Obstetric echodynamics: Approaching a new field of multidisciplinary action

Maternal cardiovascular adaptation during pregnancy is essential for fetal development. Structural and functional changes, including increased blood volume, heart rate, and myocardial hypertrophy, are crucial for optimal tissue perfusion. Recent evidence supports viewing maternal and fetal cardiovascular systems as a unified functional unit, emphasizing the significance of hemodynamic evaluation in pregnancy. Some obstetrical syndromes result from maladaptive maternal cardiovascular responses. Non-invasive hemodynamic tests, like transthoracic echocardiography, aid in distinguishing phenotypes, guiding tailored management strategies for hypertensive disorders. Establishing obstetric hemodynamics as a multidisciplinary field, termed "Obstetric Echodynamics," promises improved clinical care through standardized practices, interdisciplinary cooperation, and enhanced education.

Human Papillomavirus Same Genotype Persistence and Risk: A Systematic Review

OBJECTIVE

The aim of the study was to examine whether high-grade cervical intraepithelial neoplasia (CIN) was more closely associated with human papillomavirus (HPV) same-genotype persistence (SGTP) versus clearance of prior infection with a subsequent infection by a new genotype (genotype switch [GS]), clearance of HPV infection, or acquisition of a new HPV infection after a negative infection status, during a follow-up testing subsequent to abnormal screening results.

MATERIALS AND METHODS

MEDLINE, Cochrane Library, Health Technology Assessment, and clinicaltrials.gov were searched from January 2000 to July 2019 for prospective controlled trials and observational studies of women and retrospective studies using HPV assays with extended- or full-genotype reporting. The primary outcome was high-grade CIN after at least 2 rounds of testing. Overall quality of evidence for the risk estimate outcomes was assessed. Of the 830 identified abstracts, 66 full-text articles were reviewed, and 7 studies were included in the synthesis. The study protocol was registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42018091093).

RESULTS

Continued HPV-positive women falls in 2 equally large groups: SGTP and GS. Sensitivity, positive predictive value, and positive likelihood ratio of SGTP were significantly higher than for GS. Human papillomavirus genotypes may be ranked into 3 tiers (immediate colposcopy, follow-up testing, return to routine screening), according to associated risk of persistence for high-grade CIN and to prevailing clinical action thresholds.

CONCLUSIONS

There is moderately high-quality evidence to support the clinical utility of SGTP to improve risk discrimination for high-grade CIN compared with qualitative HPV testing without genotype-specific information.

Prophylactic vaccination against human papillomaviruses to prevent vulval and vaginal cancer and their precursors

Introduction: Safety and efficacy of prophylactic HPV vaccines against HPV infection and associated cervical cancers and precursors is well documented in the literature; however, their efficacy against vulval and vaginal endpoints has not been previously assessed.Areas covered: Published results of trials involving licensed HPV vaccines were included. Main efficacy outcomes were histologically confirmed high-grade vulval and vaginal precancer distinguishing those associated with vaccine HPV types and any vulval and vaginal precancerous lesions. Exposure groups included women aged 15-26 or 24-45 years being initially negative for high-risk HPV (hrHPV), negative for the HPV vaccine types, and women unselected by HPV status.Expert opinion: Our results show that the HPV vaccines are equally highly efficacious against vulval/vaginal disease as previously noted for cervical disease. The vaccines demonstrated excellent protection against high-grade vulval and vaginal lesions caused by vaccine-related HPV types among young women who were not initially infected with hrHPV types or types included in the vaccines (vaccine efficacies more than 90%). No protection against high-grade vulval and vaginal lesions associated with HPV16/18 was observed for mid-adult women. Trials were not powered to address protection against invasive cancers.

Multidisciplinary Management of Sexual Dysfunction, Perineal Pain, and Elimination Dysfunction in a Woman with Multiple Sclerosis

BACKGROUND

Multiple sclerosis (MS) is a chronic disease that commonly affects young women and is associated with sexual dysfunction (SD) and lower anourogenital dysfunction, which affect quality of life. We evaluated the importance of an integrated multidisciplinary approach in the Lower Female Ano-Uro-Genital Network (LFAUGN) to manage a variety of complex symptoms.

