Minerva obstetrics and gynecology最新文献

Background: The primary purpose of this study was to verify if trabecular bone score (TBS) might fit with the changes of bone mineral density (BMD) confirming as a reliable marker of bone fragility.

Methods: A retrospective observational study on 898 Italian women (aged 40-90 years) was conducted between January 2021 and February 2023. All recruited women were divided into two main groups according to TBS (Group A: TBS ≥1.31; Group B: TBS<1.31) and, further, in five subgroups according to age.

Results: According to univariate ANOVA, there was not significant difference of BMI between group A and group B but Bonferroni Test found that BMI significantly differed for age subgroups and TBS value (P<0.05). ANOVA analysis reported that mean L1-L4 BMD and/or T-score were significantly different for age and TBS (P=0.000); Bonferroni Test found that L1-L4 BMD significantly differed in the comparison of age subgroups for Group A and Group B (P<0.05). Besides, Bonferroni analysis found significant differences regarding total and neck femoral BMD and/or T-score in the comparison between age subgroups for group A and group B (P<0.05). As for neck femoral BMD and T-score, all significances were observed for group B in the comparison between subgroups aged over 60 years and others (P<0.05). Multivariate logistic regression analysis showed that age and femoral neck BMD significantly contribute to TBS (P<0.05).

Conclusions: Our results seem to suggest that low level of TBS may detect patients that could be more prone to bone frailty consistently with age and BMD at both vertebral and cortical level. However, its role in clinical practice should be refined.

Estetrol (E4) is a natural estrogen that has recently emerged as new option for contraception and hormone replacement therapy (HRT). Unlike other estrogens, E4 primarily stimulates nuclear estrogen receptor alpha (ERα) and does not activate membrane ERα. For this reason, this novel estrogen has tissue-specific effects across various organs such as liver, vascular endothelium, mammary glands, brain, vagina, and uterus. The selective activation of the nuclear ERα results in distinct pharmacological properties that contribute to its unique therapeutic profile. Moreover, E4 shows minimal interaction with the hepatic cytochrome P450 enzyme system, leading to a favorable pharmacokinetic profile and a reduced potential for drug-drug interactions. Currently, E4 is commercially available in combination with drospirenone as a combined oral contraceptive and its application in HRT is undergoing late-stage clinical development. Many studies have demonstrated that E4 has a lower impact on hemostatic and metabolic parameters compared to other estrogens, potentially reducing the risk of adverse effects commonly associated with hormonal therapies such as thromboembolic events or dyslipidemia. Beyond its role in contraception and HRT, E4 shows promising therapeutic potential in other medical fields, including neuroprotection in neonatal hypoxic-ischemic encephalopathy, enhancement of hematopoietic stem cell transplantation outcomes and prostate cancer management. This review synthesizes the latest evidence on E4 primarily focusing on its pharmacological characteristics and clinical applications. The findings suggest that E4 versatility and peculiar mechanism of action may represent an important therapeutic option for a broad spectrum of medical conditions.

Uterine myomas are the most common benign gynecological tumors among women of reproductive age. The laparoscopic approach, when feasible, is considered the most suitable and safe technique for intervention. Typically, uterine muscular wall defects are sutured with absorbable filaments. However, performing intra-corporeal knots during laparoscopic procedures demands significant surgical abilities and experience. While laparoscopic myomectomies are often recommended, they pose a high risk of hemorrhage. Barbed sutures may address the challenges of laparoscopic knotting due to their inherent barbs, leading to filament cohesion with tissues. This characteristic could potentially reduce the total operative time and blood loss during surgery. In consideration of the latest literature meta-analysis on the topic, published in 2018 and cited in the present work, six papers were included in this review, excluding case reports, reviews and articles without a control group. The objective of this narrative review is to explore the literature and establish the safety profile of barbed suture compared to conventional laparoscopic sutures. Additionally, given the potential for postoperative adhesion formation with the use of barbed sutures, the review also emphasizes reproductive outcomes. Consistent with previous literature, patients undergoing barbed suture laparoscopic myomectomy experienced significantly lower suturing time and blood loss. Regarding obstetric outcomes, all studies analyzing this aspect concluded that barbed sutures in myomectomy are as safe as, and represent an easier alternative to, conventional sutures. Importantly, these findings did not adversely affect pregnancy outcomes.

