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Micić J, Macura M, Andjić M, Ivanović K, Dotlić J, Micić DD, Arsenijević V, Stojnić J, Bila J, Babić S, Šljivančanin U, Stanišić DM, Dokić M. Currently Available Treatment Modalities for Uterine Fibroids. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:868. [PMID: 38929485 PMCID: PMC11205795 DOI: 10.3390/medicina60060868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 05/04/2024] [Accepted: 05/21/2024] [Indexed: 06/28/2024]
Abstract
Uterine fibroids (leiomyomas and myomas) are the most common benign gynecological condition in patients presenting with abnormal uterine bleeding, pelvic masses causing pressure or pain, infertility and obstetric complications. Almost a third of women with fibroids need treatment due to symptoms. OBJECTIVES In this review we present all currently available treatment modalities for uterine fibroids. METHODS An extensive search for the available data regarding surgical, medical and other treatment options for uterine fibroids was conducted. REVIEW Nowadays, treatment for fibroids is intended to control symptoms while preserving future fertility. The choice of treatment depends on the patient's age and fertility and the number, size and location of the fibroids. Current management strategies mainly involve surgical interventions (hysterectomy and myomectomy hysteroscopy, laparoscopy or laparotomy). Other surgical and non-surgical minimally invasive techniques include interventions performed under radiologic or ultrasound guidance (uterine artery embolization and occlusion, myolysis, magnetic resonance-guided focused ultrasound surgery, radiofrequency ablation of fibroids and endometrial ablation). Medical treatment options for fibroids are still restricted and available medications (progestogens, combined oral contraceptives andgonadotropin-releasing hormone agonists and antagonists) are generally used for short-term treatment of fibroid-induced bleeding. Recently, it was shown that SPRMs could be administered intermittently long-term with good results on bleeding and fibroid size reduction. Novel medical treatments are still under investigation but with promising results. CONCLUSIONS Treatment of fibroids must be individualized based on the presence and severity of symptoms and the patient's desire for definitive treatment or fertility preservation.
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Affiliation(s)
- Jelena Micić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
| | - Maja Macura
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
| | - Mladen Andjić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
| | - Katarina Ivanović
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
| | - Jelena Dotlić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
| | - Dušan D. Micić
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
- Clinic of Emergency Surgery, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Vladimir Arsenijević
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
- Clinic of Emergency Surgery, Emergency Center, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Jelena Stojnić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
| | - Jovan Bila
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
| | - Sandra Babić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
| | - Una Šljivančanin
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
| | - Danka Mostić Stanišić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
| | - Milan Dokić
- Clinic of Gynecology and Obstetrics, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (J.M.); (M.M.); (M.A.); (K.I.); (J.D.); (J.S.); (J.B.); (S.B.); (U.Š.); (D.M.S.)
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia; (D.D.M.); (V.A.)
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Evangelisti G, Ferrero S, Perrone U, Gustavino C, Volpi E, Izzotti A, Barra F. Experimental and new investigational drugs for the treatment of uterine fibroids. Expert Opin Investig Drugs 2024; 33:497-508. [PMID: 38618931 DOI: 10.1080/13543784.2024.2343786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 04/12/2024] [Indexed: 04/16/2024]
Abstract
INTRODUCTION Uterine fibroids, the most prevalent benign tumors among reproductive-age women, pose treatment challenges that range from surgical interventions to medical therapies for symptom control. Progestins and estroprogestins effectively manage uterine bleeding by suppressing dysfunctional endometrium over fibroids. While GnRH agonists represent a crucial milestone in symptom treatment, their prolonged use results in menopausal-like symptoms and irreversible bone mineral density loss. Advancements in understanding fibroid pathophysiology have prompted the exploration of new compounds to overcome current therapy limitations. AREAS COVERED This manuscript offers an updated overview of investigational drugs for symptomatic uterine fibroids. EXPERT OPINION Despite ulipristal acetate's well-established efficacy as a selective progesterone receptor modulator (SPRM) in fibroid treatment, its prescription has declined due to the rare but severe risk of liver damage. Oral GnRH antagonists, like elagolix, relugolix, and linzagolix, with their novel pharmacodynamic properties, are gaining traction in fibroid management, inducing a dose-dependent reduction in circulating sex hormone levels. Ongoing research on natural compounds, such as vitamin D and epigallocatechin gallate (EGCG), presents emerging options for treating uterine fibroids. This evolving landscape reflects the ongoing efforts to improve therapeutic outcomes for individuals with symptomatic uterine fibroids.
