Safety and efficacy of a class II medical device based on highly purified and standardized plant extracts in the management of post-menopausal patients with vulvar and vaginal atrophy: a single-center prospective observational study

BACKGROUND

Despite the gold standard treatment for genitourinary syndrome of menopause (GSM) is based on the use of local or systemic estrogen-containing products, the typical long-term side effects of hormonal treatments and, most importantly, the contraindications in patients with history of breast and endometrial neoplasms do limit in some extent its use. As hyaluronic acid and some highly purified botanicals have clearly demonstrated their anti-inflammatory and mucosa-protecting properties, we have tested, in women with GSM, a class II vaginal medical device containing hyaluronate gel and a mucoadhesive active enriched with purified alkylamides from Zanthoxylum bungeanum, triterpenes from Centella asiatica and high molecular weight polysaccharides from Tamarindus indica.

METHODS

Our single-center, open-label, prospective and observational study was conducted on 50 menopausal women enrolled at the Department of Maternal-Fetal Medicine at Umberto I Polyclinic Hospital in Rome, Italy. Gel administration lasted 150 days and was performed daily for the first 12 days and every 48 hours for the remaining 138 days. Clinical evaluations were performed at baseline and after 12, 57 and 150 days. Besides product safety, main outcomes of our study were: 1) vaginal health (by Vaginal Health Index score [VHI]); 2) sexual quality of life (by Female Sexual Distress Scale [FSDS]); and 3) percentage of women declaring regular sexual activity.

RESULTS

The product was safe with no specific adverse events reported. It significantly improved VHI (about 5% after 57 days and 8% after 150 days), FSDS (about 7% after 57 days and 10% after 150 days), and sexual activity (about 20% after 150 days). It also reduced dryness, dyspareunia, burning, itching, and dysuria incidence, respectively by about 18%, 14%, 14%, 27% and 11% after 150 days.

CONCLUSIONS

In women with GSM, the intravaginal administration of a hyaluronate-based gel enriched with purified botanical actives endowed with anti-inflammatory and mucosal-protecting properties, reduced painful sensation during sexual acts and increased regular sexual activity.

The role of microbiota in female fertility and infertility

In recent years, the introduction of advanced technologies has led to a new scientific revolution: the discovery of the human microbiota. Next-generation sequencing (NGS) allowed the identification of microbial communities in all districts of the human body and, among these, 9% are distributed in the genitourinary system. The microbiota plays a key role in controlling the homeostasis, therefore dysbiosis can lead to an alteration of the physiological state of health. An alteration of female reproductive microbial communities may affect fertility due to an alteration of the vaginal and endometrial ecosystem. A perturbation of the vaginal, cervical or endometrial flora may also have an impact on the outcome of assisted reproductive technology (ART) procedures, particularly in vitro fertilization (IVF) and embryo transfer (ET). This review examines the role of microbiota in human reproduction and its contribution to infertility. In addition we investigate the role of endometrial bacteria in recurrent implantation failure (RIF).

Radical Surgery After Neoadjuvant Chemotherapy for Locally Advanced Neuroendocrine Cancer of the Cervix

BACKGROUND/AIM

Although still controversial, the current treatment for locally advanced neuroendocrine carcinoma of the cervix (NECC) relies on chemoradiation (CRT). The aim of this study is to evaluate the alternative role of combined chemotherapy and surgery in treating NECC.

PATIENTS AND METHODS

This is a retrospective series of patients undergoing radical surgery after neoadjuvant chemotherapy (NACT) for locally advanced NECC (stages IIB-IVA). Histological examination and immunohistochemistry were performed on surgical specimens to confirm diagnosis. Systematic literature search was conducted to identify other cases treated with chemotherapy and surgery.

RESULTS

Seven patients with a mean age of 49 years were identified. The mean greatest diameter at diagnosis was 59.3±24.7 mm. FIGO stage was IIB in 14.3% of patients, IIIB in 28.6%, IIIC in 42.9%, and IVA in 14.3%. The response to NACT was partial, ranging from 50% to 80%. Neuroendocrine markers were expressed in all cases. The mean progression-free survival (PFS) and overall survival (OS) were 15.0±30.6 months and 26.3±36.4 months, respectively. Eleven studies encompassing a total of 27 patients met eligibility criteria for the systematic review.

CONCLUSION

Surgery after NACT for locally advanced NECC may yield similar outcomes compared to CRT. The benefit of performing surgery as a primary approach could lie in the possibility of reserving CRT for recurrences. Since randomized clinical trials are difficult to be designed, an expert consensus is required to address the non-inferiority of radical surgery over CRT.