METHODS

A 40-year-old woman with MS and primary concerns about perineal pain and SD was treated by a trained midwife from the LFAUGN and a physical therapist after a multidisciplinary diagnostic process that included gynecologic evaluation for perineal pain and SD, physiatric assessment, urologic assessment for bladder retention (BR), and surgical examination for obstructed defecation syndrome (ODS). Physical therapy was integrated with pharmacologic therapy for ODS and with self-catheterization for BR.

RESULTS

After 5 months of treatment, the patient reported improvement in functional perineal parameters and perineal pain (visual analogue scale score: 9 at T1 vs. 5 at T2), with resolution of pelvic floor hypertonia. Furthermore, ODS and BR symptoms improved (5-item score: 18 of 20 at T1 vs. 10 of 20 at T2; 1 self-catheterization daily, with postvoid residual volume [PRV] <200 mL at T1 vs. 1 self-catheterization weekly, with PRV <100 mL at T2) and sexual satisfaction increased (Female Sexual Function Index score: 18 of 36 at T1 vs. 23 of 36 at T2).

CONCLUSIONS

These results suggest that physical therapy, as an integral component of a multidisciplinary approach in a multiprofessional network, may play a pivotal role in improving anourogenital dysfunction and sexual satisfaction.

Vulvar Intraepithelial Neoplasia (VIN) and Condylomata

Human papillomavirus (HPV) infection of the lower genital tract is common and its effects are variable. The majority of infections are transient and the related pathology is self-resolving. Condyloma accuminatum is caused predominantly by HPV 6, 11 and can be managed with medical or surgical therapy. Vulvar intraepithelial neoplasia is a treatable precursor to vulvar cancer with 2 main forms: one related to HPV and the other to chronic vulvar inflammatory conditions. It may be treated medically, surgically, or potentially via the use of therapeutic HPV vaccines. Preventive utilization of a quadrivalent HPV vaccine has the potential to decrease HPV-related lower genital disease burden substantially.

Role of the Physical Therapy in the Multidisciplinary Approach to Vulvodynia: preliminary results

Objectives: In the clinical practice different specialists approach to the women with vulvar pain, often without an integrated care pathway. Recently, musculoskeletal factors have been recognized as contributors of the mechanism of vulvodynia. The objective of this study is to evaluate the role of the physical therapy as a first line treatment multidisciplinary in vulvodynia management. Methods: Between October 2013 to October 2014, 14 women with vulvar pain (according to ISSVD Vulvodynia 2003 Classification) referred to the Lower Female Genital Tract Outpatient Service of our Hospitals. Every woman was submitted to a Physical Therapy Pathway, managed by a trained midwife and composed by manual therapy and pelvic floor exercises. The efficacy of Physical therapy was assessed by adopting VAS score. Results: After 4 months-treatment, 9 patients reported an improvement in vulvar and sexual pain with good relief (reduction of 2-3 points VAS score). Two patients lost to follow up. Three patients referred any significantly effect Conclusions: Vulvodynia is a complex syndrome associated to sexual dysfunctions and worstening of quality of life. According to our preliminary results, Physical Therapy may play a pivotal role, in an integral component of the multidisciplinary approach.

Considering the implication of variations within Delphi research

Delphi research is an increasingly popular method within medical, social and psychological research. It tends to be employed where established theory or knowledge are lacking but where 'experts' are thought to hold relevant information. It consists of developing and administering sequential questionnaires that seek to move towards a position of relative consensus. Although the original authors of the technique established a specific method, the literature reveals modifications in the way this is applied. Variations include (i) restricting the ability of experts to respond to the original question, (ii) changing or varying the expert groups used and (iii) the point at which the research ends. This paper provides an overview of the technique and explains these variations and their implications before highlighting possible ways forward.