Background: Ovarian cancer is the leading cause of death from gynecological cancer in the UK. The standard of care is a combination of surgery and chemotherapy. The aim of the treatment is the resection of all macroscopic disease. In selected cases of advanced ovarian cancer this is achieved with ultra-radical surgery. However, NICE encourages further research due to low quality evidence on the safety and efficacy of this extensive surgery. The aim of this study was to examine the morbidity and survival rates of ultra-radical surgery for advanced ovarian cancer performed in our unit and compare our findings with the current literature.

Methods: This is a retrospective study of 39 patients diagnosed with stage IIIA-IV ovarian and primary peritoneal cancer who underwent surgery in our unit between 2012 and 2020. The main outcome measures were the perioperative complications, the disease-free survival, the overall survival rate and the recurrence rate.

Results: The study enrolled 39 patients with stages IIIA-IV who were treated in our unit between 2012 and 2020. 21 patients were at stage III (53.8%) whereas 18 (46.1%) at stage IV. 14 patients underwent primary and 25 secondary debulking surgery. Major and minor complications occurred 17.9% and 56.4% of the patients, respectively. Complete cytoreduction following surgery was achieved in 24 cases (61.5%). The mean and the median survival time were 4.8 years and 5 years, respectively. The mean disease-free survival time was 2.9 years while median disease-free survival time was 2 years. Age (P=0.028) and complete cytoreduction (p=0.048) were found to be significantly associated with survival. Primary debulking surgery was significantly associated with lower probability of recurrence (P=0.049).

Conclusions: Although the number of patients is relatively small, our study indicates that ultra-radical surgery in centers with high expertise may result in excellent survival rates with an acceptable rate of major complications. All patients in our cohort were operated by an accredited gynecological oncologist and a hepatobiliary general surgeon with a special interest in ovarian cancer. A few cases required input from a colorectal and a thoracic surgeon. We believe that the careful selection of the patients that can benefit from ultra-radical surgery and our model of joint surgery can explain our excellent results. Further research is essential to establish that ultra- radical surgery has an acceptable rate of morbidity for patients with advanced ovarian cancer.

Electrosurgery is a continuously evolving field that has nowadays become a necessity in operating theatres. The expanding use of electrosurgery has been associated with a high number of thermal injuries, thus the fundamental understanding of how each of the energy devices work and their effect on biological tissues is very important and continuing education regarding electrosurgical technology is paramount for avoiding patient complications. This review describes the basic principles and modalities of electrosurgery, their biological effects on tissues and variables that can affect them, the evolution in the field of electrosurgery, its wide use in gynecological procedures, as well as the risk and complications that are commonly seen in electrosurgery.

Background: Women with unfavorable obstetric history can benefit from prophylactic cerclage ("history indicated") which can be performed vaginally or transabdominally with laparoscopic techniques. The aim of our study is to evaluate the effectiveness in the prevention of preterm birth of the vaginal technique and of the minimally invasive laparoscopic technique in women with an unfavorable obstetric history.

Methods: This was a retrospective cohort study examining elective cerclages performed in women with adverse obstetrics history. The primary outcome was rate of early preterm and second trimester deliveries while other outcomes analyzed were surgical complications, the time needed for cerclage procedures, live birth rate, gestational age at delivery, birth weight, Apgar score.

