Urethral sphincter innervation and clitoral blood flow after the transobturator (TOT) approach

Multicentric data analysis of the learning curve for laparoscopic Shull's repair of pelvic floor defects

Introduction

Pelvic organs prolapse remains a significant health concern affecting millions of women worldwide. The use of native tissues to suspend the apex has acquired relevance in urogynecologic surgery. One of the most commonly used procedures performed without mesh is the technique described by Shull, consisting of suturing the vaginal apex to the uterosacral ligaments. The objective of the study is to evaluate the learning curve of laparoscopic Shull's repair for the correction of pelvic floor defects, including the surgery time and surgical outcomes.

Materials and methods

This is a retrospective study conducted at the Policlinico G. Martino, University of Messina, Messina, Italy, and Policlinico Vanvitelli, Vanvitelli University, Naples, Italy. All patients affected by grade I-IV POP, consisting of apical prolapse with or without cystocele, and who underwent laparoscopic Shull's technique for prolapse correction were enrolled. The endpoints to estimate the learning curve for the procedure were the percentage of laparoscopic procedures completed, operative time, and the early complication rate.

Results

A total of 31 laparoscopic Shull repairs were collected for the study. To evaluate the learning curve of the technique, we divided the 31 cases into three different groups: Procedures 0-10; 11-20; 21-31. The parameter for evaluating technique learning was the operative time. Group 21-31 demonstrated an operative time of 97 min (SD 20), compared with 121 min (SD 23) in group 0-10 and 120 min (SD 13) in group 11-20. A comparison of these means through ANOVA showed a p-value of 0.01 for the entire system, and 0.95 for the comparison between 0 and 10 and 11-20, 0.04 for 0-10 vs. 21-31, and 0.02 between 11 and 20 and 21-31.

Conclusions

The rate of surgical improvement in terms of time became effective after an average of 20 procedures. However, the improvement seems to be effective case by case for surgeons skilled in basic endoscopy.

Ultralow 0.03 mg vaginal estriol in postmenopausal women who underwent surgical treatment for stress urinary incontinence: effects on quality of life and sexual function

OBJECTIVE

To evaluate the efficacy of low-dose, intravaginal estriol ovules in postmenopausal women with stress urinary incontinence (SUI) before and after transobturator tape (TOT) placement, assessing vaginal health, quality of life (QoL), and sexual function.

METHODS

Ninety-six postmenopausal women affected by SUI and scheduled for TOT placement were enrolled. Women were randomized and divided into two groups through 1:1 at baseline (T0): study group (group A, n = 48) and control group (group B, n = 48). Group A was treated daily for 16 weeks with an intravaginal ovule containing 0.03 mg estriol. Vaginal epithelium maturation, QoL, and sexual function were investigated by using the Vaginal Maturation Index (VMI), Short Form-36 (SF-36) questionnaire, and Female Sexual Function Index (FSFI) questionnaire at baseline (T0), before surgery (T1), and 8 weeks after surgery (T2), respectively.

RESULTS

Thirty-six women from group A and 44 women from group B completed the study. The VMI improved in group A at T1 (T1 [43.1] vs T0 [38.1]; P = 0.04) and T2 (T2 [47.8] vs T0 [38.1]; P = 0.001). The physical index score of the QoL improved only after surgery in group A (T2 [49.4] vs T0 [39.7]; P = 0.001). On the contrary, the mental index score improved at T1 [T1 (41.9) vs T0 (37.9), (P = 0.02)] and at T2 [T2 (49.6) vs T0 (37.9), P = 0.001]. Group B had improvement of the physical (45.6 vs 39.4; P = 0.001) and mental (43.6 vs 38.9; P = 0.002) index scores at T2. Sexual function improved in group A at T1 (13.9 vs 18.6; P = 0.001) and at T2 (13.9 vs 25.2; P = 0.001), and in group B at T2 (14 vs 17.2; P = 0.001). Moreover, it improved after TOT placement more in group A than in group B (P = 0.001).

CONCLUSIONS

Ultralow-dose topical vaginal ovules containing 0.03 mg estriol administrated before and after TOT placement could improve the vaginal epithelium maturation of postmenopausal women affected by SUI. Moreover, vaginal estriol ovules also improved the surgical outcome investigated by SF-36 and FSFI.

Sexual function and quality of life of patients affected by ovarian cancer

INTRODUCTION

The sexual function (SF) in patients affected by malignancies represents an important aspect influencing the quality of life (QoL). The most frequent symptoms reported are the decreased sexual desire, dyspareunia, and/or problems with arousal or achieving orgasm. The present study is aimed at analyzing the available scientific evidence regarding the QoL and especially SF of patients affected by ovarian cancer who underwent surgical and medical treatment.

EVIDENCE ACQUISITION

A preliminary research was conducted using Pubmed database with specific keywords combinations regarding SF, QoL and ovarian cancer. The principal findings considered in the present review were: the study design, the number of patients included in each study, the information about the malignancy (histology and stage of disease), the questionnaires administered and the principal findings concerning SF and QoL.

EVIDENCE SYNTESIS

The studies selected were 5 prospective series and 3 case control cross-sectional studies. The scores used were focused on SF, QOL, fatigue and psychological aspects. All studies reported a decreased SF and QOL. Different factors coexist in the influence on outcomes such as physical, hormonal, psychological, self body image, and mechanic outcomes.

CONCLUSIONS

SF represents a fundamental aspect strictly related with QoL. Patients with ovarian cancer (as well all oncological patients) experience a reduction in their SF after diagnosis of malignancy and they should receive adequate counseling regarding this aspect.

