Fertility-Sparing Surgery versus Radical Hysterectomy in Early Cervical Cancer: A Propensity Score Matching Analysis and Noninferiority Study.

OBJECTIVE: Fertility-sparing surgery (FSS) is the treatment of choice for patients with early cervical cancer (ECC) and fertility desire, but survival rates compared to radical hysterectomy (RH) have been scarcely reported. The aim of this study was to analyse the oncological outcomes of FSS compared to a balanced group of standard RH. METHODS: A retrospective multicentre study of ECC patients who underwent FSS or RH was carried out in 12 tertiary hospitals in Spain between January 2005 and January 2019. The experimental group included patients who underwent a simple and radical trachelectomy, and the control group included patients who underwent RH. Optimal 1:1 propensity score (PS) matching analysis was performed to balance the series. RESULTS: The study included 222 patients with ECC; 111 (50%) were treated with FSS, and 111 (50%) were treated with RH. After PS matching, a total of 38 patients in the FSS group and 38 patients in the RH group were analysed. In both groups, the overall survival (HR 2.5; CI 0.89, 7.41) and recurrence rates (28.9% in the FSS group vs. 13.2% in RH group) were similar. The rate of disease-free survival at 5 years was 68.99% in the FSS group and 88.01% in the RH group (difference of -19.02 percentage points; 95% CI -32.08 to -5.96 for noninferiority). In the univariate analysis, only tumour size reached statistical significance. CONCLUSION: FSS offers excellent disease-free and overall survival in women with ECC with fertility desire and is not inferior compared to RH.

Tumor Size and Oncological Outcomes in Patients with Early Cervical Cancer Treated by Fertility Preservation Surgery: A Multicenter Retrospective Cohort Study.

Background: The aim of this study was to analyze the impact of tumor size > 2 cm on oncological outcomes of fertility-sparing surgery (FSS) in early cervical cancer in a Spanish cohort. Methods: A multicenter, retrospective cohort study of early cervical cancer (stage IA1 with lymphovascular space invasion -IB1 (FIGO 2009)) patients with gestational desire who underwent FSS at 12 tertiary departments of gynecology oncology between 01/2005 and 01/2019 throughout Spain. Results: A total of 111 patients were included, 82 (73.9%) with tumors < 2 cm and 29 (26.1%) with tumors 2−4 cm. Patients' characteristics were balanced except from lymphovascular space invasion. All were intraoperative lymph node-negative. Median follow-up was 55.7 and 30.7 months, respectively. Eleven recurrences were diagnosed (9.9%), five (6.0%) and six (21.4%) (p < 0.05). The 3-year progression-free survival (PFS) was 95.7% (95%CI 87.3−98.6) and 76.9% (95% CI 55.2−89.0) (p = 0.011). Only tumor size (<2 cm vs. 2−4 cm) was found to be significant for recurrence. After adjusting for the rest of the variables, tumor size 2−4 cm showed a Hazard Ratio of 5.99 (CI 95% 1.01−35.41, p = 0.036). Conclusions: Tumor size ≥ 2 cm is the most important negative prognostic factor in this multicenter cohort of patients with early cervical cancer and gestational desire who underwent FSS in Spain.

Colouterine Fistula Treated by a Double Endoscopic Approach.

Colouterine fistula associated with the use of an intrauterine device (IUD) is extremely rare. Clinical presentation may vary; however, to our knowledge, only 1 paper has previously reported menochezia as the main symptom of an utero-intestinal fistula as a complication of IUD use. Surgery is generally needed for definitive resolution of the fistula. Various surgical approaches have been proposed, mainly using open approaches owing to the presence of severe pelvic adhesions. Reports of laparoscopic treatment have been rarely described. We performed a successful conservative double endoscopic repair, with hysteroscopy followed by laparoscopy. Follow-up of IUD users is important, as complications may appear at any time. Unusual signs or symptoms warrant attention. Imaging tests aid in diagnosis and treatment selection, which in the majority of cases means planning for surgery. An endoscopic approached is preferred because of its lower risk of complications and shorter postoperative recovery period.