Results: Data from 64 women were analyzed; among them, 14 underwent a laparoscopic procedure (22%) while 50 a vaginal cerclage (78%). The two groups were homogeneous in terms of demographic characteristics, but of course differed significantly in terms of obstetrics history, as well as for the surgical indications of cerclage procedures. The rate of early preterm deliveries and second trimester miscarriage were the same in the vaginal and laparoscopic group (8%), comparable to what was reported in literature. The operative time was longer in the laparoscopic group, but with similar duration of the hospital stay. We reported no intraoperative complications in both groups.

Conclusions: As the laparoscopic procedure, usually reserved for women with a previous failed vaginal cerclage, has been proved to be equally safe and effective, it may could be proposed to a wider group of women. Prospective randomized studies are needed to provide new and conclusive data about this topic.

Background: There is emerging evidence of improved outcomes with induction of labour for pregnancies in which the baby is thought to be large. This trial identifies scan accuracy and the effect of intervention for pregnancies complicated by suspected large for gestational age (LGA) on customized chart outside an academic center.

Methods: This is a retrospective cohort study of 3 groups of induced pregnancies; women with a suspected LGA fetus, women with diabetes (DM) and a control group (C) of women that underwent induction of labour on or after 280 days gestation. Data collection and analysis were prespecified. Scan accuracy and outcomes between the cohorts were compared.

Results: Over 1 year there were 845 cases: LGA (128), DM (116) and control cases (601). Mean birthweights differed significantly. PPV of EFW for birthweight >90^th centile on GROW chart, WHO chart, and >4 kg was 0.35-0.40. Projected birthweight of >4 kg significantly better predicted itself (AUROC 0.70, 0.74 and 0.80). Mean scan error was -5.2% and +15.6% for DM and LGA. Shoulder dystocia and neonatal morbidity were not increased in LGA despite the significant increase in AVD 28/128, 21.9% vs. 99/601, 16.5%, aOR 2.20 (1.07-4.5). SVD was significantly less likely LGA vs. C at 69/128, 53.9% vs. 413/601, 68.7% aOR 0.38 (95% CI: 0.21-0.70).

Conclusions: Third trimester EFW for bigger babies was poorly predictive of macrosomia. Fetal outcomes were good but women selected and induced as LGA had higher rates of hemorrhage and intervention.

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.

Background: The aim of this study was to evaluate rate of complications with the use of prophylactic ureteral localization stents (PULSe) in gynecologic surgery. To compare the occurrence of complications according to the indication of surgery.

Methods: This retrospective study included 1248 women who underwent 1275 different gynecologic surgeries with PULSe between 2007 and 2020. Data was collected regarding patient characteristics (age, sex, race, ethnicity, parity, previous pelvic surgery, creatinine), operative characteristics (trainee, guidewire use, indication) and complications in the first 30 days (ureteral injury, urinary tract complication, re-stenting, hydronephrosis, urinary tract infection (UTI), pyelonephritis, emergency room visit, re-admission).

Results: Median age was 57 years (range: 18-96 years), most women were Caucasian (88.9%), and had previous pelvic surgery (77.7%). Indication of surgery was benign for 459 (36.0%), female pelvic medicine and reconstructive surgery (FPMRS) for 545 (42.7%), and gynecologic oncology (gyn-onc) for 271 (21.3%). Disabling complications occurred rarely with 8 patients (0.6%) having a ≥III Clavien Dindo Grade (CDG), and only 1 (0.08%) ≥IV CDG. Statistically significant differences between benign, FPMRS, and gyn-onc groups were noted for re-stenting (0.9% vs. 0.0% vs. 1.1%, P=0.020), hydronephrosis (0.9% vs. 0.2% vs. 2.2%, P=0.014), UTI (4.6% vs. 9.4% vs. 7.0%, P=0.016), and re-admission (2.4% vs. 1.1% vs. 4.4%, P=0.014).

Conclusions: The incidence of 30-day CDG III and IV complications after PULSe placement is low. FPMRS patients had a higher rate of complicated UTI, however gyn- onc patients appear to be at overall higher risk of stent related complications when compared to surgeries for FPMRS or benign indications.