in 6 patients (12%), with at least 1 positive SLN. The sensitivity and negative predictive value of SLN detection were 100%. All procedures were successfully completed without conversion to open laparotomy, and no intraoperative or postoperative complications occurred. In our preliminary experience, ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer and cervical cancer. Laparoscopic SLN mapping with ICG appears to be safe, easy, and reproducible, with a positive impact on patient management.

Profiling cancer gene mutations in longitudinal epithelial ovarian cancer biopsies by targeted next-generation sequencing: a retrospective study

BACKGROUND

The majority of patients with stage III-IV epithelial ovarian cancer (EOC) relapse after initially responding to platinum-based chemotherapy, and develop resistance. The genomic features involved in drug resistance are unknown. To unravel some of these features, we investigated the mutational profile of genes involved in pathways related to drug sensitivity in a cohort of matched tumors obtained at first surgery (Ft-S) and second surgery (Sd-S).

PATIENTS AND METHODS

Matched biopsies (33) taken at Ft-S and Sd-S were selected from the 'Pandora' tumor tissue collection. DNA libraries for 65 genes were generated using the TruSeq Custom Amplicon kit and sequenced on MiSeq (Illumina). Data were analyzed using a high-performance cluster computing platform (Cloud4CARE project) and independently validated.

RESULTS

A total of 2270 somatic mutations were identified (89.85% base substitutions 8.19% indels, and 1.92% unknown). Homologous recombination (HR) genes and TP53 were mutated in the majority of Ft-S, while ATM, ATR, TOP2A and TOP2B were mutated in the entire dataset. Only 2% of mutations were conserved between matched Ft-S and Sd-S. Mutations detected at second surgery clustered patients in two groups characterized by different mutational profiles in genes associated with HR, PI3K, miRNA biogenesis and signal transduction.

CONCLUSIONS

There was a low level of concordance between Ft-S and Sd-S in terms of mutations in genes involved in key processes of tumor growth and drug resistance. This result suggests the importance of future longitudinal analyses to improve the clinical management of relapsed EOC.

Stem cell augmented mesh materials: an in vitro and in vivo study

INTRODUCTION AND HYPOTHESIS

To test in vitro and in vivo the capability of mesh materials to act as scaffolds for rat-derived mesenchymal stem cells (rMSCs) and to compare inflammatory response and collagen characteristics of implant materials, either seeded or not with rMSCs.

METHODS

rMSCs isolated from rat bone marrow were seeded and cultured in vitro on four different implant materials. Implants showing the best rMSC proliferation rate were selected for the in vivo experiment. Forty-eight adult female Sprague-Dawley rats were randomly divided into two treatment groups. The implant of interest-either seeded or not with rMSCs-was laid and fixed over the muscular abdominal wall. Main outcome measures were: in vitro, proliferation of rMSCs on selected materials; in vivo, the occurrence of topical complications, the evaluation of systemic and local inflammatory response and examination of the biomechanical properties of explants.

RESULTS

Surgisis and Pelvitex displayed the best cell growth in vitro. At 90 days in the rat model, rMSCs were related to a lower count of neutrophil cells for Pelvitex and a greater organisation and collagen amount for Surgisis. At 7 days Surgisis samples seeded with rMSCs displayed higher breaking force and stiffness.

CONCLUSIONS

The presence of rMSCs reduced the systemic inflammatory response on synthetic implants and improved collagen characteristics at the interface between biological grafts and native tissues. rMSCs enhanced the stripping force on biological explants.

Patient-derived ovarian tumor xenografts recapitulate human clinicopathology and genetic alterations

Epithelial ovarian cancer (EOC) is the most lethal gynecologic malignancy. On the basis of its histopathology and molecular-genomic changes, ovarian cancer has been divided into subtypes, each with distinct biology and outcome. The aim of this study was to develop a panel of patient-derived EOC xenografts that recapitulate the molecular and biologic heterogeneity of human ovarian cancer. Thirty-four EOC xenografts were successfully established, either subcutaneously or intraperitoneally, in nude mice. The xenografts were histologically similar to the corresponding patient tumor and comprised all the major ovarian cancer subtypes. After orthotopic transplantation in the bursa of the mouse ovary, they disseminate into the organs of the peritoneal cavity and produce ascites, typical of ovarian cancer. Gene expression analysis and mutation status indicated a high degree of similarity with the original patient and discriminate different subsets of xenografts. They were very responsive, responsive, and resistant to cisplatin, resembling the clinical situation in ovarian cancer. This panel of patient-derived EOC xenografts that recapitulate the recently type I and type II classification serves to study the biology of ovarian cancer, identify tumor-specific molecular markers, and develop novel treatment modalities.