Evolving trends in the management of pelvic inflammatory disease (PID) during SARS-CoV-2 pandemic: A multicenter retrospective cohort study.

BACKGROUND AND AIM: Pelvic inflammatory disease (PID) is usually managed by conservative treatment, but in selected cases, especially in the presence of a tubo-ovarian abscess (TOA), surgical management is a recognized treatment option. We compared the trends in managing PID and short-term outcomes before and during the SARS-CoV-2 pandemic. METHODS: This is a retrospective study performed in three Italian gynecological centers. We included patients admitted to hospital with a diagnosis of PID. Demographic characteristics, management, time to diagnosis, and time to treatment were compared before versus during the SARS-CoV-2 pandemic. RESULTS: One hundred nineteen PID patients were screened, eighty-one before the SARS-CoV-2 pandemic, and thirty-eight after the onset. At admission, leukocytosis (median 19.73 vs. 13.99 WBC/mm3, p-value = 0.02) was significantly higher in patients who underwent surgery after the onset of the pandemic. TOA incidence was higher in patients who underwent surgery during the SARS-CoV-2 pandemic, but the difference did not reach statistically significance (p = 0.06). The proportion of patients treated with surgery dropped to 26.3% after the onset from 46% of patients before the onset of pandemic (p = 0.03). Furthermore, a higher percentage of emergency surgical procedures on day 0 of hospital admission were performed after the onset of the pandemic (50% vs. 13.1%, p = 0.01). CONCLUSIONS: In this retrospective cohort study, we found that the SARS-CoV-2 pandemic influenced the clinical presentation and management of PID in favor of conservative treatment. Patients who underwent surgery during the SARS-CoV-2 pandemic had higher inflammatory markers.

Simple hysterectomy versus radical hysterectomy in early-stage cervical cancer: A systematic review and meta-analysis.

BACKGROUND: This systematic review (SR) and meta-analysis aims to compare the surgery-related results and oncological outcomes between SH and RH in patients with early-stage cervical cancer. METHOD: We systematically searched databases including PubMed, Embase and Cochrane to collect studies that compared oncological and surgery-related outcomes between SH and RH groups in patients with stage IA2 and IB1 cervical cancer. A random-effect model calculated the weighted average difference of each primary outcome via Review Manager V.5.4. RESULT: Seven studies comprising 6977 patients were included into our study. For oncological outcomes, we found no statistical difference in recurrence rate [OR = 0.88; 95% CI (0.50, 1.57); P = 0.68] and Overall Survival (OS) [OR = 1.23; 95% CI (0.69, 2.19), P = 0.48]. No difference was detected in the prevalence of positive LVSI and lymph nodes metastasis between the two groups. Concerning surgery-related outcomes, the comprehensive effects revealed that the bladder injury [OR = 0.28; 95% CI (0.08, 0.94), P = 0.04] and bladder disfunction [OR = 0.10; 95% CI (0.02, 0.53), P = 0.007] of the RH group were higher compared to the SH group. CONCLUSION: This meta-analysis suggested there are no significant differences in terms of both recurrence rate and overall survival among patients with stage IA2-IB1 cervical cancer undergoing SH or RH, while the SH group has better surgery-related outcomes. These data confirm the need to narrow the indication for RH in early-stage cervical cancer.

Major and minor complications in Veress needle (VN) and direct trocar insertion (DTI) for laparoscopic closed-entry techniques: an updated systematic review and meta-analysis.