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Affiliation(s)
- Giulio Evangelisti
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
| | - Simone Ferrero
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Umberto Perrone
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DiNOGMI), University of Genoa, Genoa, Italy
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Claudio Gustavino
- Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Eugenio Volpi
- Unit of Obstetrics and Gynecology, San Paolo Hospital - ASL2, Savona, Italy
| | - Alberto Izzotti
- Unit of Mutagenesis and Cancer Prevention, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Experimental Medicine (DIMES), University of Genoa, Genoa, Italy
| | - Fabio Barra
- Unit of Obstetrics and Gynecology, P.O. "Ospedale del Tigullio"- ASL4, Chiavari, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Evangelisti G, Barra F, Perrone U, Di Donato N, Bogliolo S, Ceccaroni M, Ferrero S. Comparing the pharmacokinetic and pharmacodynamic qualities of current and future therapies for uterine fibroids. Expert Opin Drug Metab Toxicol 2022; 18:441-457. [DOI: 10.1080/17425255.2022.2113381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Umberto Perrone
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Nadine Di Donato
- Southern Endometriosis Centre, Queen Alexandra Hospital, Portsmouth, UK
| | - Stefano Bogliolo
- Department of Obstetrics and Gynecology, “P.O del Tigullio” Hospital-ASL4, Metropolitan Area of Genoa, Genoa, Italy
| | - Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecology Oncology and Minimally-Invasive Pelvic Surgery, International School of Surgical Anatomy (ISSA), IRCCS Ospedale Sacro Cuore - Don Calabria, Via Don A. Sempreboni, 5, 37024, Negrar (Verona), Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Moawad NS, Palin H. Hysteroscopic Myomectomy. Obstet Gynecol Clin North Am 2022; 49:329-353. [DOI: 10.1016/j.ogc.2022.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Loddo A, Djokovic D, Drizi A, De Vree BP, Sedrati A, van Herendael BJ. Hysteroscopic myomectomy: The guidelines of the International Society for Gynecologic Endoscopy (ISGE). Eur J Obstet Gynecol Reprod Biol 2021; 268:121-128. [PMID: 34902749 DOI: 10.1016/j.ejogrb.2021.11.434] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/11/2021] [Accepted: 11/27/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE With this publication, the International Society for Gynecologic Endoscopy (ISGE) aims to provide the clinicians with the recommendations arising from the best evidence currently available on hysteroscopic myomectomy (HM). STUDY DESIGN The ISGE Task Force for HM defined key clinical questions, which led the search of Medline/PubMed and the Cochrane Database. We selected and analyzed relevant English-language articles, published from January 2005 to June 2021, including original works, reviews and the guidelines previously published by the European Society for Gynecological Endoscopy (ESGE) and the American Association of Gynecologic Laparoscopists (AAGL), in which bibliographies were also checked in order to identify additional references, using the medical subject heading (MeSH) term "Uterine Myomectomy" (MeSH Unique ID: D063186) in combination with ''Myoma" (MeSH Unique ID: D009214) and ''Hysteroscopy" (MeSH Unique ID: D015907). We developed the recommendations through multiple cycles of literature analysis and expert discussion. RESULTS The ISGE Task Force did develop 10 grade 1A-C and 4 grade 2A-C recommendations. For planning HM, evaluation of the uterus with saline infusion sonohysterography (SIS) or combined assessment by transvaginal ultrasound (TVUS) and diagnostic hysteroscopy is recommended (Grade 1A). The use of STEPW (Size, Topography, Extension of the base, Penetration and lateral Wall position) classification system of submucosal leiomyoma (LM) is recommended to predict the complex surgeries, incomplete removal of the LM, long operative time, fluid overload and other major complications (grade 1B). For type 0 LMs, in addition to resectoscopy (slicing technique), morcellation is recommended, being faster and having a shorter learning curve with respect to resectoscopy (grade 1C). For type 1-2 LMs, slicing technique is currently recommended (grade 1C). A fluid deficit of 1000 mL also in case of bipolar myomectomy with saline solution, in healthy women of reproductive age, contains low risk for major complications. Lower thresholds (750 mL) for fluid deficit should be considered in the elderly and in women with cardiovascular, renal or other co-morbidities (Grade 1B). CONCLUSION HM is the most effective conservative minimally invasive gynecologic intervention for submucous LM. The set of 14 ISGE recommendations can significantly contribute to the success of HM and the safety of patients for whom the choice of appropriate surgical technique, as well as the surgeon's awareness and measures to prevent complications are of the utmost importance.