Vulvoscopy: review of a diagnostic approach requiring clarification

The objective of this review is to clarify what, if any, role there is for colorimetric (acetic acid and toluidine blue) testing and colposcopic examination of the vulva by reviewing the literature regarding use of the colposcope and colorimetric tests in the diagnosis of vulvar disorders. The lack of established usefulness of colposcopic observation for common dermatologic entities affecting the vulva markedly reduces the need for the colposcopist's skills in dealing with disorders of the vulva. Conversely, vulvar, as opposed to cervical, disorders place more emphasis on a gynecologist's knowledge and experience with dermatologic disease. The use of the colposcope and acetic acid, toluidine blue or both adds little or nothing to "naked-eye" examination of the vulva. The term vulvoscopy is appropriate and useful because it is easy to comprehend. However, vulvoscopy should be defined as a composite diagnostic act composed of careful naked-eye and low-power magnified examination carried out by those with interdisciplinary skills, such as vulvologists.

Vulvodynia as a possible somatization disorder. More than just an opinion

Vulvodynia, defined as vulvar pain, soreness or burning as opposed to pruritus, is a common and important problem. Despite its high prevalence and associated distress, the etiology, diagnosis and management of this disorder have not been clearly delineated. On the basis of recent advances in psychosomatic medicine, vulvodynia can be considered a somatiform disorder affecting the vulva. Psychosomatic assessment is useful in patients with vulvodynia. This review covered recent advances in psychosomatic medicine with reference to somatization disorders and their application to vulvodynia. According to the literature, vulvodynia shares some basic criteria by which functional pain disturbances are defined. Thus, all patients with vulvodynia should undergo psychologic and sexual evaluation since in some instances psychotherapy may offer the only successful approach to the alleviation of vulvar pain.

2006 ISSVD classification of vulvar dermatoses: pathologic subsets and their clinical correlates

The International Society for the Study of Vulvovaginal Disease (ISSVD) has, as one of its major societal goals, the development and promulgation of nomenclature and classification of vulvar disease. A committee of the ISSVD has developed new nomenclature and classification for the specific area of vulvar dermatoses. This classification was approved by the ISSVD members at the most recent international congress, held in New Zealand in February 2006.

Primary "breast-like" cancer of the vulva: a case report and critical review of the literature

Ectopic mammary gland tissue in the vulva is an uncommon clinical or pathologic finding. Such ectopic tissue can be the site of the same physiologic and pathologic processes found in the normal breast. However, the occurrence of adenocarcinoma is very rare, the first case being reported by Greene in 1935. We here report the 16th case of primary "breast-like" cancer arising in the vulva, together with a critical review of the literature, in order to highlight the dilemmas of a clinical approach to this neoplasm. Clear guidelines for diagnosis and therapy are still unavailable. The main diagnostic criteria suggested by the authors of previous reports are discussed together with our own findings. The therapeutic approach to this rare malignancy is also critically reviewed. In our opinion, when diagnosis of breast-like vulvar cancer is finally confirmed, treatment and follow-up should be the same as that would be chosen in a case of orthotopic breast neoplasm.

Primary “breast-like” cancer of the vulva: a case report and critical review of the literature

Ectopic mammary gland tissue in the vulva is an uncommon clinical or pathologic finding. Such ectopic tissue can be the site of the same physiologic and pathologic processes found in the normal breast. However, the occurrence of adenocarcinoma is very rare, the first case being reported by Greene in 1935. We here report the 16th case of primary “breast-like” cancer arising in the vulva, together with a critical review of the literature, in order to highlight the dilemmas of a clinical approach to this neoplasm. Clear guidelines for diagnosis and therapy are still unavailable. The main diagnostic criteria suggested by the authors of previous reports are discussed together with our own findings. The therapeutic approach to this rare malignancy is also critically reviewed. In our opinion, when diagnosis of breast-like vulvar cancer is finally confirmed, treatment and follow-up should be the same as that would be chosen in a case of orthotopic breast neoplasm.

Groin lymphadenectomy with Preservation of Femoral Fascia: Total Inguinofemoral Node Dissection for Treatment of Vulvar Carcinoma