OBJECTIVE: Direct insertion of the trocar is an alternative method to Veress needle insertion for the creation of pneumoperitoneum. We conducted a systematic review and meta-analysis to compare these two entry closed techniques. DATA SOURCE: A systematic review of the literature was done on PubMed, MEDLINE, Embase, Scopus, and EBSCO. METHODS: The literature search was constructed until May 01, 2022, around search terms for "Veress," "direct trocar," "needle," "insertion," and "laparoscopic ways of entry." This systematic review was reported according to the PRISMA Statement 2020. RESULTS: Sixteen controlled trials (RCTs) and 5 observational studies were included in the systematic review. We found no significant differences in the risk of major complication during the access manoeuvres between DTI and VN: bowel injuries (OR = 0.76, 95% CI: 0.24-2.36, P = 0.63), major vascular injuries (OR = 1.74, 95% CI 0.56-5.38, P = 0.34), port site hernia (OR = 2.41, 95% CI: 0.28-20.71, P = 0.42). DTI has a lower risk of minor complications such as subcutaneous emphysema (OR = 5.19 95% CI: 2.27-11.87, P < 0.0001), extraperitoneal insufflation (OR = 5.93 95% CI: 1.69-20.87, P = 0.006), omental emphysema (OR = 18.41, 95% CI: 7. 01-48.34, P < 0.00001), omental bleeding (OR = 2.32, 95% CI: 1.18-4.55, P = 0.01), and lower number of unsuccessful entry or insufflation attempts (OR = 2.25, 95% CI: 1.05-4.81, P = 0.04). No significant differences were found between the two groups in terms of time required to achieve complete insufflation (MD = - 15.53, 95% CI: - 91.32 to 60.27, P = 0.69), trocar site bleeding (OR = 0.66, 95% CI, 0.25-1.79, P = 0.42), and trocar site infection (OR = 1.19, 95% CI, 0.34-4.20, P = 0.78). CONCLUSION: There were no statistically significant differences in the risk of major complications during the access manoeuvres between DTI and VN. A lower number of minor complications were observed in DTI compared with those in Veress access.

Three-dimensional vision versus two-dimensional vision on laparoscopic performance of trainee surgeons: a systematic review and meta-analysis.

Laparoscopic surgery underwent great improvements during the last few years. This review aims to compare the performance of Trainee Surgeons using 2D versus 3D/4 K laparoscopy. A systematic review of the literature was done on Pubmed, Embase, Cochrane's Library and Scopus. The following words and key phrases have been searched: "Two-dimensional vision", "Three-dimensional vision", "2D and 3D laparoscopy", "Trainee surgeons". This systematic review was reported according to the PRISMA statement 2020. PROSPERO registration No. CRD42022328045. Twenty-two randomized controlled trials (RCTs) and two observational studies were included in the systematic review. Two trials were carried out in a clinical setting, and twenty-two trials were performed in a simulated setting. In studies involving the use of a box trainer, the number of errors in the 2D laparoscopic group was significantly higher than in the 3D laparoscopic group during the performance of FLS skill tasks: peg transfer (MD: -0.82; 95% CI - 1.17 to - 0.47; p < 0.00001), cutting (MD: - 1.09; 95% CI - 1.50 to - 0.69 p < 0.00001), suturing (MD: - 0.48; 95% CI - 0.83 to - 0.13 p = 0.007), However, in clinical studies, there was no significant difference in the time taken for laparoscopic total hysterectomy (MD: 8.71; 95% CI - 13.55 to 30.98; p = 0.44) and vaginal cuff closure (MD: 2.00; 95% CI - 0.72 to - 4.72; p = 0.15) between 2D group and 3D group. 3D laparoscopy facilitates learning for novice surgeons and shows improvements in their laparoscopic performance.

Influence of uterine manipulator on oncological outcome in minimally invasive surgery of endometrial cancer: A systematic review and meta-analysis.

AIM: The endoscopic approach for early-stage endometrial cancer (EC) treatment is considered gold standard. Some authors expressed their concern regarding uterine manipulator (UM) as a risk factor for tumor spillage and dissemination allowing peritoneal or lympho-vascular spaces invasion (LVSI). This meta-analysis aimed to evaluate the effect of UM on the presence of LVSI, recurrence rate and presence of atypical or malignant peritoneal cytology in patients with endometrial cancer. METHODS: We searched electronic databases including PubMed, MEDLINE, Embase, Scopus, EBSCO, Google Scholar, and ClinicalTrials.gov. The pooled results were used to evaluate the association between the use of UM and oncological outcomes. This systematic review was reported according to PRISMA statement 2020. Statistical meta-analysis was performed using Review Manager software. RESULTS: This systematic review included 18 studies (3 prospective studies, 13 retrospective studies, and 2 RCT). The pooled results showed no significant difference (RR: 0.86, 95% CI, 0.69 to 1.08) in the incidence of LVSI between manipulated hysterectomy and total abdominal hysterectomy (TAH) and between UM group and non-UM group in minimally invasive surgery (RR: 1.18, 95% CI, 0.76 to 1.85), no significant difference in the rate of recurrence (RR: 1.11, 95% CI, 0.71 to 1.74), in the incidence of positive peritoneal cytology between manipulated and non-manipulated hysterectomies in minimally invasive surgery (RR: 1.89, 95% CI, 0.74 to 4.83) and before and after the use of uterine manipulator (RR: 1.21, 95% CI, 0.68 to 2.16). We found a positive association between malignant cytology and hysterectomies in which a uterine manipulator had been used in a sub-group analysis where LH/LAVH were compared to TAH. (RR = 2.26, 95% CI, 1.08-4.71. P = 0.03). CONCLUSIONS: This meta-analysis supports that the use of uterine manipulator for minimally invasive treatment of endometrial cancer does not increase the rate of recurrence and LVSI. Therefore, the opportunity of any other studies on its use in endometrial cancer women should be questioned.

