Efficacy and safety of robotic-assisted surgery in challenging hysterectomies - a single institutional experience.

OBJECTIVE: An increasing number of robotic hysterectomies are being performed and the most common indication is fibroids. Fibroid uterus is common indication for hysterectomy for enlarged uteri. The role of robotic approach for complex pathologies as enlarged uterus is still debatable. The study aimed to analyze the feasibility of robotic hysterectomy in patients with enlarged uteri and the impact of uterine weight on surgical outcomes and on operative time length. PATIENTS AND METHODS: One hundred and thirty-eight patients who underwent robotic hysterectomy for benign indications at the 2nd Division of Obstetrics and Gynecology, Azienda Ospedaliero-Universitaria Pisana, University of Pisa were consecutively enrolled. RESULTS: Data of patients undergoing robotic surgery for benign indications were collected. Patients were stratified in two groups based on their uterine weight, to analyze the effective impact of uterine weight and dimension on surgical performance, operative time and postoperative outcomes. Conversion rate was 0%. Median uterine weight was 615 g (range 400-1900 g). Median total operating time was 131 minutes (range 70-255 minutes). Increase in uterine weight significantly increased operative times (p=0.003) and morcellation time (p=0.001). On the other hand, operative time was just partially influenced by route for removal of the uterus (p=0.085) but significantly affected by uterine weight (p=0.008), previous surgeries (p=0.003) and BMI of the patient (p=0.005). CONCLUSIONS: Robotic hysterectomy is feasible and safe for challenging cases as large uteri. This technique could enable patients with outsized uteri, not suitable for vaginal hysterectomy, to undergo minimally invasive surgery with excellent results. Larger studies to investigate and compare robotic with other surgical approaches for difficult hysterectomies are needed to confirm these data.

Safety and efficacy of tigecycline in complicated and uncomplicated pelvic inflammatory disease.

OBJECTIVE: Tigecycline is a glycylcycline antimicrobial structurally related to minocycline, with a wide spectrum of activity that includes anaerobes and typical and atypical microorganisms causing pelvic inflammatory disease (PID). This study aimed to evaluate efficacy and safety of tigecycline in complicated PID and un-complicated PID after the failure of first-line antibiotic therapy. PATIENTS AND METHODS: Between May 2014 and April 2016 at the 2nd Unit of Obstetrics and Gynecology, Santa Chiara Hospital of Pisa a pilot study on 20 women with mild/moderate PID after the failure of first-line antibiotic therapy and on 8 women with complicated PID was conducted. The treatment protocol was 10-day course of tigecycline, with a loading dose of 100 mg intravenously (i.v.) at day one and then 50 mg IV twice daily. The primary endpoint was to evaluate tigecycline's efficacy in terms of clinical response to test-of-cure (TOC) at the end of therapy and 30 days after the last dose. Clinical response during therapy and safety were analyzed as well. RESULTS: A total of 28 women were enrolled, and 25 patients completed the study protocol, because 3 patients reported adverse drug effects resulting in treatment interruption. PID was mainly caused by Chlamydia, Gardnerella, Mycoplasma/Ureaplasma. Tigecycline showed a 100% remission of signs and symptoms in patients resistant to first-line antibiotic regimen and in patients with complicated PID. Moreover, tigecycline showed good tolerability and compliance. CONCLUSIONS: Despite the limited sample size, tigecycline seemed an effective and safe treatment for women with complicated/resistant PID. Nevertheless, further clinical trials are needed to confirm these results.

Laparoscopic nerve-sparing complete excision of deep endometriosis: is it feasible?

BACKGROUND: Little is known about the morbidity associated with laparoscopic complete excision of endometriosis in terms of urinary, digestive and sexual function. METHODS: We performed a prospective non-randomized study in 45 patients with laparoscopic complete excision of all detectable foci of endometriosis with segmental bowel resection using a non nerve-sparing technique (control group-group A n=20) and a nerve-sparing technique (case group-group B n=25). At initial gynaecological evaluation, and at follow-up details on dysmenorrhoea, pelvic pain, dyspareunia and dyschezia were evaluated using an interview-based questionnaire (10-point analogue rating scale: 0=absent, 10=unbearable). RESULTS: The mean (+/-SD) follow-up period was 15.3+/-10 months (range, 8.8-23 months) for group A and 3.5+/-2.1 months (range, 0.3-5.2 months) for group B. In the immediate postoperative course, in group A three women required blood transfusion vs seven women in group B (P=0.003). The median time to resume the voiding function was significantly shorter in group B (12.5 vs 3.0 days; P<0.01). At the time of follow-up a higher proportion of patients in group B were 'very satisfied' than those in group A (87.7% vs 59.0%, P=0.013). CONCLUSIONS: Laparoscopic nerve-sparing complete excision of endometriosis seems to be feasible and offers good results in terms of bladder morbidity reduction with apparently higher satisfaction than classical technique. Larger series with longer follow-up are needed to confirm our results.

Recurrence patterns in patients with early stage cervical cancer treated with radical hysterectomy and external pelvic irradiation.

One hundred and fifty patients with clinical FIGO stage IB-II cervical cancer who underwent radical surgery followed by external pelvic irradiation between 1978 and 1991 were reviewed. Until June 1994, 28 (18.7%) patients developed recurrent disease. Seventeen (60.7%) of them experienced a pelvic failure, 7 (25.0%) an extrapelvic failure and 4 (14.3%) both a pelvic and an extrapelvic failure. The median time to recurrence was 16 months for patients with pelvic failure (range = 4-50 months), 27 months for those with extrapelvic failure (range = 6-49 months), and 21 months for those with both pelvic and extrapelvic failure (range u 8-56 months). Recurrence rates were significantly related to surgical-pathologic stage, tumor size and lymph node status, but not to histologic type. An extrapelvic recurrence, alone or associated with a pelvic failure, was found in 0.9% of 117 patients with negative lymph nodes, 6.2% of 16 patients with one or two positive lymph nodes, and 52.9% of 17 patients with three or more positive lymph nodes, (p = 0.0001). It is worth noting that 9 (81.8%) out of the 11 patients who developed extrapelvic recurrences had three or more involved lymph nodes. The number of positive lymph nodes (p = 0.0001) and the tumor size (p = 0.0046) were independent prognostic variables for disease-free survival.