Response to Neoadjuvant Chemotherapy in Locally Advanced Cervical Cancer: The Role of Immune-related Factors

BACKGROUND/AIM

Treatment of locally advanced cervical cancer (LACC) consists of concomitant chemoradiation or neoadjuvant chemotherapy (NACT) plus radical surgery (RS). This study analyzed the prognostic role of neutrophil to lymphocyte ratio (NLR), platelet to lymphocyte ratio (PLR), tumor infiltrating lymphocytes (TILs), and PD-L1 expression in LACC patients, treated with NACT+RS.

PATIENTS AND METHODS

We prospectively analyzed 37 LACC patients treated from December 2016 to September 2019. Patients were submitted to pelvic examination, biopsy and imaging.

RESULTS

In 65% of cases, a nodal involvement was present at pre-treatment MRI. All cancers showed the presence of stromal TILs and PD-L1 staining of inflammatory cells. No significant correlations were found between clinicopathological parameters and the number of TILs and PDL-1 at baseline. After NACT, 29 patients (78%) were submitted to RS; 28% of patients showed pathological complete response, 62% partial response and 10% stable disease. Seven (24%) patients reported a positive node. Patients with high levels of stromal TILs and low NLR and PLR showed a significantly better response to NACT. No significant correlation was observed between PD-L1 expression and response to NACT.

CONCLUSION

The number of TILs, the expression of PDL1, and NLR and PLR ratios correlate significantly with the response of LACC patients to NACT.

Relationship between cervical excisional treatment for cervical intraepithelial neoplasia and obstetrical outcome

INTRODUCTION

The aim of our systematic review was the assessment of effects of excisional treatments for the management of cervical intraepithelial neoplasia (CIN) on preterm delivery (PD), lower birth weight (LBW), preterm premature rupture of membrane (PPROM) and obstetrical outcomes.

EVIDENCE ACQUISITION

A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through November 30, 2019. The search included a combination of the following terms: "loop electrosurgical excision procedure (LEEP)," "large loop excision of transformation zone (LLETZ)," "cold-knife conization (CKC)," "laser cervical conization (CLC)," "preterm delivery" and "neonatal outcome."

EVIDENCE SYNTHESIS

Thirty-two of 561 publications considered were included: 28 retrospective series, 2 prospective studies and 2 multicenter trials. Globally in several studies there was a significant increase in PD, measured by the relative risk, in the women underwent a surgical procedure for the CIN. In their majority, the studies were retrospective and therefore a high risk of bias.

CONCLUSIONS

This systematic review shows that the surgical treatment of the CIN was associated with an increased risk of PD, LBW and pPROM before 37 pregnancy weeks compared to untreated women, especially in a CKC and LLETZ procedure. Moreover, the increase of the of PD was associated with cone size, cervical length, repeated treatment and a short conization-to-pregnancy interval.

Non-invasive treatment of vulvovaginal atrophy in menopause with CO2 laser

Genitourinary syndrome of menopause (GSM) may affect up to 90% of menopausal women, including vulvovaginal atrophy (VVA), burning, pain, bleeding, irritation, dyspareunia, anorgasmia, and urinary symptoms. Vaginal symptoms from lack of estrogens can have a significant impact on the sexual health and quality of life (QoL) in as many as 50% of postmenopausal women. Several therapeutic alternatives, both hormonal and non- hormonal, have been proposed. Microablative CO<inf>2</inf> laser is one of the three non-surgical energy-based therapies, with Erbium:YAG laser and temperature-controlled radiofrequency (RF). Microablative CO<inf>2</inf> laser induces morphological changes in vaginal tissues and results of several clinical trials suggest that this type of laser improves symptoms of GSM. Moreover, this treatment seems to be safe. Given the increasingly widespread use of laser CO<inf>2</inf> as a non-hormonal alternative treatment for GSM, the authors reviewed the current published literature evaluating this therapy, to compare efficacy and safety of different protocols.

Minimally invasive surgery in cervical cancer

In recent years, minimally invasive surgery has replaced open surgery for almost all surgical indications in gynecological practice. Recently, the results of the laparoscopic approach to cervical cancer (LACC) trial questioned the role of minimally invasive surgery for patients affected by early-stage cervical cancer. In the present paper, we discussed the current evidence regarding the adoption of minimally invasive surgery for patients with cervical cancer. We evaluated the current evidence focusing on four interesting features: 1) the impact of tumor volume; 2) reasons explaining worse outcomes of patients undergoing minimally invasive surgery; 3) methods to reduce the risk of recurrence during minimally invasive surgery; and 4) the effect of minimally invasive surgery in patients with locally advanced cervical cancer. At the moment, in the light of current evidence, minimally invasive radical hysterectomy should be offered only in the context of clinical trials. Extensive counseling and appropriate patients' selection are needed. Further prospective evidence is warranted to identify the better approach for cervical cancer patients.

