Spanish consensus on vulvar disorders in postmenopausal women.

INTRODUCTION: The consequences of vulvar disorders in terms of health, sexuality, and quality of life are usually undervalued, with disparities in the conceptual, diagnosis and treatment criteria. AIM: The objective of this guide will be to analyse the factors associated with the diagnosis and treatment of vulvar disorders and to provide recommendations for the most appropriate diagnostic and therapeutic measures. METHODOLOGY: A panel of experts from various Spanish scientific societies related to sexual health (Spanish Menopause Society [SMS] and the Asociación Española de Patología Cervical y Colposcopia [AEPCC]) met to reach a consensus on these issues and to decide the optimal timing and methods based on the best evidence available. RESULTS: We recommend a biopsy of all vulvar lesions with an uncertain diagnosis, especially with asymmetry, irregular borders, variegated and irregular colour and diameter >6mm. For vulvodynia, we recommend the use of lubricants or topical treatments with lidocaine or bupivacaine, amitriptyline, baclofen or triamcinolone. For vulvar epithelial disorders, we recommend beginning with topical corticosteroids of moderate to high potency. For sexual dysfunction, a multidisciplinary approach is the best management strategy in these patients.

Impact of the lymphadenectomy in high-risk histologic types of endometrial cancer: a matched-pair study.

OBJECTIVE: The aim of this study is to assess the impact of lymphadenectomy (LND) on morbidity, survival, and cost for high-risk histologic types of endometrial cancer (EC). MATERIALS AND METHODS: We analyzed a multicenter retrospective cohort of 389 women with high-risk histotypes of EC (poor differenced tumors [G3], clear cell, serous papillary, and mixed mesodermal tumors) preoperatively confined to the corpus and diagnosed between 2000 and 2013. All patients underwent hysterectomy and bilateral salpingo-oophorectomy. A matched-pair analysis identified 97 pairs (97 with LDN and 97 without) equal in age, body mass index, comorbidities, International Federation of Gynecology and Obstetrics stage, and adjuvant treatment. Demographic data, pathologic examination results, perioperative morbidity, and survival were abstracted from medical records. Cost was provided by the cost unit of the local hospital. Disease-free and overall survival were analyzed using the Kaplan-Meier curves and Cox multivariable regression analysis. RESULTS: Both study groups were homogeneous in demographic data and pathologic examination results. At a median follow-up of 24.5 months (range, 5.4-146.3), disease-free survival (hazard ratio, 1.09; 95% confidence interval, 0.70-1.90) and overall survival (hazard ratio, 0.86; 95% confidence interval, 0.56-1.33) were similar in both groups regardless of nodal count. Positive nodes were found in 23.7%. Predictor factors of nodal involvement were advanced age (P = 0.024), deep myometrial invasion (P < 0.001), and high CA 125 levels (P = 0.003). In the LDN group, operating time, late postoperative complications, and surgical cost were higher (P < 0.05). There were no statistical differences between both groups relative to surgical morbidity. Early postoperative complications and hospital stay were lower in the LDN group. The global cost was similar for both groups (6027&OV0556; for the LND group and 5772&OV0556; for the no-LND group). CONCLUSIONS: Lymphadenectomy in high-risk histotypes of EC does not increase perioperative morbidity or global cost and has not benefit on survival.

Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL).

STUDY OBJECTIVE: To compare perioperative outcomes and cost of robotic-assisted and laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) for treatment of gynecologic malignant conditions. DESIGN: Prospective non-randomized study (Canadian Task Force classification II-2). SETTING: Tertiary center for women's health. PATIENTS: Sixty-two patients with gynecologic cancer operated on by the same surgical team. INTERVENTIONS: Thirty-two patients underwent TIPAL via robotic-assisted laparoscopy, and 30 via conventional laparoscopy. Comparison analyses of perioperative outcomes and estimated costs were performed. MEASUREMENTS AND MAIN RESULTS: There were no differences between robotic-assisted and laparoscopy insofar as age, body mass index, presurgical morbidity, operating time (92.5 minutes for robotics vs 96.6 minutes for laparoscopy), number of aortic nodes (12 vs. 12), hospitalization stay (2 vs. 2 days), or rate of complications (12.5% vs. 13.3%). Blood loss tended to be lower in the robotic group (75.0 vs. 92.5 mL; p = .08). Surgical cost was higher in the robotic group ($3.42 vs. $2.55; p < .001), although hospitalization cost was similar. CONCLUSION: Robotic-assisted and laparoscopy provide similar perioperative outcomes. However, the robotic-assisted approach is associated with higher surgical cost.

Comparison of perioperative outcomes and cost of robotic-assisted laparoscopy, laparoscopy and laparotomy for endometrial cancer.