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Affiliation(s)
- Alessandro Loddo
- Clinica Ostetrica e Ginecologica Azienda Ospedaliero-Universitaria di Cagliari, Policlinico Duilio Casula, Monserrato, CA, Italy
| | - Dusan Djokovic
- Maternidade Dr. Alfredo da Costa, Centro Hospitalar Universitário Lisboa Central (CHULC), Lisbon, Portugal; Department of Obstetrics and Gynecology, NOVA Medical School - Faculdade de Ciências Médicas, NOVA University of Lisbon, Lisbon, Portugal; Department of Obstetrics and Gynecology, Hospital CUF Descobertas, Lisbon, Portugal
| | - Amal Drizi
- Independent Consultant in Obstetrics and Gynecology, Algiers, Algeria
| | - Bart Paul De Vree
- Department of Obstetrics & Gynecology, Ziekenhuis Netwerk Antwerpen (ZNA), Campus Middelheim, Antwerp, Belgium; Department of Obstetrics & Gynecology, Universitair Ziekenhuis Antwerpen (UZA), Edegem, Belgium
| | - Adel Sedrati
- Independent Consultant in Gynecology Obstetrics and Gynecology, Constantine, Algeria
| | - Bruno J van Herendael
- Endoscopic Training Center Antwerp (ETCA), Stuivenberg General Hospital, Ziekenhuis Netwerk Antwerpen (ZNA), Antwerp, Belgium; Università degli Studi dell'Insubria, Varese, Italy
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Capozzi VA, Rosati A, Rumolo V, Ferrari F, Gullo G, Karaman E, Karaaslan O, HacioĞlu L. Novelties of ultrasound imaging for endometrial cancer preoperative workup. Minerva Med 2020; 112:3-11. [PMID: 33205640 DOI: 10.23736/s0026-4806.20.07125-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Endometrial cancer (EC) is the most frequent gynecological cancer. Transvaginal ultrasound (TVU) plays a leading role in the preoperative workup and often is the first diagnostic instrumental examination. Despite expert hands' ultrasound is recommended to assess myometrial invasion in early stage EC, this method is a strictly operator-dependent examination, and varying degrees of sensitivity and specificity have been reported. The present review aims to provide an update of ultrasound imaging in the preoperative work-up for EC patients. EVIDENCE ACQUISITION A double-blind search was performed from May to September 2020. The following keywords: "ultrasound," "transvaginal ultrasound" and "endometrial cancer" were searched in Pubmed search engines, Scopus, and Web of Science. The Prisma statement was followed for the selection of the articles included. EVIDENCE SYNTHESIS The initial search provided 958 studies, of which 11 were included in the analysis. non-English articles, not relevant to the purposes of this study, case reports and articles with fewer than 40 cases were excluded. CONCLUSIONS TVU sensitivity and specificity in myometrial infiltration and cervical invasion is comparable to MRI but has lower costs, greater patient tolerability, and does not require contrast agents. An expert operator should perform the ultrasound examination in patients with suspected EC The presence of myometrial lesions, such as leiomyomas, could lower the diagnostic accuracy of ultrasound, so special attention should be paid to patients with concomitant uterine lesions.