Update on surgical treatment of female stress urinary incontinence

INTRODUCTION

Urinary incontinence is a common condition that negatively impacts quality of life of millions of women. It is a result of a synergy between the structures of pelvic floor in particular levator ani muscle and pelvic connective tissues. Urinary incontinence, increasing with age, is associated with considerable personal and societal expenditure.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/Medline database up to August 20, 2020. Focus was only for English language publications of original studies on urinary incontinence and in particular stress urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Many surgical options exist for women with stress urinary incontinence. Nevertheless, new strategies need to be evaluated in order to improve quality of life of patients.

Urinary incontinence in women: state of the art and medical treatment

INTRODUCTION

Urinary incontinence, the involuntary loss of urine, is a common condition that affects approximately 50% of adult women. This condition increases with age, affecting 10% to 20% of all women and up to 77% of elderly women residing in nursing homes.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/MEDLINE database up to July 20, 2020. Focus was only for English language publications of original studies on urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Patients need an overview of their health condition through a detailed anamnestic collection and physical examination to identify the type of incontinence and offer the best treatment.

Reducing the radicality of surgery for vulvar cancer: are smaller margins safer?

INTRODUCTION

Vulvar cancer accounts for ~4% of all gynecological malignancies and the majority of tumors (>90%) are squamous cell (keratinizing, ~60% and warty/basaloid, ~30%). Surgical excision forms the foundation of treatment, with resection margin status being the single most influential factor when predicting clinical outcome. There has been a paradigm shift concerning surgical approaches and radicality when managing vulvar cancer within recent times, largely owing to a desire to preserve vulvar structure and function without compromising oncological outcome. As such the safety of the size of resection margin has been called into question. In this narrative review we consider the current literature on the safety of resection margins for vulvar cancer.

EVIDENCE ACQUISITION

PubMed, Medline and the Cochrane Database were searched for original peer-reviewed primary and review articles, from January 2005 to January 2020. The following search terms were used vulvar cancer surgery, vulvar squamous cell carcinoma, excision margins, adjuvant radiation.

EVIDENCE SYNTHESIS

A pathological tumor margin of <8 mm has been widely considered to indicate "close" margins. This measurement after fixation of the tumor is considered comparable to a surgical resection margin of around 1cm, following an estimated 20% tissue shrinkage after formalin fixation and a 1-2cm clinical surgical margin in order to achieve the 8 mm final pathological margin.

CONCLUSIONS

A surgical resection margin of 2-3mm does not appear to be associated with a higher rate of local recurrence than the widely used limit of 8 mm. As such the traditional practice of re-excision or adjuvant radiotherapy based on "close" surgical margins alone needs to be closely evaluated, since the attendant morbidity associated with these procedures may not be outweighed by oncological benefit.

Reducing the radicality of surgery for vulvar cancer: are smaller margins safer?

INTRODUCTION

Vulvar cancer accounts for ~4% of all gynecological malignancies and the majority of tumors (>90%) are squamous cell (keratinizing, ~60% and warty/basaloid, ~30%). Surgical excision forms the foundation of treatment, with resection margin status being the single most influential factor when predicting clinical outcome. There has been a paradigm shift concerning surgical approaches and radicality when managing vulvar cancer within recent times, largely owing to a desire to preserve vulvar structure and function without compromising oncological outcome. As such the safety of the size of resection margin has been called into question. In this narrative review we consider the current literature on the safety of resection margins for vulvar cancer.

EVIDENCE ACQUISITION

PubMed, Medline and the Cochrane Database were searched for original peer-reviewed primary and review articles, from January 2005 to January 2020. The following search terms were used vulvar cancer surgery, vulvar squamous cell carcinoma, excision margins, adjuvant radiation.

EVIDENCE SYNTHESIS

A pathological tumor margin of <8 mm has been widely considered to indicate "close" margins. This measurement after fixation of the tumor is considered comparable to a surgical resection margin of around 1cm, following an estimated 20% tissue shrinkage after formalin fixation and a 1-2cm clinical surgical margin in order to achieve the 8 mm final pathological margin.

CONCLUSIONS

A surgical resection margin of 2-3mm does not appear to be associated with a higher rate of local recurrence than the widely used limit of 8 mm. As such the traditional practice of re-excision or adjuvant radiotherapy based on "close" surgical margins alone needs to be closely evaluated, since the attendant morbidity associated with these procedures may not be outweighed by oncological benefit.