This article describes a new technique for groin lymphadenectomy with preservation of the femoral fascia based on correct embryologic and anatomic knowledge of inguinofemoral lymph node disposition and their exact relation with the fascial structures of Scarpa's triangle. Scarpa's triangle dissection follows a three-step procedure: development of the side starting from the inguinal ligament; development of the angles proceeding from the apex where the saphenous vein is resected; and dissection of the fossa ovalis by grasping and elevating the entire block of adipose tissue containing the superficial inguinofemoral nodes and the stump of the great saphenous vein. This surgical step allows us to expose and remove en bloc the deep femoral nodes lying medial to the portion of the femoral vein located within the fossa ovalis. The total number of inguinofemoral nodes removed from a series of 156 patients operated on during 1981-2002 ranged from 8 to 35 (mean 20) bilaterally and from 4 to 18 (mean 10) unilaterally. The 5-year survivals by stage were, respectively, 86.2% for stage Ib, 69.2% for stage II, 49.3% for stage III, and 13.3% for stage IVa; these figures are comparable to the survival rates reported by those performing the classic groin lymphadenectomy. Groin lymphadenectomy with preservation of the femoral fascia is thus an oncologically sound conservative procedure that can replace the classic Way's technique, which involves femoral vessel skeletonization, and can be useful for treating malignant diseases requiring groin dissection.

Vulvology. A proposal for a multidisciplinary subspecialty

OBJECTIVE

To underline the usefulness of a new multidisciplinary subspecialty devoted entirely to vulvar diseases, to be termed vulvology.

STUDY DESIGN

Disorders of the vulva present a wide spectrum of clinical appearance, rendering clinical diagnosis difficult, if not impossible. The three types of physicians usually involved in treating the vulva (generalists, dermatologists and gynecologists) receive little training in and have little experience with vulvar problems. The end result is that women today are receiving far less than optimal care for vulvar disorders.

RESULTS

This situation can be much improved through the establishment of vulvology as a new multidisciplinary subspecialty. Vulvology can become a neutral field for research and debate and can provide a point of consolidation for all clinical care (infectious, metabolic, oncologic, neurologic, psychological, etc.) of vulvar disorders. The interdisciplinary nature of this new subspecialty will also facilitate the standardization and systematization of the currently confusing terminology and classification applicable to vulvar disorders.

CONCLUSION

Vulvology, as a new, well-defined, multidisciplinary subspecialty, will improve the care of women with vulvar problems through the delineation of vulvologists as physicians with special expertise in this area, the establishment of clinics devoted specifically to the care of vulvar problems and the provision of education for physicians, other health care providers and the public.

Rationale and definition of the lateral extension of the inguinal lymphadenectomy for vulvar cancer derived from an embryological and anatomical study

BACKGROUND AND OBJECTIVES

The objective of the present study was to define the location of the most lateral superficial inguinal node lying along the inguinal ligament, through an embryological and anatomotopographical study, in order to rationalize the lateral extension of the groin lymphadenectomy in vulvar cancer.

METHODS

Sections of the upper portion of the femoral triangle belonging to three human fetuses, whose crown-rump (CR) length ranged from 70 to 310 mm, corresponding to a developmental age of 11 and 35 weeks, were studied. In addition, for an objective topographical evaluation of the disposition of the superficial inguinal lymph nodes, adult cadavers photographs of dissected Scarpa's triangle, reported in anatomical atlases, were analyzed.

RESULTS

Both the embryological investigation and the anatomotopographical evaluation on cadavers photographs demonstrate that the most lateral superficial inguinal lymph node does not rise above the medial margin of the sartorius muscle, nor far lateral to the point where the superficial circumflex iliac vessels cross the inguinal ligament.

CONCLUSIONS

On the basis of the present study, the authors believe that the superficial circumflex iliac vessels could represent the lateral surgical landmark, easily detectable, at which the inguinal lymphadenectomy should cease. Therefore, there is no need to extend the lateral excision to the anterior superior iliac spine. Finally, leaving the fatty tissue laterally to these vessels, some lymphatic channels could be preserved, decreasing the incidence and the entity of wound seroma and lymphedema.

