Hysterectomy by transvaginal natural orifice transluminal endoscopic surgery: An Italian initial experience.

Background: The aim of this study is to evaluate the initial feasibility, safety, and outcomes of hysterectomy performed by transvaginal natural orifice transluminal endoscopic surgery (vNOTES) at three institutions in Italy. Materials and methods: All women who underwent vNOTES hysterectomy ± salpingo-oophorectomy for benign indications at three tertiary referral medical centers between July 2019 and April 2021 were included in a retrospective analysis. All vNOTESs were performed with the use of Alexis® and Vpath Gel paths® (Applied Medical). Perioperative data were extracted from patient records. Patient satisfaction and dyspareunia were prospectively inquired about at 60 days and 6 months. Results: Forty-six patients underwent vNOTES in the study period. Indications for surgery included myomas ± metrorrhagia (52.2%), H-Sil/in situ cervical cancer (10.7%), adenomyosis ± metrorrhagia (8.7%), BRCA 1-2 mutations (6.5%), endometrial hyperplasia (6.5%), ovarian cyst + history of breast cancer (6.5%), metrorrhagia (6.5%), and hydatidiform mole (2.2%). The mean operation time was 91.1 (±32.6) minutes. The mean hemoglobin drop was 1.2 (±0.8). The mean visual analog scale at 24 h for post-operative pain was 3.3 (±1.8). Secondary to our limited experience with the surgical technique, we favor discharge only from day 1. The mean length of hospital stay was 2 (±1.4) days. Two conversions to conventional laparoscopy were reported (4.3%), due to an obliterated pouch of Douglas and a preoperative complication. Two post-operative complications were reported (4.3%). Overall, our data on peri- and post-operative outcomes are similar to those already published for vNOTES. Conclusion: Our initial experience suggests that introducing vNOTES as an alternative to conventional surgery is feasible and may offer some advantages in selected women.

SARS-CoV-2 infection testing at delivery: a clinical and epidemiological priority.

BACKGROUND: Universal testing has been suggested as a useful strategy for a safe exit from the total lockdown, without recurrence of COVID-19 epidemic, delivering women being considered a sentinel population. Further universal testing for pregnant women may be useful in order to define appropriate access to COVID19 areas, dedicated neonatal care, and personal protective equipment. METHODS: During the period 10-26 April, all consecutive women admitted for delivery at the Maternity Hospitals of the city of Milan and in six provinces of Lombardy: Brescia, Como, Lecco Monza, Pavia, and Sondrio. areas were tested with nasopharyngeal swabs.Results and conclusion: Out of 1566 women, 49 were tested positive for SARS-Cov-2 (3.1%, 95% Confidence Interval (CI) 2.3-4.0). This value is largely higher than Heath Authorities estimate. Of tested positive women, 22 (44.9%) had symptoms or reported close contacts with positive patients, that is were found at risk by the itemized questionnaire. In conclusion, routine estimate of frequency of positivity among delivering women can be consider a useful methods to monitor positivity at least in females in their fertile ages.

Mode of birth in women with low-lying placenta: protocol for a prospective multicentre 1:3 matched case-control study in Italy (the MODEL-PLACENTA study).

INTRODUCTION: The term placenta praevia defines a placenta that lies over the internal os, whereas the term low-lying placenta identifies a placenta that is partially implanted in the lower uterine segment with the inferior placental edge located at 1-20 mm from the internal cervical os (internal-os-distance). The most appropriate mode of birth in women with low-lying placenta is still controversial, with the majority of them undergoing caesarean section. The current project aims to evaluate the rate of vaginal birth and caesarean section in labour due to bleeding by offering a trial of labour to all women with an internal-os-distance >5 mm as assessed by transvaginal sonography in the late third trimester. METHODS AND ANALYSIS: The MODEL-PLACENTA is a prospective, multicentre, 1:3 matched case-control study involving 17 Maternity Units across Lombardy and Emilia-Romagna regions, Italy. The study includes women with a placenta located in the lower uterine segment at the second trimester scan. Women with a normally located placenta will be enrolled as controls. A sample size of 30 women with an internal-os-distance >5 mm at the late third trimester scan is needed at each participating Unit. Since the incidence of low-lying placenta decreases from 2% in the second trimester to 0.4% at the end of pregnancy, 150 women should be recruited at each centre at the second trimester scan. A vaginal birth rate ≥60% in women with an internal-os-distance >5 mm will be considered appropriate to start routinely admitting to labour these women. ETHICS AND DISSEMINATION: Ethical approval for the study was given by the Brianza Ethics Committee (No 3157, 2019). Written informed consent will be obtained from study participants. Results will be disseminated by publication in peer-reviewed journals and presentation in international conferences. TRIAL REGISTRATION NUMBER: NCT04827433 (pre-results stage).

Total laparoscopic radical parametrectomy, partial colpectomy, and pelvic lymphadenectomy in patients with occult cervical cancer.

OBJECTIVE: To assess total laparoscopic radical parametrectomy (TLRP) with pelvic lymphadenectomy and partial colpectomy as a safe and feasible treatment option for patients with occult cervical cancer. METHODS: Twelve patients with occult invasive cervical cancer underwent TLRP after prior extrafascial hysterectomy. RESULTS: No intraoperative complications occurred. Two patients experienced postoperative complications: an iliac lymphocyst with pyelectasis, and a vaginal evisceration that occurred during sexual intercourse. Nine patients required no further treatment. One patient with residual disease received brachytherapy as adjuvant treatment. Two patients with positive nodes not detected at preoperative work-up received adjuvant concomitant radiochemotherapy. CONCLUSION: TLRP with pelvic lymphadenectomy is a safe and feasible treatment in patients with occult invasive cervical cancer discovered after extrafascial hysterectomy.

Total laparoscopic radical hysterectomy and pelvic lymphadenectomy in early stage cervical cancer.

OBJECTIVES: The aim of the study was to evaluate the adequacy, morbidity, and survival outcome of laparoscopic type II radical hysterectomy and pelvic lymphadenectomy in patients with early invasive cervical cancer. PATIENTS AND METHODS: Between February 2003 and December 2005, 57 patients underwent total laparoscopic radical hysterectomy (TLRH) with pelvic lymphadenectomy. Eligibility criteria were good general condition, tumor size < 3 cm, no evidence of lymph node metastases in imaging study (magnetic resonance imaging and/or computed tomography and/or positron emission tomography) and body mass index < or = 35. RESULTS: TLRH was completed in 56 patients; in 1 patient, surgery was converted to laparotomy because of positive nodal status at the frozen section. Median age was 43 years and median body mass index was 21.5 kg/m2. The majority of patients (86%) had FIGO stage Ib1 cervical cancer, and the predominant histotype was squamous (59%). Median operating time was 310 minutes and median blood loss 200 mL. No patient required hemotransfusion. Median number of resected lymph nodes was 24, and 6 patients had microscopic node metastasis. Margins were positive in one patient. The only intraoperative complication was a 1-cm cystotomy repaired laparoscopically during the intervention. Four patients required a second surgery, 2 for ureteral stenosis and 2 for the reparation of vaginal cuff diastasis. After a median follow-up of 13 months, 4 patients had a relapse; all 56 patients are alive at present. CONCLUSIONS: TLRH with pelvic lymphadenectomy is an adequate and feasible surgical option in treating early invasive cervical cancer; however a longer follow-up is required to evaluate the oncologic outcome of these patients.