Transperitoneal Laparoscopic Para-Aortic Lymphadenectomy and Body Mass Index: Is It Really a Limiting Factor for the Procedure?

Objective: To explore if obesity measured by body mass index (BMI) ≥30 kg/m2 represents a limiting factor for para-aortic lymphadenectomy done with a transperitoneal laparoscopic approach. Materials and Methods: Retrospective observational study with 146 consecutive patients, diagnosed with a gynecological cancer submitted to para-aortic surgical staging between January 2010 and December 2018. The mean age was 52 years and the mean BMI was 27 kg/m2. 72.6% (106 patients) had BMI <30 kg/m2 and 27.4% (40 patients) had BMI ≥30 kg/m2. Half of the patients did not have prior abdominal surgeries. Results: The statistical analysis showed that there were no significant differences between two groups depending on their BMI in the lymph node count: BMI <30 kg/m2 14 nodes versus BMI ≥30 kg/m2 10 nodes (P = .122); rate of intraoperative complications: BMI <30: 6.3% versus BMI ≥30: 0% (P = .180), postoperative complications: BMI <30: 6.6% versus BMI ≥30: 5% (P = .723); feasibility rate: BMI <30: 97.1% versus BMI ≥30: 95.6% (P = .063) or the mean hospital stay BMI <30: 2.47 ± 2.05 days (standard deviation [SD]), BMI ≥30: 2.64 ± 0.93 days (SD) (P = .171). The only significant difference observed was due to the operating time: BMI <30: 103.1 ± 60.8 (SD) versus BMI ≥30: 146.9 ± 82.5 (SD) (P = .019), being longer in obese patients. Conclusions: Obesity, estimated by BMI, does not seem to represent a limiting factor for this surgical procedure in our series. We feel it is a feasible and justified approach in obese patients when other surgical procedures have to be carried out in the same surgical act. Probably, other factors and anthropometric measurements are more accurate to select patients in which this approach is feasible.

Transperitoneal laparoscopic para-aortic lymphadenectomy and body mass index / Linfadenectomía para-aórtica laparoscópica transperitoneal e índice de masa corporal

Objective: To determine whether obesity (BMI ≥ 30 kg/m2) is a limiting factor for para-aortic lymphadenectomy performed using transperitoneal laparoscopy in a series of 146 consecutive cases. Patients and methods: We performed a retrospective observational study of 146 consecutive patients diagnosed with gynecologic cancer who underwent para-aortic surgical staging by transperitoneal laparoscopy. The study sample included 45 cases (30.8%) for staging of apparent stage I ovarian carcinoma I, 56 cases (38.4%) of locally advanced cervical carcinoma and/or positive pelvic nodes, 34 cases (23.3%) of endometrial carcinoma with a poor prognosis and high risk of locoregional recurrence, 4 cases (2.7%) of carcino-sarcoma, and 7 cases (4.8%) of local recurrence of previously treated cervical carcinoma. Statistical significance was set at p < 0.05. Results: The feasibility rate was 93.2%. The intraoperative complication rate was 5.4% (6 cases). The postoperative complication rate was 8.9% (13 cases); if we include those patients who required a blood transfusion (6.8%), then complications were recorded in 23 cases. Mean (SD) operative time was 122.4 (72.9) minutes. The mean number of lymph nodes removed was 13 (8-17). The mean hospital stay was 2.5 (1.7) days. Patients were divided into 2 groups according to their BMI: < 30 kg/m2 and ≥ 30 kg/m2. The statistical analysis revealed no significant differences between the groups for lymph node count (p = 0.122), percentage of complications (p = 0.459), feasibility rate (p = 0.063), or mean hospital stay (p = 0.171). Differences were found with respect to operative time (p = 0.019), which was greater in obese patients. Conclusions: In our series, obesity did not appear to be a limiting factor for surgery in terms of lymph node count and rate of complications although it continues to affect operative time. The surgical feasibility rate was adequate. We believe that surgery is both feasible and justified in obese patients when other procedures are necessary during surgery