Relationships between gastric development and anatomic bases of radical surgery for cancer

The aim of this study was to determine with all possible accuracy the processes of embryologic development of the stomach and its lymphatics in order to confirm their supposed link with the modern anatomic bases of gastric cancer surgery. The knowledge of the anatomic behavior of the peritoneal folds and of the lymphatic drainage of the stomach is, in fact, considered the essential basis for the comprehension of the oncologic dissection of the stomach. The study was based on reconstruction of serial histologic sections of 9 human embryos and 8 human fetuses regarding the mesogastric area, as well as anatomic microdissection of 2 9-month fetuses. The proximal part of the stomach is not involved in the rotation mechanism of the other portions; the lesser sac development follows cranial migration of the spleen; the cardiac (pars cardiaca gastris) area is in continuity with the zone of paraaortic lymph node development; lateral and posterior lymph nodes of the hepatoduodenal ligament do not take origin in the dorsal mesogastrium: they develop together with the common bile duct and the ventral pancreas inside the mesoduodenum; the fusion of the dorsal mesogastrium and the gastric fundus with the posterior abdominal wall appears late in development. The embryologic study of the mesogastric area clarifies the real mechanism of development of the stomach and its lymphatic pathways with some differences from classic reports; these results agree with the more recent modification of the lymph nodes classification used in the radical treatment of gastric cancer.

[Vestibular papillomatosis]

The aim of the present study is to re-update the clinical significance of vestibular papillomatosis. At the beginning of the eighties this condition has been related to HPV infection based on histological and/or molecular evidence of the virus presence and considered responsible of many cases of pruritus and/or vulvodynia. Based upon these findings a lot of clinicians have been treating this condition by laser ablation or by topical application of podophyllin or trichloroacetic acid. At present the majority of the authors believes that vestibular papillomatosis should be considered an anatomical variant of the vestibular mucosa not HPV related. Therefore HPV-DNA presence should be considered a causal rather than a causal agent. This evidence is important in defining the management of vestibular papillomatosis: the papillae are usually distinguishable from condylomata acuminata by clinical examination and biopsies or HPV testing are not necessary. According to the studies considering vestibular papillomatosis a non HPV related condition and on the bases of a series of 252 women examined, the Authors share the opinion that this clinical entity should be considered a normal vestibular findings. As a consequence no ablative treatment is usually required even if in presence of symptomatology or HPV molecular infection.

[Vulvar lesions caused by HPV]

Human papillomavirus subclinical lesions are well known on the cervix and are identified by colposcopy after acetic acid staining. The transfer of this technique from the cervix to the vulva has led to the identification of areas of white epithelial changes which have been defined by similarity as vulvar subclinical HPV (VSHPV) lesions. A critical revision of the different clinical VSHPV lesions classifications, the vulvar diagnostic role of acetic acid staining, the natural history of HPV infection and the histological-biomolecular diagnostic techniques has the authors to the conclusions that the majority of the "so called" VSHPV lesions should not be considered a real disease. The presence of HPV-DNA in these subclinical lesions should be considered causal and not causal. To avoid overtreatments in women with proven HPV-DNA positivity without macroscopic clinical lesions, the authors recommend to abandon the acetic acid staining on the vulva and invite to consider the VSHPV lesions a faked diagnosis and not a clinical entity.

A proposed glossary of terminology related to the surgical treatment of vulvar carcinoma

BACKGROUND

The authors' objective was to provide a glossary of terminology related to the surgical treatment of invasive vulvar carcinoma. There is currently no consensus in the literature regarding the names of the surgical procedures used to treat this disease.

METHODS

A surgical glossary should be supported by clear definitions and acceptance of notions related to topographic anatomy that are specific to the surgical practice. A critical review of the classic, chiefly used Italian, French, German, and English textbooks of anatomy revealed some discrepancies and lack of uniformity in descriptions of vulvar and inguinal fascial structures and lymph nodes, which represent the principal landmarks of surgical treatment. In the proposed glossary, the descriptions of these anatomic landmarks integrate classic anatomic knowledge, data from recent gynecologic studies of inguinal anatomy, and the clinical experiences of the authors.

RESULTS

The glossary is composed of 16 surgical definitions, which are divided into 3 main sections of terminology describing the surgical treatment of the: 1) vulva, 2) inguinal lymph nodes, and 3) pelvic lymph nodes. The fundamental objective behind the glossary is to describe the area and the depth of the surgical procedure. Three determinants of the area (local, partial, and total) and three determinants of the depth of surgery (superficial, simple, and deep) were used to arrive at the fully articulated definitions in the glossary.