Recurrent pneumothorax after cesarean delivery in the critically ill pregnant with severe COVID-19 ARDS: a case report.

OBJECTIVE: Few data are available on the ICU management and on the possible respiratory complications of invasively ventilated pregnant patients affected by COVID-19 pneumonia, especially in the early phase of pregnancy. Tension pneumothorax has been previously described as a rare cause of respiratory failure after delivery, but its occurrence in the postpartum of COVID-19 patient has not been reported yet. We hereby describe the ICU management of a 23rd gestational week pregnant woman who underwent invasive mechanical ventilation, prone positioning, and cesarean delivery during her ICU stay for COVID-19 related pneumonia. Moreover, we focused on the occurrence and management of recurrent tension pneumothorax after the cesarean delivery. CASE REPORT: A 23rd gestational week pregnant woman was admitted to the ICU for a COVID-19 bilateral pneumonia and underwent invasive mechanical ventilation and prone positioning. Cesarean delivery was planned during the ICU stay, while the patient was receiving invasive mechanical ventilation. After delivery, the patient experienced a recurrent pneumothorax that required the positioning of multiple chest drains. CONCLUSIONS: In pregnant critically ill COVID-19 patients, mechanical ventilation management is particularly challenging, especially in the postpartum period. Prone positioning is feasible and can improve oxygenation and respiratory system compliance, while tension pneumothorax must be suspected if the respiratory function suddenly deteriorates after delivery.

Hypoxic events during non-obstetric abdominal surgery in pregnant women.

OBJECTIVE: Every year 0.5-2% of women undergo non-obstetric surgery in pregnancy. Hypoxic events with short-term and long-term consequences are one of the most frequent complications in surgery. There is only limited data available regarding the impact of these events. This review aims to analyze the current literature on hypoxic events occurring in non-obstetric abdominal surgery in pregnant women, focused on maternal and fetal outcomes. MATERIALS AND METHODS: We performed a non-systematic review of the literature, through a PubMed search using the key words "hypoxemia", "non-obstetric surgery", "surgical procedures", "pregnancy", "pregnant women" and "outcome". RESULTS: There is little data available regarding maternal and fetal outcomes after hypoxic episodes during non-obstetric surgery in pregnancy. In these cases, conservative intrauterine resuscitation maneuvers or immediate delivery should be taken into account. Perimortem cesarean section can be lifesaving for both mother and fetus when maternal collapse is non responsive to resuscitation procedures. Inaccurate information regarding maternal and fetal outcomes is due to the lack of robust data and the heterogeneity of the causes underlying maternal respiratory complications during surgery. CONCLUSIONS: Non-obstetric surgery during pregnancy must be performed when indicated. An expert multidisciplinary team, composed of obstetricians, surgeons, and anesthesiologists need to be included, giving appropriate attention to the physiological changes of respiratory, cardiovascular, and gastrointestinal system that occur during pregnancy. The shortest operative time and peri-operative assistance should be ensured. Complications, such as hypoxic events in pregnant patients need adequate assistance. Multidisciplinary cooperation, continuous training and simulation for anesthesiology and resuscitative procedures can guarantee this.

Post-abortion long-acting reversible contraception in a sample of Italian women: intrauterine device versus subdermal implant.

