Antonella Cromi

Female Sexual Function during Pregnancy and after Childbirth

INTRODUCTION Healthy sexual function during pregnancy and after childbirth is one of the cornerstones for couples to evolve from partners to parents. AIM The aim of our review is to evaluate the available evidence and define present knowledge about female sexual function during pregnancy and after childbirth. METHODS PubMed was searched for articles on sexual function during pregnancy and after childbirth, published from 1960 up to date. The most relevant articles have been reviewed and included. MAIN OUTCOME MEASURES The main outcome is the review of the effect of pregnancy, delivery, and postpartum on female sexuality. RESULTS A total of 48 articles which specifically addressed this topic were included. Sexual function was found to have a significant global decline during pregnancy, particularly in the third trimester and this persisted for 3-6 months following delivery. The lack of adequate information about sex in pregnancy and concerns about the possible adverse obstetric outcomes are the most relevant factors responsible for the avoidance of sexual activity during pregnancy. Breast-feeding, dyspareunia, and postpartum pelvic floor dysfunction were reported as possible causes for the delay in resuming sexual intercourses after childbirth. CONCLUSIONS Couples should be informed about the decline of libido, desire and orgasm, commonly encountered during pregnancy, particularly in the last trimester, and puerperium which may lead to reduction in sexual intercourse frequency.

Tension-free Vaginal Tape for the Treatment of Urodynamic Stress Incontinence: Efficacy and Adverse Effects at 10-Year Follow-Up

BACKGROUND One of the most effective and popular current procedures for the surgical treatment of stress urinary incontinence (SUI) is tension-free midurethral slings. OBJECTIVE To evaluate the outcomes of women with retropubic tension-free vaginal tape (TVT) for urodynamic stress incontinence (USI) after 10-yr follow-up. DESIGN, SETTING, AND PARTICIPANTS This was a prospective observational study. Consecutive women with proven USI were treated with TVT. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. INTERVENTION Standard retropubic TVT. MEASUREMENTS Patients underwent preoperative clinical and urodynamic evaluations. During follow-up examinations, women were assessed for subjective satisfaction and objective cure rates. Multivariable analyses were performed to investigate outcomes. RESULTS AND LIMITATIONS A total of 63 women were included. After 10 yr, 5 patients (8%) were lost or no longer evaluable. The 10-yr subjective, objective, and urodynamic cure rates were 89.7%, 93.1%, and 91.4%, respectively. These rates were stable across the whole study period (p>0.99). De novo overactive bladder was reported by 30.1% and 18.9% of patients at 3-mo and 10-yr follow-up, respectively (p for trend = 0.19). A total of 84.2% of women with detrusor overactivity received antimuscarinic drugs, but 43.8% were nonresponders 12 wk later. At multivariable analysis, maximum detrusor pressure during the filling phase >9cm H(2)O (hazard ratio [HR]: 16.2; p=0.01) and maximum detrusor pressure during the voiding phase ≤29cm H(2)O (HR: 8.0; p=0.01) were independent predictors for the recurrence of SUI, as well as obesity was for the recurrence of objective SUI (HR: 17.1; p=0.01) and of USI (HR: 8.9; p=0.02), respectively. Intraoperatively, bladder perforation occurred in two cases; no severe bleeding or other complications occurred. CONCLUSIONS The 10-yr results of this study seem to demonstrate that TVT is a highly effective option for the treatment of female SUI, recording a very high cure rate with low complications after a 10-yr follow-up.