Objetivo: explorar si la obesidad (índice de masa corporal ≥ 30 kg/m2) representa un factor limitante para la linfadenectomía para-aórtica mediante abordaje laparoscópico transperitoneal en una serie de 146 casos consecutivos. Material y métodos: estudio observacional retrospectivo constituido por 146 pacientes consecutivas con diagnóstico de cáncer ginecológico, sometidas a estadificación quirúrgica para-aórtica mediante abordaje laparoscópico transperitoneal. Se incluyeron 45 casos (30,8%) para la estadificación del carcinoma ovárico aparentemente en estadio clínico I, 56 casos (38,4%) para el carcinoma cervical en formas localmente avanzadas y/o ganglios pélvicos positivos, 34 casos (23,3%) de estadificación del carcinoma endometrial en los casos de mal pronóstico y alto riesgo de recidiva locorregional, 4 casos (2,7%) de carcinosarcoma y 7 casos (4,8%) de recidiva local de carcinoma de cérvix inicialmente tratado. Para el análisis estadístico se consideró P < 0,05 como significativo. Resultados: la tasa de factibilidad fue del 93,2%. La tasa de complicaciones intraoperatorias fue del 5,4 % (6 casos). La tasa de complicaciones posoperatorias se situó en 8.9 % registrándose 13 casos; 23 casos si incluimos a aquellas pacientes que requirieron la realización de una transfusión sanguínea, con una tasa de la misma del 6,8%. El tiempo medio quirúrgico fue 122,4 +/- 72,9 (DE) minutos. Se registró un número medio de ganglios extraídos del 13 (8-17). La estancia media hospitalaria se situó en 2,5 +/- 1,7 (DE) días. Se dividió a las pacientes en 2 grupos en función de su índice de masa corporal: < 30 kg/m2 y ≥ 30 kg/m2, el análisis estadístico demostró que no existen diferencias significativas en el recuento ganglionar (p = 0,122) entre ambos grupos; tampoco se hallaron diferencias en cuanto al porcentaje de complicaciones (p = 0,459) o la tasa de factibilidad (p = 0,063) ni en la estancia media hospitalaria (p = 0,171). Sí se establecieron diferencias en cuanto a tiempo operatorio (p = 0,019), siendo mayor en aquellas pacientes obesas. Conclusiones: la obesidad parece no representar un factor limitante para la técnica quirúrgica en nuestra serie en cuanto a recuento ganglionar y tasa de complicaciones, con una tasa de factibilidad adecuada. Por el contrario, se sigue estableciendo como factor condicionante del tiempo operatorio. A pesar de ello, creemos factible y justificado este abordaje en pacientes obesas, cuando se requieran otros procedimientos en el mismo acto quirúrgico

Colposacropexia laparoscópica y cistocele / No disponible

No disponible

Microinvasive squamous carcinoma of neovagina created with peritoneal flap (Davidov): Case report and literature review.

Carcinoma of the vagina is a rare disease, and it is even more rare when it appears in a neovagina, having its incidence and optimum treatment constantly discussed. The aim of this article was to review the cases described in the currently available literature and describe the second documented case of carcinoma in a neovagina created with peritoneal flaps, and also list the possible pathways and risk factors for its development. The case we present is a 49-year-old female who after undergoing a laparoscopic colpectomy of the upper two-thirds of the vagina, with an immediate reconstruction with peritoneal flaps by laparoscopy, at a 4 months follow up presented a focal microinvasive squamous carcinoma in the vault of the neovagina. After reviewing the literature, we conclude that excisional treatment is the preferable option to avoid the progression to an invasive carcinoma. However, this case demonstrates the importance of the necessity to do regular cito-vulvovaginoscopic examinations after the complete surgical treatment because of the chance of persistent or recurrent lesions on the transplanted tissue.