Minimally invasive surgery in cervical cancer

In recent years, minimally invasive surgery has replaced open surgery for almost all surgical indications in gynecological practice. Recently, the results of the laparoscopic approach to cervical cancer (LACC) trial questioned the role of minimally invasive surgery for patients affected by early-stage cervical cancer. In the present paper, we discussed the current evidence regarding the adoption of minimally invasive surgery for patients with cervical cancer. We evaluated the current evidence focusing on four interesting features: 1) the impact of tumor volume; 2) reasons explaining worse outcomes of patients undergoing minimally invasive surgery; 3) methods to reduce the risk of recurrence during minimally invasive surgery; and 4) the effect of minimally invasive surgery in patients with locally advanced cervical cancer. At the moment, in the light of current evidence, minimally invasive radical hysterectomy should be offered only in the context of clinical trials. Extensive counseling and appropriate patients' selection are needed. Further prospective evidence is warranted to identify the better approach for cervical cancer patients.

Relationship between cervical excisional treatment for cervical intraepithelial neoplasia and obstetrical outcome

INTRODUCTION

The aim of our systematic review was the assessment of effects of excisional treatments for the management of cervical intraepithelial neoplasia (CIN) on preterm delivery (PD), lower birth weight (LBW), preterm premature rupture of membrane (PPROM) and obstetrical outcomes.

EVIDENCE ACQUISITION

A structured search was carried out in PubMed-Medline, Embase, and Cochrane Controlled Trials Register databases through November 30, 2019. The search included a combination of the following terms: "loop electrosurgical excision procedure (LEEP)," "large loop excision of transformation zone (LLETZ)," "cold-knife conization (CKC)," "laser cervical conization (CLC)," "preterm delivery" and "neonatal outcome."

EVIDENCE SYNTHESIS

Thirty-two of 561 publications considered were included: 28 retrospective series, 2 prospective studies and 2 multicenter trials. Globally in several studies there was a significant increase in PD, measured by the relative risk, in the women underwent a surgical procedure for the CIN. In their majority, the studies were retrospective and therefore a high risk of bias.

CONCLUSIONS

This systematic review shows that the surgical treatment of the CIN was associated with an increased risk of PD, LBW and pPROM before 37 pregnancy weeks compared to untreated women, especially in a CKC and LLETZ procedure. Moreover, the increase of the of PD was associated with cone size, cervical length, repeated treatment and a short conization-to-pregnancy interval.

Update on surgical treatment of female stress urinary incontinence

INTRODUCTION

Urinary incontinence is a common condition that negatively impacts quality of life of millions of women. It is a result of a synergy between the structures of pelvic floor in particular levator ani muscle and pelvic connective tissues. Urinary incontinence, increasing with age, is associated with considerable personal and societal expenditure.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/Medline database up to August 20, 2020. Focus was only for English language publications of original studies on urinary incontinence and in particular stress urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Many surgical options exist for women with stress urinary incontinence. Nevertheless, new strategies need to be evaluated in order to improve quality of life of patients.

Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study

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.

Urinary incontinence in women: state of the art and medical treatment

INTRODUCTION

Urinary incontinence, the involuntary loss of urine, is a common condition that affects approximately 50% of adult women. This condition increases with age, affecting 10% to 20% of all women and up to 77% of elderly women residing in nursing homes.

EVIDENCE ACQUISITION

Systematic data search performed using PubMed/MEDLINE database up to July 20, 2020. Focus was only for English language publications of original studies on urinary incontinence.

EVIDENCE SYNTHESIS

Given the basis of published evidence and the consensus of European experts, this study provides an updated overview on clinical applications and surgical procedures of urinary incontinence.

CONCLUSIONS

Urinary incontinence is an underestimated health problem. Patients need an overview of their health condition through a detailed anamnestic collection and physical examination to identify the type of incontinence and offer the best treatment.

Non-invasive treatment of vulvovaginal atrophy in menopause with CO2 laser

Genitourinary syndrome of menopause (GSM) may affect up to 90% of menopausal women, including vulvovaginal atrophy (VVA), burning, pain, bleeding, irritation, dyspareunia, anorgasmia, and urinary symptoms. Vaginal symptoms from lack of estrogens can have a significant impact on the sexual health and quality of life (QoL) in as many as 50% of postmenopausal women. Several therapeutic alternatives, both hormonal and non- hormonal, have been proposed. Microablative CO<inf>2</inf> laser is one of the three non-surgical energy-based therapies, with Erbium:YAG laser and temperature-controlled radiofrequency (RF). Microablative CO<inf>2</inf> laser induces morphological changes in vaginal tissues and results of several clinical trials suggest that this type of laser improves symptoms of GSM. Moreover, this treatment seems to be safe. Given the increasingly widespread use of laser CO<inf>2</inf> as a non-hormonal alternative treatment for GSM, the authors reviewed the current published literature evaluating this therapy, to compare efficacy and safety of different protocols.