Vaginal cuff closure after minimally invasive hysterectomy: our experience and systematic review of the literature

OBJECTIVE To determine the incidence of vaginal cuff dehiscence after minimally invasive hysterectomy, we reported our series of total laparoscopic hysterectomies with transvaginal colporraphy. STUDY DESIGN We then conducted a systematic search of PubMed to retrieve published series of laparoscopic and robotic hysterectomies, in which different techniques for vaginal cuff closure were used. RESULTS In our study group, vaginal cuff dehiscence occurred in 2 of 665 (0.3%) patients. Our literature search identified 57 articles, for a total of 13,030 endoscopic hysterectomies. Ninety-one postoperative vaginal separations were reported (0.66%). The pooled incidence of vaginal dehiscence was lower for transvaginal cuff closure (0.18%) than for both laparoscopic (0.64%; odds ratio [OR], 0.28; 95% confidence interval [CI], 0.12-0.65) and robotic (1.64%; OR, 0.11; 95% CI, 0.04-0.26) colporraphy. Laparoscopic cuff closure was associated with a lower risk of dehiscence than robotic closure (OR, 0.38; 95% CI, 0.28-0.6). CONCLUSION Current evidence indicates that transvaginal colporraphy after total laparoscopic hysterectomy is associated with a 3- and 9-fold reduction in risk of vaginal cuff dehiscence compared with laparoscopic and robotic suture, respectively.

One-trocar salpingectomy for the treatment of tubal pregnancy: a 'marionette-like' technique

Laparoscopic salpingectomy for the treatment of tubal pregnancy has traditionally been performed with two ancillary trocars. We report a novel single‐port technique requiring only an umbilical operative laparoscope and a percutaneous midline suture, inserted with a straight needle, to retract the affected fallopian tube. A total of 10 ectopic pregnancies have been successfully treated with this approach. The procedure was not technically demanding and the operative time was comparable to that of standard laparoscopic methods. No intraoperative and postoperative complication occurred. Ancillary trocars were not necessary in any of these cases. Our results showed that one‐trocar salpingectomy is a feasible and safe technique.

Vaginal cuff dehiscence in a series of 12,398 hysterectomies: effect of different types of colpotomy and vaginal closure.

OBJECTIVE: To investigate the risk of vaginal cuff dehiscence after different routes of hysterectomy and methods of cuff closure. METHODS: A multi-institutional analysis of 12,398 patients who underwent hysterectomy for both benign and malignant disease between 1994 and 2008 was performed. We analyzed how different routes of hysterectomy and approaches to cuff suture may influence the risk of development of vaginal dehiscence. RESULTS: Women who had total laparoscopic (n=3,573), abdominal (n=4,291), and vaginal (n=4,534) hysterectomies experienced 23 (0.64%), 9 (0.2%), and 6 (0.13%) cases of vaginal cuff dehiscence, respectively. Total laparoscopic hysterectomy was associated with a higher incidence of cuff separations, compared with abdominal hysterectomy (0.64% compared with 0.21%, P=.003) and vaginal hysterectomy (0.64% compared with 0.13%, P<.001). Within the endoscopic group, patients who underwent vaginal closure with laparoscopic knots had a higher rate of cuff dehiscence than patients who had suture with transvaginal knots (20 of 2,332 [0.86%] compared with 3 of 1,241 [0.24%], P=.028). When vaginal suture was performed transvaginally, no statistical difference in vaginal cuff dehiscence rate was observed compared with both abdominal hysterectomy (0.24% compared with 0.21%, P=.83) and vaginal hysterectomy (0.24% compared with 0.13%, P=.38). Use of monopolar energy at the time of colpotomy and reducing the power of monopolar energy from 60 watts to 50 watts when colpotomy was performed at the end of total laparoscopic hysterectomy did not alter the rate of cuff separations. CONCLUSION: Transvaginal suturing appears to reduce the risk of vaginal dehiscence after total laparoscopic hysterectomy. LEVEL OF EVIDENCE: II

Robot-assisted Sacrocolpopexy for Pelvic Organ Prolapse: A Systematic Review and Meta-analysis of Comparative Studies