El láser fraccionado de CO2 como tratamiento del síndrome genitourinario de la menopausia: revisión de la evidencia y recomendaciones de uso / The fractional CO2 laser for treatment of genitourinary syndrome of menopause: evidence update and using recommendations

Publicaciones recientes han demostrado que el láser fraccionado de CO2 es una opción terapéutica no hormonal efectiva, sencilla, bien tolerada y sin efectos adversos, para el tratamiento del síndrome genitourinario de la menopausia. Debido a la restauración del epitelio vaginal, el proceso de neocolagénesis y una mayor vascularización, obtenidas por la reacción térmica desencadenada, se restablecerá la estructura de la mucosa, su grosor y trofismo funcional, mejorando por tanto la sintomatología. No obstante, son necesarios estudios a largo plazo, controlados, frente a placebo, estrógenos locales y otros tratamientos no hormonales, para validar la duración de los efectos y la seguridad de las sucesivas aplicaciones. El objetivo de este trabajo es revisar la evidencia disponible hasta la fecha, relacionada con esta terapia emergente y proponer unas recomendaciones de uso (AU)

Recent reported studies have demonstrated that non-invasive fractional CO2 laser is a valid, safe, effective and well tolerated therapeutic option, without adverse events to treat the genitourinary syndrome of menopause. The heat shock effect induces the increase of vaginal epithelium thickness, the new glycogen content and the vascular changes, improving the vaginal epithelium structure, functionality and menopausal symptoms. Nevertheless, duration of treatment effects and safety of repeated session are not clear enough. Further controlled long-term follow-up research on laser versus placebo, local estrogens and other non-hormonal therapies are needed. The aim of this paper is to review the scientific evidence related to this emergent treatment and proposing recommendations of use (AU)

[Influence of age on laparoscopic colposacropexy]. / Influencia de la edad en el rendimiento de la colposacropexia laparoscópica.

OBJECTIVES: To evaluate the influence of age on laparoscopic colposacropexy (LCS) outcome and complications for pelvic organ prolapse. MATERIAL AND METHODS: A retrospective and comparative study of 105 patients who underwent standard LCS for Baden-Walker graded pelvic organ prolapse from February 2002 to March 2015. They were categorized into two groups according to age. Group 1 consisted in ≤ 50 years old patients and included 55 women. Group 2 included 50 women who were ≥ 60 years old. Outcomes and complications were compared in both groups. RESULTS: Previous history of abdominal surgery or surgery for pelvic floor disorders was significantly greater in group 2 (43.6 vs 70%). There was no significant difference regarding urinary stress incontinence, urge incontinence or severe organ prolapse between groups (47.2 vs 36%; 1.8 vs 8% and 90.9 vs 92% for Groups 1 and 2 respectively). Although a statistically significant greater proportion of vaginal vault prolapse was present in the elderly group (16.3 vs 38%), the same LCS surgical technique was used in both groups of patients. Despite operating time was significantly greater in the younger group (205.8 ± 53.4 minutes in Group 1 vs 182 ± 42.3 minutes in Group 2), hospital stay was similar in both groups (2.9 ± 1.1 days vs 3.0 ± 1.9 days in group 1 and group 2 respectively). Postoperative complications were not severe and there were no clinically significant differences between groups (20 vs 14%). We found no statistically differences between groups when comparing cure rates (87 vs 92%) in groups 1 and 2 respectively, patient satisfaction and postoperative anatomical findings. CONCLUSIONS: LCS has shown excellent cure rates in both young and elder female patients with pelvic organ prolapse.

Endometriosis: alternative methods of medical treatment.