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Affiliation(s)
- Vito A Capozzi
- Department of Gynecology and Obstetrics, University of Parma, Parma, Italy
| | - Andrea Rosati
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Valerio Rumolo
- Division of Gynecologic Oncology, Department of Women and Children's Health, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Federico Ferrari
- Department of Women's and Reproductive Health, University of Oxford, Headington, Oxford, UK
| | - Giuseppe Gullo
- Department of Obstetrics and Gynecology, AOOR Villa Sofia Cervello, IVF Public Center, Palermo, Italy
| | - Erbil Karaman
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey -
| | - Onur Karaaslan
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
| | - Latif HacioĞlu
- Department of Gynecology and Obstetrics, Faculty of Medicine, Yuzuncu Yil University, Van, Turkey
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Küpker W, Plathow D, Bullerdiek J, Felberbaum R. Neue Behandlungsoptionen mit GnRH-Antagonisten bei Endometriose und Uterus myomatosus. GYNAKOLOGISCHE ENDOKRINOLOGIE 2020. [DOI: 10.1007/s10304-020-00329-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Vitale SG, Riemma G, Ciebiera M, Cianci S. Hysteroscopic treatment of submucosal fibroids in perimenopausal women: when, why, and how? Climacteric 2020; 23:355-359. [DOI: 10.1080/13697137.2020.1754390] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- S. G. Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy
| | - G. Riemma
- Department of Woman, Child and General and Specialized Surgery, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
| | - M. Ciebiera
- Second Department of Obstetrics and Gynecology, The Center of Postgraduate Medical Education, Warsaw, Poland
| | - S. Cianci
- Department of Woman, Child and General and Specialized Surgery, University of Campania ‘Luigi Vanvitelli’, Naples, Italy
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Barra F, Vitale SG, Seca M, Scala C, Leone Roberti Maggiore U, Cianci A, Ferrero S. The potential role of elagolix for treating uterine bleeding associated to uterine myomas. Expert Opin Pharmacother 2020; 21:1419-1430. [PMID: 32401547 DOI: 10.1080/14656566.2020.1755254] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Uterine myomas represents a widespread gynecological disease of women in reproductive age. Although surgery remains the first choice for treating most patients, in the last years, new medical approaches have been considered in order to ameliorate heavy menstrual bleeding (HMB) related to their presence. Elagolix is a second-generation gonadotropin-releasing hormone (GnRH) antagonist under investigation for the long-term treatment of uterine myomas. AREAS COVERED The aim of this drug evaluation is to give a complete overview of pharmacokinetic and pharmacodynamic data on elagolix for treating HMB related to uterine myomas and to report the results of the current clinical trials in this setting. EXPERT OPINION In two previous phase II studies, this drug succeeded in ameliorating blood loss and quality of life of patients affected by uterine myomas with a good safety profile. Three phase III trials (ELARIS UF-I, UF-II, and EXTEND) investigated the efficacy, tolerability, and safety of elagolix at 300 mg twice daily with add-back therapy. The primary endpoint, consisting in the reduction in HMB compared to placebo, was met in the majority of patients under treatment. Currently, elagolix is under investigation in two other ongoing multicenter phase III clinical studies.
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Affiliation(s)
- Fabio Barra
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
| | - Salvatore Giovanni Vitale
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania , Catania, Italy
| | - Marta Seca
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
| | - Carolina Scala
- Unit of Obstetrics and Gynecology, Gaslini Institute , Genova, Italy
| | | | - Antonio Cianci
- Obstetrics and Gynecology Unit, Department of General Surgery and Medical Surgical Specialties, University of Catania , Catania, Italy
| | - Simone Ferrero
- Academic Unit of Obstetrics and Gynaecology, IRCCS Ospedale Policlinico San Martino , Genova, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova , Italy
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