CONTEXT Surgery represents the mainstay of treatment for pelvic organ prolapse (POP). Among different surgical procedures, abdominal sacrocolpopexy (SC) is the gold standard for apical or multicompartmental POP. Research has recently focused on the role of robot-assisted sacrocolpopexy (RASC). OBJECTIVE To conduct a systematic review on the outcomes of RASC. EVIDENCE ACQUISITION PubMed, Scopus, and Web of Science databases as well as ClinicalTrials.gov were searched for English-language literature on RASC. A total of 509 articles were screened; 50 (10%) were selected, and 27 (5%) were included. Studies were evaluated per the Grading of Recommendations, Assessment, Development, and Evaluation system and the European Association of Urology guidelines. EVIDENCE SYNTHESIS Overall, data on 1488 RASCs were collected from 27 studies, published from 2006 to 2013. Objective and subjective cures ranged from 84% to 100% and from 92% to 95%, respectively. Conversion rate to open surgery was <1% (range: 0-5%). Intraoperative, severe postoperative complications, and mesh erosion rates were 3% (range: 0-19%), 2% (range: 0-8%), and 2% (range: 0-8%), respectively. Surgical-related outcomes have improved with increased experience, with an estimated learning curve of about 10-20 procedures. Laparoscopic SC is less costly than RASC, although the latter has lower costs than abdominal SC. CONCLUSIONS RASC is a safe and feasible procedure for POP; it allows the execution of complex surgical steps via minimally invasive surgery without medium- and long-term anatomic detriments. Further prospective studies are needed to confirm these findings. PATIENT SUMMARY We looked at the outcomes of robotic sacrocolpopexy for prolapse. We found that the use of robotic technology is safe and effective for the treatment of prolapse in women.

Shift work and pregnancy outcomes: a systematic review with meta-analysis of currently available epidemiological studies

Please cite this paper as: Bonzini M, Palmer K, Coggon D, Carugno M, Cromi A, Ferrario M. Shift work and pregnancy outcomes: a systematic review with meta‐analysis of currently available epidemiological studies. BJOG 2011;118:1429–1437.

Ultrasonographic measurement of thymus size in IUGR fetuses: a marker of the fetal immunoendocrine response to malnutrition

To test the hypothesis that intrauterine growth restriction (IUGR) is associated with decreased thymus size in the human fetus.

Postoperative pain after laparoscopic and vaginal hysterectomy for benign gynecologic disease: a randomized trial

OBJECTIVE To compare postoperative pain after laparoscopic and vaginal hysterectomy for benign disease. STUDY DESIGN A prospective randomized trial was designed to compare laparoscopic hysterectomy and vaginal hysterectomy in patients with uterine volume <or=14 weeks of gestation. Postoperative pain was measured using the visual analog scale (VAS) at 1, 3, 8, and 24 hours postoperatively. Intra- and postoperative outcomes were carefully recorded, including the need for postoperative rescue doses of analgesia. RESULTS A total of 82 patients were enrolled. Patients who underwent vaginal hysterectomy complained of higher postoperative pain at each VAS evaluation (VAS-1 hour, P < .0001; VAS-3 hour, P < .0001; VAS-8 hour, P < .0001; VAS-24 hour, P = .0003) with a higher need for rescue analgesia (P < .0001) and a longer hospitalization (P = .001). The other perioperative characteristics were comparable between the 2 groups. CONCLUSION Laparoscopic hysterectomy provides an advantage over vaginal hysterectomy in terms of postoperative pain, need for rescue analgesia and hospital stay, with similar perioperative outcomes.

Cosmetic outcomes of various skin closure methods following cesarean delivery: a randomized trial

OBJECTIVE The objective of the study was to compare scar quality associated with different types of wound closure methods after cesarean section (CS). STUDY DESIGN Patients were randomized to have skin closure following CS with either staples or 3 different types of subcuticular sutures. Scar quality was evaluated 2 and 6 months postoperatively. The Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale were used as scar assessment tools. RESULTS Of the 180 patients who were recruited, 123 successfully completed the study. No difference in both subjective and objective scar rating was detected across groups at either 2 months or 6 months. In the overall study population, objective scores correlated with patient rating, and correlation was strongest between the observer and patient components of the POSAS (r = 0.48). CONCLUSION In women undergoing CS, stapled wounds and those closed with subcuticular sutures result in equivalent cosmetic appearance of the scar.