OBJECTIVE: To analyze the perioperative outcomes and cost of three surgical approaches in the treatment of endometrial cancer: robotic, laparoscopy and laparotomy. STUDY DESIGN: We studied 347 patients with endometrial cancer treated in a single institution: 71 patients were operated by robotics, 84 by conventional laparoscopy and 192 by laparotomy. All patients underwent total hysterectomy, bilateral salpingoophorectomy and pelvic and para-aortic lymphadenectomy depending on the pathological features. RESULTS: Operative time was longer in the laparoscopy group as compared to robotics and laparotomy (218.2 min, 189.2 min, and 157.4 min respectively, p=0.000). The estimated blood loss was lower in the robotic group relative to the other groups (99.4 ml in robotic, 190.0 ml in laparoscopy and 231.5 ml in laparotomy, p=0.000). Similar findings were observed for the pre- and post-operative mean hemoglobin levels (-1.3g/dl, -2.3g/dl and -2.5 g/dl respectively, p=0.000), and transfusion rate (4.2%, 7.1% and 14.1% respectively, p=0.036). The length of hospital stay was higher in the laparotomy group compared to robotics and laparoscopy (8.1, 3.5 and 4.6 days respectively; p=0.000). The conversion rate to laparotomy was lower for robotics (2.4% for robotics and 8.1% for laparoscopy, p=0.181). Overall complications were similar for robotics and laparoscopy (21.1%, 28.5%) (p=0.079). Robotic complications were significantly lower as compared to laparotomy (21.2 vs 34.9% (p=0.036). No differences were found relative to disease-free or overall survival among the three groups. The global costs were similar for the three approaches (p=0.566). CONCLUSION: Robotics is a safe alternative to laparoscopy and laparotomy for endometrial cancer patients, offering improved perioperative outcomes and similar cost as compared to the other two surgical approaches.

Usefulness of an educational leaflet to modify sexual risk behaviour in women with external genital warts.

We aimed to assess the effectiveness of an educational leaflet to modify sexual risk behaviour in women with external genital warts. Women with genital warts who attended in daily gynecological practice participated in a 12-month prospective randomised observational study. Randomisation was carried out by centres. At the initial visit, patients underwent complete gynecological examination, including an acetic acid test. Those assigned to the intervention group received an educational leaflet to improve patient's knowledge about warts (counselled group). Only patients with complete clearance after 6 months of initial therapy continued the study. The counselled group included 114 women and the non-counselled group 97. A significant increase in the use of condoms at visit 3 as compared with baseline (83.2% vs 66.1%, P < 0.05) was observed in the counselled group. The mean number of sexual partners was also significantly lower in the counselled group at each follow-up visit. Recurrences were documented in 9 of the 145 patients who completed the study (recurrence rate 6.2%). Recurrences occurred in 7 patients in the counselled group and in 2 in the non-counselled group (8.6% vs 3.1%, P = 0.299), and in all cases occurred at 9 months after initiation of treatment. In conclusion, the educational leaflet, which is simple and easy to implement in routine daily practice, proved to be effective in modifying sexual risk behaviour in women with external genital warts. This educational strategy did not seem to affect recurrence if an acetic acid test is routinely performed during the initial work-up studies.

Heterogeneous expression of HLA-G1, -G2, -G5, -G6, and -G7 in myeloid and plasmacytoid dendritic cells isolated from umbilical cord blood.

Human leukocyte antigen (HLA)-G is a human nonclassic major histocompatibility complex (MHC) molecule characterized by a limited polymorphism and a low, restricted cell surface expression. HLA-G is constitutively expressed on trophoblasts, fetal endothelial, and epithelial cells, conferring alloimmune protection during pregnancy. HLA-G is also expressed in some malignancies and on macrophages and dendritic cells (DC) in tumoral and inflammatory diseases. Because DC constitute an important component in the immune response and umbilical cord blood has a different immune behavior than peripheral blood, the HLA-G protein profile and mRNA expression were investigated on the different DC subsets present in cord blood. Surface and intracellular expression have been reported on DC and HLA-G1, -G2, -G5, -G6, and -G7 transcripts were present. Different levels of soluble HLA-G were obtained from serum and correlated with gene expression. These data are in contrast with the data previously described for adult peripheral blood, where a limited pattern of HLA-G transcripts was reported; only in the maturation process were more isoforms present. These results demonstrate that DC from cord blood have a different behavior than DC in peripheral blood and could be in accordance with the results obtained in cord blood transplantation, where a lesser effect of graft-versus-host disease exists than in bone marrow transplantation.

Association between BRCA1 mutations and ratio of female to male births in offspring of families with breast cancer, ovarian cancer, or both.

CONTEXT: Defects in X-chromosome inactivation distort sex ratio in mice. The BRCA1 gene is also involved in X-chromosome inactivation, suggesting the possibility that some sex-ratio distortion may be associated with BRCA1-related human cancer syndromes. OBJECTIVE: To determine whether BRCA1 mutations are associated with distortion of the sex ratio of births in families with breast cancer, ovarian cancer, or both. DESIGN AND SETTING: Analysis of germline mutations in participants from Spain who had been screened for BRCA between 1998 and 2002. PARTICIPANTS: Sixty-eight families with at least 3 breast cancer cases or ovarian cancer cases, or both types of cancer in 2 generations (germline mutations: BRCA1, n = 17; BRCA2, n = 15; and BRCA unrelated, n = 36). An average of 4 relatives per family were tested for the corresponding BRCA mutation. MAIN OUTCOME MEASURE: Male and female births registered in breast and/or ovarian pedigrees tested for the presence of BRCA1 and BRCA2 germline mutations. RESULTS: Of BRCA1-related breast and/or ovarian cancer pedigrees, there was a 2-fold excess of female births (218 female vs 109 male births). Of BRCA2-related or BRCA-unrelated breast and/or ovarian cancer pedigrees, there was not an excess of female births (175 female/150 male and 344 female/315 male, respectively). Of 327 BRCA1 births, 218 (67%) were female births compared with 54% among BRCA2 pedigrees (175/327; P<.001) and 52% among BRCA-unrelated pedigrees (344/659; P<.001). Female births increased in the offspring of BRCA1 carriers compared with BRCA2 carriers (67% vs 52%; P =.004). CONCLUSION: In these families with breast and/or ovarian cancer, mutations in BRCA1 but not BRCA2 were associated with a sex ratio skewed against male births.