Endometriosis is an inflammatory estrogen-dependent disease defined by the presence of endometrial glands and stroma at extrauterine sites. The main purpose of endometriosis management is alleviating pain associated to the disease. This can be achieved surgically or medically, although in most women a combination of both treatments is required. Long-term medical treatment is usually needed in most women. Unfortunately, in most cases, pain symptoms recur between 6 months and 12 months once treatment is stopped. The authors conducted a literature search for English original articles, related to new medical treatments of endometriosis in humans, including articles published in PubMed, Medline, and the Cochrane Library. Keywords included "endometriosis" matched with "medical treatment", "new treatment", "GnRH antagonists", "Aromatase inhibitors", "selective progesterone receptor modulators", "anti-TNF α", and "anti-angiogenic factors". Hormonal treatments currently available are effective in the relief of pain associated to endometriosis. Among new hormonal drugs, association to aromatase inhibitors could be effective in the treatment of women who do not respond to conventional therapies. GnRH antagonists are expected to be as effective as GnRH agonists, but with easier administration (oral). There is a need to find effective treatments that do not block the ovarian function. For this purpose, antiangiogenic factors could be important components of endometriosis therapy in the future. Upcoming researches and controlled clinical trials should focus on these drugs.

La colposacropexia laparoscópica en el tratamiento del cistocele / Laparoscopic sacrocolpopexy for the treatment of cystoceles

Objetivo: Estudiar los resultados de la colposacropexia sobre el cistocele. Material y métodos: Setenta y siete pacientes con cistocele sometidas a colposacropexia. Con seguimiento mínimo de 6 meses, se practicó la exploración y la detección de síntomas de prolapso, urinarios rectales y sexuales. La curación objetivo se definió como un grado < II en la clasificación de Baden-Walker. Resultados: La edad media ± desviación estándar era de 53,8 ± 8,9 años. El tiempo medio operatorio de 193,6 ± 44 min. Las complicaciones intraoperatorias existieron en el 11,6% y las postoperatorias en el 19,4%. La estancia media fue de 2,7 días (1-8). Con un seguimiento medio de 15,5 ± 12,8 meses, la curación subjetiva se alcanzó en el 89,6% y la mejoría en el 6,4%. Hubo en el seguimiento un 11,6% de pacientes con cistoceles con criterios de recidiva anatómica. Setenta y cinco pacientes se declararon satisfechas o moderadamente satisfechas (97,7%). Conclusión: La colposacropexia es también efectiva para corregir el compartimento anterior (AU)

Objective: To study the results of sacrocolpopexy in our hospital for the treatment of cystoceles. Material and methods: A total of 77 patients were treated by laparoscopic sacrocolpopexy. With a minimum mean follow-up of 6 moths, a clinical examination was performed to detect symptoms of prolapse or urinary, sexual and rectal symptoms. Objective cure was defined as < grade 2 prolapse in the Baden-Walker classification. Results: The mean age was 53.8 ± 8.9 years. The mean operating time was 193.6 ± 44 minutes. Intra-operative and post-operative complications rates were 11.6% and 19.4%, respectively. The mean length of hospital stay was 2.7 (1-8) days. With a mean follow-up of 15.3 ± 12.8 months, the subjective cure rate was 89.6% and the improvement rate was 6.4%. The rate of anatomical recurrence of cystocele was 11.6%. Seventy-five patients reported they were satisfied or moderately satisfied (97.7%). Conclusion: Laparoscopy sacrocolpopexy appears to be an effective method for the treatment of cystocele (AU)

Histerectomía radical laparoscópica total en el cáncer de cérvix. Factibilidad, morbilidad y supervivencia / Total laparoscopic radical hysterectomy in cervical cancer. Feasibility, morbidity and survival