Long-acting reversible contraceptives (LARC) represent an especially effective kind of post-abortion contraception. We aimed at assessing satisfaction, discontinuation, efficacy, and tolerability associated with either levonorgestrel intrauterine device (L-IUCD), the copper intrauterine device (C-IUCD) and implant (IMP) after termination of pregnancy (TOP). We recorded baseline data about the patients and performed phone surveys at 3, 6 and 12 months after insertion to assess the bleeding profile. Furthermore, women were inquired about possible adverse events, satisfaction, and discontinuation at 12 months after insertion. LARC continuers (>12 months after TOP) were divided into three groups: L-IUCD (n = 47), C-IUCD (n = 6) and IMP (n = 36). Satisfaction rates among L-IUCD users were higher than among IMP users (100% vs. 72.2%, p < .05). A higher, yet not significant, share of patients decided to withdraw contraception in IMP group (3.6% in IUCD group and 12.2% in IMP group). The bleeding profile was significantly more favorable among L-IUCD users than among IMP users. Finally, the reported rate of treatment-associated adverse events did not differ significantly among the groups. L-IUCD insertion after TOP is associated with higher satisfaction and lower discontinuation rates than IMP. Such pattern could be attributed to a more favorable bleeding profile.

Role of interventional radiology in pregnancy complicated by placenta accreta spectrum disorder: systematic review and meta-analysis.

OBJECTIVE: To evaluate the potential benefit of interventional radiology (IR) in improving the outcome of women undergoing surgery for a placenta accreta spectrum (PAS) disorder. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for studies comparing outcomes of women with a prenatal diagnosis of PAS who underwent an IR procedure before surgery vs those who did not, using a robust collection of terms relating to PAS. The primary outcome was intraoperative estimated blood loss (EBL). Secondary outcomes were the number of transfused units of packed red blood cells (PRBC), fresh frozen plasma (FFP), platelets and cryoprecipitate, operation time, length of hospital stay, EBL ≥ 2.5 L, PRBC transfused ≥ 5 units, surgical complications, bladder or ureteral injury, relaparotomy, infection, disseminated intravascular coagulation, and complications related to endovascular catheter placement. Only studies reporting on the incidence of, or the mean difference in, the observed outcomes in women affected by a PAS disorder who had vs those who did not have an IR procedure before surgery were considered for inclusion. All outcomes were explored in the overall population of women with a prenatally diagnosed PAS disorder and in those undergoing hysterectomy. Quality assessment of each included study was performed using the Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I) tool. The GRADE methodology was used to assess the quality of the body of retrieved evidence. RESULTS: Fifteen studies (958 women with PAS) were included. In women who underwent IR before surgery, compared with those who did not, mean EBL (mean difference (MD), -1.02 L; 95% CI, -1.60 to -0.43 L; P < 0.001) and the risk of EBL ≥ 2.5 L (odds ratio (OR), 0.18; 95% CI, 0.04-0.78; P = 0.02) were significantly lower. There was no significant difference between the two groups in the other outcomes explored. On subgroup analysis of pregnancies complicated by PAS undergoing hysterectomy, EBL (MD, -0.68 L; 95% CI, -1.24 to -0.12 L; P = 0.02) and the number of transfused FFP units (MD, -1.66; 95% CI, -2.71 to -0.61; P = 0.02) were significantly lower in women who had an endovascular IR procedure compared with controls. Furthermore, women undergoing IR had a significantly lower risk of EBL ≥ 2.5 L (OR, 0.10; 95% CI, 0.02-0.47; P = 0.004). Overall, complications related to the placement of an endovascular catheter occurred in 5.3% (95% CI, 2.6-8.9; I2 , 65.3%) of pregnancies undergoing IR. Overall quality of evidence, as assessed by GRADE, was very low. CONCLUSIONS: The current available data provide encouraging evidence that IR procedures may be associated with lower EBL and need for transfusion in pregnancies undergoing surgery for a PAS disorder. However, given the overall very low quality of the evidence, further large studies are needed in order to confirm the beneficial role of IR in improving the outcome of these women. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.

Biomolecular basis related to inflammation in the pathogenesis of endometrial cancer.