Senhance robotic platform for gynecologic surgery: a review of literature

The advantages of endoscopic procedures are well demonstrated in various surgical procedures. In this field, the technological improvement has been significant. One of the most relevant was made by the introduction of robotic surgery that, thanks to the instruments articulation and the precision of movement, made possible to perform even the most complex procedures. The terms "Alf-X" OR "Senhance" OR "robot" OR "robotic" were systematically used to search the PubMed and Scopus databases. The principal findings considered in the present review were: the study design, the number of patients included in each study, operative time, estimated blood loss (EBL), conversion rate to standard laparoscopy (SLPS) or laparotomy (LPT), post-operative complications, post-operative hospital stay, and the possible advantages and disadvantages reported by the authors of the studies. A total of eight studies were considered eligible for the present review. The average operative time for TH reported was 110-140 min. In two case-control studies, the operative time was significantly prolonged (P < 0.05) for robotic procedures when compared with SLPS. The EBL was ≤ 100 ml in all studies. Whereas no statistically significant differences were shown in the two case-control studies in terms of conversion to LPT, all studies were in accordance with the post-operative hospital stay, reporting an average of 2 days for total hysterectomy and 1 day for adnexal surgery.

Hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal malignancies using new hybrid CO2 system: preliminary experience in referral center

The most frequent peritoneal surface malignancies originate principally by gastric cancer, colorectal cancer and ovarian cancer. Apart from the origin, peritoneal carcinosis (PC) is considered a negative prognostic factor. The hyperthermic intraoperative intraperitoneal chemotherapy (HIPEC) in the treatment of peritoneal malignancies is considered an attractive method to deliver chemotherapy with enhanced effect directly at the tumor site. The use of such loco-regional approach has proved to improve prognosis of peritoneal carcinomatosis from different origins. Recently, new devices are suitable for loco-regional intraperitoneal chemotherapy as Peritoneal Recirculation System (PRS-1.0 Combat) with CO₂ technology. This is a retrospective study with the aim to assess the perioperative outcomes using PRS. Seventeen patients were enrolled affected by colorectal or ovarian cancer. Complete cytoreduction (RT = 0) was achieved for all cases. Median operative time was 420 min (range: 335-665) and median drugs dose used for HIPEC was 137 mg/m2 (115-756). Median EBL was 200 ml (range 50-1000). Median post-operative hospital stay was 9 days (range: 4-24). Treatment-related early complications were recorded in 8 (47.0%) cases and were G1-G2 Major complications occurred in two (11.7%) cases. Considering our aim to test the PRS in different cases and in different pathologies, the results confirmed that the technique is feasible with good perioperative outcomes.

A novel HIPEC technique using hybrid CO2 recirculation system: intra-abdominal diffusion test in a porcine model

The role of loco-regional treatment of peritoneal carcinomatosis using intraperitoneal chemotherapy is still investigated. Actually, new technologies are suitable for these procedures, especially a new hybrid system using CO₂ called Peritoneal Recirculation System (PRS-1.0 Combat). A HIPEC procedure in a porcine model using the PRS system was conducted. The objective of experimentation was to assess the distribution of liquid inside the abdomen, by using methylene blue instead of chemotherapy. Moreover, we positioned six different thermal probes in different abdominal regions inside the abdomen to measure the temperature during procedure. During the procedure, all thermal probes recorded an average temperature of 41.5°. At the end of infusion, the abdomen was emptied and then opened; the tracer distribution was recorded. No technical problems were recorded during the procedure. Good distribution of tracer was recorded. More studies are needed to investigate better this new technology.

Determinants of pelvic organ prolapse among gynecologic patients in Bahir Dar, North West Ethiopia: a case-control study

Introduction

Pelvic organ prolapse (POP) is a significant public health problem in developing countries including Ethiopia. However, less has been documented on risk factors of POP. Therefore, the aim of this study was to identify the determinants factors of POP.

Methods

An unmatched case–control study was conducted among gynecologic patients in Bahir Dar city, North West Ethiopia, from July to October 2014. A total of 370 women (selected from outpatient departments) were included in the study. Cases (clients with stage III or IV POP) and controls (who declared free of any stages of POP) were identified by physicians using the Pelvic Organ Prolapse Quantitative Examination tool. Data analysis was carried out by SPSS version 20.0. Descriptive, bivariate, and multivariable logistic regression analyses were performed. Statistical differences were considered at P<0.05, and the strength of association was assessed by odds ratio (OR) and respective confidence intervals (CIs).

Results

This study revealed that determinants such as age of women (>40 years) (adjusted OR [AOR] =3.0 [95% CI: 1.59–5.89]), sphincter damage (AOR =8.1 [95% CI: 1.67–39.7]), family history of POP (AOR =4.9 [95% CI: 1.94–12.63]), parity (≥4) (AOR =4.5 [95% CI: 2.26–9.10]), nonattendance of formal education (AOR =4.3 [95% CI: 1.25–14.8]), carrying heavy objects (AOR =3.1 [95% CI: 1.56–6.30]), body mass index (BMI) <18.5 kg/m² (AOR =3.1 [95% CI: 1.22–7.82]), and delivery assisted by nonhealth professionals (AOR =2.6 [95% CI: 1.24–5.56]) were significantly associated with POP.

Conclusion

In our study, sphincter damage, family history of POP, being uneducated, having ≥4 vaginal deliveries, carrying heavy objects, BMI <18.5 kg/m², age ≥40 years, and having delivery assisted by nonhealth professional were the independent determinants of POP. Therefore, skilled delivery, further promoting family planning and girls’ education, early pelvic floor assessment, and counseling on avoidance of carrying heavy objects are recommended.