CONCLUSIONS

The authors are aware that the proposed glossary should not be considered a definitive one; however, it could serve as a good basis for further debate. The terms employed in the glossary are accompanied by anatomic and descriptive references to help avoid confusion and promote better understanding among gynecologic oncologists who are involved in the treatment of vulvar carcinoma.

Anatomosurgical implications derived from an embryological study of the Scarpa's triangle with particular reference to groin lymphadenectomy

OBJECTIVE

To clarify some anatomical controversies of the fascial structures and lymph node development of the inguinal region through an embryological study in relation to the surgical techniques of groin lymphadenectomy.

METHODS

Sections of the femoral triangle belonging to four fetuses whose crown-rump (CR) length ranged from 70 to 310 mm, corresponding to a developmental age of 11 and 35 weeks, were studied.

RESULTS

The femoral fascia is formed of one layer and is not divided into superficial and deep layers. The cribriform fascia has a morphogenetic origin different from that of the femoral fascia and it is defined by the thickening of the connective tissue filling the fossa ovalis and therefore would be more correctly named lamina cribrosa. The deep inguinal lymph nodes originate directly from the superficial lymphatic tissue located in the fossa ovalis. This last observation supports the fact that no lymph nodes are present beneath the femoral fascia distal to the lower margin of the fossa ovalis.

CONCLUSIONS

The results of this study, from a surgical point of view, support the technique of total or radical inguinal-femoral lymphadenectomy with preservation of the femoral fascia and, from an anatomical point of view, resolve some of the contradictory statements reported in the anatomical literature regarding morphogenesis and terminology of the structures of the Scarpa's triangle. In addition, the present study provides useful anatomic and terminological landmarks to those surgical oncologists (gynecologist, urologist, dermatologist, etc.) dealing with malignant diseases requiring groin dissection practices. In addition, it could represent a useful background for a future more precise surgical terminology which represents a vital issue for institutional studies with multiple surgeons as well as for large multi-institutional studies.

Observations on surgical anatomy for rectal cancer surgery

BACKGROUND/AIMS

The investigators studied the surgical anatomy of the main structures involved in the mobilization of the rectum (Denonvilliers' fascia, mesorectum, middle rectal artery, superior and inferior hypogastric plexuses).

METHODOLOGY

The study was carried out on 20 cadavers (17 unembalmed and 3 embalmed). To study Denonvilliers' fascia, ten embryos and fetuses (11 mm to 80 mm CRL) were also examined.

RESULTS

Denonvilliers' fascia originates from the fusion of the primary pouch of Douglas. The two leaves making up this structure are easily separated. The mesorectum surrounds the rectum on three sides; it is easily separated from the presacral fascia and its connective tissue is bordered by a thin membrane. The middle rectal artery varies in appearance rate, origin, size, distribution and anastomosis. It runs under the lateral ligament and also sends branches to the genital apparatus. Of the two hypogastric plexuses, the inferior is the most difficult one to identify. Its superior branches extend to the rectum, and the inferior ones to the genital apparatus. Because the anterior part contains the parasympathetic nerves and the middle rectal artery, this region is at major risk during surgical dissection.

CONCLUSIONS

A sound understanding of the surgical anatomy of the rectum enables the surgeon to perform a more correct and reasonable procedure in terms of both the extent of surgical treatment and the preservation of important anatomical structures.

Embryologic bases of extended radical resection in pancreatic cancer

OBJECTIVE

To analyze whether an embryologic "rationale" exists to the clinical and anatomicopathological data that suggest the execution of extended resections in patients with pancreatic cancer.

METHODS

Reconstruction of serial histological sections of 18 human embryos and fetuses regarding the pancreatic region; anatomical microdissections of two 9-month fetuses.

RESULTS

The ventral and dorsal pancreatic buds can be identified until the eighth week of development. A close developmental relationship between the dorsal pancreas and the lymphatic and nervous structures in the dorsal mesogastrium is observed. Other lymphatic stations are exclusively related to the ventral pancreas. The posterior fusion of the dorsal mesogastrium is a late event in embryologic development.

CONCLUSIONS

The complete fusion of the 2 pancreatic buds occurs later than previously reported in the literature. The close embryologic relations of these buds with the lymphatic and nervous peripancreatic structures may support the need for extended resections in patients with pancreatic cancer.