OBJECTIVE: Endometrial cancer (EC) is a complex gynecological neoplasm with several clinical, histopathological and genetic features. Different hormonal, metabolic and biochemical axes are involved in pathogenesis. Obesity is a well-known risk factor for this disease and the role of local and systemic effects of adipose tissue, especially in the promotion of subclinical chronic inflammation, is an important issue. Indeed, inflammation is related to the pathogenesis of different tumors, including EC. This review aims to remark the role of obesity and inflammation in the pathogenesis of EC cancer through an exploration of the current literature. MATERIALS AND METHODS: We performed a comprehensive review of the literature through a PubMed search using key words and including English language papers looking at this topic. RESULTS: Only few authors analyzed the role of inflammatory cytokines released by adipose tissue in visceral abdominal fat depots. Tumor Necrosis Factor-α, Interleukin-6, Interleukin-1 Receptor Antagonist, Nuclear Factor-kB, Leptin, Adiponectin and C Reactive Protein were studied for cancer risk prediction models, risk stratification or targeted therapies. Furthermore, genetic studies evaluated the effect of inflammatory cytokines secreted by visceral adipocytes in the modulation of angiogenesis and signaling pathways such as PI3K/AKT/mTOR, that result altered in the pathogenesis of EC. CONCLUSIONS: The identification of inflammatory biomarkers released by adipose tissue, in the pathogenesis of EC, could be useful in improving diagnostic accuracy, identifying targets of therapy, suggesting useful lifestyle behaviors. A deeper knowledge of the genetic background of alterations in inflammatory pathway genes could better define the population exposed to a higher susceptibility to EC due to genetic polymorphisms. Future studies are needed to better understand this field.

Pro-inflammatory M1/Th1 type immune network and increased expression of TSG-6 in the eutopic endometrium from women with endometriosis.

OBJECTIVE: The study aimed to explore the type 1 and type 2 cytokines expression in the endometrium from women affected by endometriosis compared to controls. The expression of TSG-6, a multifunctional protein involved in several inflammatory disease, was also evaluated. Study Design SETTING: Experimental clinical study. PATIENTS: 10 patients affected by endometriosis and 11 controls. INTERVENTIONS: Patients underwent to an ultrasound transvaginal examination and a diagnostic hysteroscopy in order to exclude any uterine abnormality. All patients underwent endometrial biopsy using a Novak's curette. MAIN OUTCOME MEASURES: The endometrial expression of type 1 (IL- 1 ß TNF-α, IL-8) and type 2 (IL-10) cytokines, and of TSG-6 was evaluated by immunohistochemistry and by real time PCR. The expression of TSG-6 was confirmed by western blot. RESULTS: Results of PCR analysis and of immunohistochemistry revealed an increased expression of IL-1ß, TNF-α, IL-8 and of TSG-6 in the endometrium of endometriosic patients. IL-10 expression did not show any difference. CONCLUSIONS: An increased expression of pro-inflammatory type 1 cytokines was demonstrated in the endometrium from endometriosic patients, suggesting an endometrial environment harmful for implantation due to the prevalence of Th1 related immunity. An increased expression of TSG-6 was also demonstrated for the first time. Our findings concur to better define the inflammatory imbalance and the abnormal endometrial receptivity, reported in literature, of the eutopic endometrium of women affected by endometriosis.

Predicting pelvic visceral hypersensitivity from the discomfort of Lugol' test during colposcopy.

OBJECTIVE: Assessing the pelvic visceral hypersensitivity after Lugol' staining during colposcopy. PATIENTS AND METHODS: On an unselected sample of 91 patients, pelvic discomfort and discomfort during menstruation, sexual intercourse, defecation, urination were assessed (numeric rating score from 0 to 10) before colposcopy. Few minutes after Lugol' staining, it was assessed the discomforting perception provoked by iodine by using the same numeric rating scale. All those scores were increased by 1 to allow regression models (linear, logarithmic, inverse, cubic, quadratic, exponential). RESULTS: The only significant models were the linear, logarithmic and inverse ones for pelvic discomfort overall score and the linear one for sexual intercourse score. A discomfort score of 4.5 or less after Lugol' staining should be a normal reaction to iodine nociception in the vagina. CONCLUSIONS: Lugol' staining during colposcopy causes discomfort related with visceral nociception. The rise in numeric rating score after colposcopy can be used for screening pelvic visceral hypersensitivity.