Objetivo: Evaluación retrospectiva de la factibilidad, la morbilidad perioperatoria y supervivencia a medio plazo de la histerectomía radical laparoscópica total en el cáncer de cérvix. Material y métodos: El estudio incluye 31 casos consecutivos de cáncer de cérvix en estadio clínico IA2 (n = 4), IB1 (n = 21), IIA (n = 2) y IB2 (n = 3) programados para histerectomía radical laparoscópica total. Se analizan las características histológicas de los tumores, la evolución de la técnica quirúrgica, las variables perioperatorias, las complicaciones postoperatorias y los resultados de supervivencia a medio plazo. Resultados: La tasa de factibilidad fue del 96%. La complicación operatoria más frecuente fue la cistotomía accidental (3 casos). La tasa de complicaciones postoperatorias fue del 20% (6 casos), incluido 1 caso de reintervención quirúrgica. El tiempo operatorio medio fue de 258 min (rango: 180-360). La tasa de transfusión sanguínea fue del 17% (5 casos) y la estancia hospitalaria fue de 7,8 días (rango: 2-29). Al mes de la intervención el 72% de las pacientes habían normalizado la función miccional. El tamaño tumoral medio fue de 26,5 mm y la tasa de ganglios pélvicos positivos fue del 17% (n = 5). El tiempo medio de seguimiento fue de 26 meses. La tasa de recidivas fue del 17% (n = 5) y la supervivencia libre de enfermedad fue del 100% para los estadios IB2, el 82,6% para los estadios IB1/IIA y 66,7% para los estadios IB2. Conclusiones: La histerectomía radical laparoscópica total es una técnica factible en la mayoría de los pacientes con cáncer de cérvix, requiere más tiempo operatorio que la vía abdominal, pero presenta menor morbilidad perioperatoria, menor necesidad de transfusiones y menor estancia hospitalaria. La supervivencia a medio plazo es equiparable a la vía abdominal convencional

Objective: To assess feasibility, perioperative morbidity and medium term survival of total laparoscopic radical hysterectomy in cervical cancer. Material and methods: A total of 31 consecutive patients diagnosed FIGO clinical stage IA2 (n = 4), IB1 (n = 22), IIA (n = 2) and IB2 (n = 3) in Son Llàtzer hospital (Palma de Mallorca) that were programmed for a total laparoscopic radical hysterectomy were studied. We analyzed tumor histological characteristics, surgical technique, perioperative variables, postoperative complications and mid-term survival results. Results: Feasibility rate was 96%. The most frequently operative complication was accidental bladder incision (3 cases). Postoperative complications rate was 20% (6 cases) which includes one surgical reintervention. Average operative time was 258 minutes (range: 180-360). Blood transfusion rate was 17% (n = 5) and mean hospital stay was 7.8 days (range: 2-29). After one month after surgery 72% of patients had a normal miccional function. Mean tumoral size was 26.5 mm and lymphatic positive nodes rate was 17% (n = 5). Mean follow-up time was 26 months. Tumor relapse rate was 17% (n = 5) and survival-free disease of 100% for IA2 stage, 82.6% of IB1/IIA stages and 66.7% for IB2 stage. Conclusions: Total laparoscopic radical hysterectomy is a feasible technique in most of the patients with cervical cancer. It needs more operative time than abdominal route but it presents less perioperative morbidity, less blood transfusion and less hospitalization days. The medium term survival is comparable with conventional abdominal route

Sebaceous gland hyperplasia of the vulva.

BACKGROUND: Sebaceous gland hyperplasia is a common condition of the face in elderly patients. We report a case of sebaceous gland hyperplasia on the vulva. CASE: A 19-year-old woman presented with a polypoid tumor on her left labium majus of which the greatest diameter was 2.5 cm, covered by normal appearing skin. Histologic examination revealed a sebaceous gland hyperplasia. Immunohistochemical techniques showed high expression of androgen receptors on sebaceous cells. CONCLUSION: Clinical and gross features of the two documented cases of sebaceous gland hyperplasia on the vulva are different from those of typical lesions on the face. Histologic study of a vulvar biopsy is required to reach a specific diagnosis of this hamartomatous benign condition.