Correlations between sonographically measured and actual incision site thickness of lower uterine segment after repeated caesarean section.

AIM: The aim of the present study was to verify how much the sonographically measured thickness of the lower uterine segment caesarean-section (LUS-CS) scar correlates with incision site thickness in a repeated caesarean section after uterotonic administration. METHODS: Sixty-three obstetric patients at term undergoing repeated caesarean section. LUS-CS thickness was measured sonographically before the repeated caesarean. Some seconds after delivery of the fetus and placenta and administration of an institutional, standard uterotonic, LUS was measured on the site of surgical incision (upper side and lower side) using Castroviejo's caliper. Multiple measurements were taken and averaged for improving accuracy. Mean measurements were used for calculations (unilinear correlations and multilinear regression analyses.). RESULTS: Poor correlation was found between sonographically measured scar thickness and lower uterine side incision thickness (r 0.311; C.I. 95% 0.068-0.519; P=0.013) and between sonographically measured scar thickness and uterine scar overall incision thickness (mean of upper side and lower side measurements) (r 0.254; C.I. 95% 0.007-0.472; P=0.045). Sonographically measured scar thickness was smaller in patients with two or more previous caesareans (P=0.045) and greater in patients who had undergone the last of the previous caesarean sections longer than two years earlier (P=0.043). Patients with two or more previous caesareans had smaller upper-side incision thickness (P=0.005); smaller lower-side incision thickness (P=0.038); smaller incision site overall thickness (P=0.006). CONCLUSION: Sonographically measured thickness and incision site thickness of the LUS-CS scar are poorly correlated (about 25%), despite the fact that patients most at risk for uterine rupture have thinner LUS, both sonographically and when measured during surgery.

The role of hysteroscopy in the diagnostic work-up of infertile asymptomatic patients.

PURPOSE OF INVESTIGATION: To demonstrate that office hysteroscopy has a key-role in the diagnostic work-up of infertile couples. MATERIALS AND METHODS: The entire database of hysteroscopies performed in 572 menstruated women from 2008 to 2011, was retrospectively analyzed. A two-dimensional correspondence analysis among endometrial patterns, age ranges, and indication for hysteroscopies was made. A main-effect hierarchical log-linear model was built to assess the goodness of the correspondences found. RESULTS: A clear cluster of aggregation appears in case of both primary and secondary infertility, with and without other indications for hysteroscopy, as well as in case of primary infertility with irregular menstrual bleeding. In such patients, chronic endometritis, normal pattern, and uterine malformations were frequently found. The most significant correspondence was found for normal pattern and chronic endometritis in case of secondary infertility and primary infertility, respectively. CONCLUSIONS: Office hysteroscopy should be reconsidered in the diagnostic work-up of infertile couples. It is able to assess or rule out endometrial factor for female infertility.

Effectiveness of vaginal adelmidrol for treating pelvic visceral discomforts and anxiety: a prospective observational study.

AIM: The aim of this paper was to show that self-assessed anxiety in patients with pelvic visceral discomforts is reduced after the intravaginal administration of adelmidrol. MATERIAL AND METHODS: Twenty-four patients who described themselves as anxious (scoring 5 or more in a 1 to 10 scale in a self-assessment test) and who suffered from pelvic visceral discomfort (during defecation, urination, sexual intercourse and menstruation) were enrolled in the study. Pelvic visceral discomforts were assessed using a questionnaire in which patients were asked to assign a score between 1 and 10 according to intensity. The patients were offered intravaginal adelmidrol therapy (2%, 4.5 mL twice a day for 30 days). The patients were interviewed again and asked to self-assess anxiety and pelvic visceral discomfort at the end of therapy. RESULTS: 12 patients underwent adelmidrol therapy. With the exception of urinary discomfort, all the median scores of pelvic visceral discomforts had improved after 30 days, with significant values achieved for menstruation (P=0.013) and sexual intercourse (P=0.013). Anxiety had also decreased after 30 days (P=0.025), regardless of changes in discomfort levels. CONCLUSION: Adelmidrol could selectively modulate the visceral nociceptive pathways (interoception), relieving pelvic discomfort. This action should have an independent effect on anxiety responses.