Gabriele Siesto

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.

Urinary tract infections in women

Urinary tract infections (UTIs) are conditions frequently complained by women both in the general population and in the hospital setting. Indeed it has been estimated that one woman out of three will experience at least an episode of UTI during lifetime. A comprehensive literature review of published experimental and clinical studies of UTI was carried out at the University of Insubria electronic library (SFX Bicocca-Insubria) with cross-search of seven different medical databases (AMED, BIOSIS Previews on Web of Knowledge, Cochrane Library, Embase and Medline on Web of Knowledge, OvidSP and PubMed). We aimed to draw a clinical guideline addressed to the management of UTI, based on the most recent evidence.

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.

Should adnexal mass size influence surgical approach? A series of 186 laparoscopically managed large adnexal masses

Objective  To evaluate the feasibility and safety of laparoscopic management of adnexal masses ≥10 cm in size.

TVT-O for the Treatment of Pure Urodynamic Stress Incontinence: Efficacy, Adverse Effects, and Prognostic Factors at 5-Year Follow-up

BACKGROUND Inside-out tension-free vaginal transobturator tape (TVT-O) is currently one of the most effective and popular procedures for the surgical treatment of female stress urinary incontinence (SUI), but data reporting long-term outcomes are scarce. OBJECTIVE To evaluate the efficacy and safety of TVT-O 5-yr implantation for management of pure SUI in women. DESIGN, SETTING, AND PARTICIPANTS A prospective observational study was conducted in four tertiary reference centers. Consecutive women presenting with urodynamically proven, pure SUI treated by TVT-O were included. Patients with mixed incontinence and/or anatomic evidence of pelvic organ prolapse were excluded. INTERVENTION TVT-O implantation without any associated procedure. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Data regarding subjective outcomes (International Consultation on Incontinence-Short Form [ICIQ-SF], Patient Global Impression of Improvement, patient satisfaction scores), objective cure (stress test) rates, and adverse events were collected during follow-up. Multivariable analyses were performed to investigate outcomes. RESULTS AND LIMITATIONS Of the 191 women included, 21 (11.0%) had previously undergone a failed anti-incontinence surgical procedure. Six (3.1%) patients were lost to follow-up. The 5-yr subjective and objective cure rates were 90.3% and 90.8%, respectively. De novo overactive bladder (OAB) was reported by 24.3% of patients at 5-yr follow-up. Median ICIQ-SF score significantly improved from 17 (interquartile range [IQR]:16-17) preoperatively to 0 (IQR: 0-2) (p<0.0001). Failure of a previous anti-incontinence procedure was the only independent predictor of subjective recurrence of SUI (hazard ratio [HR]: 4.4; p = 0.009) or objective (HR: 3.7; p = 0.02). No predictive factor of de novo OAB was identified. CONCLUSIONS TVT-O implantation is a highly effective option for the treatment of women with pure SUI, showing a very high cure rate and a low incidence of complications after 5-yr follow-up.

Urinary symptoms and urodynamic findings in women with pelvic organ prolapse: is there a correlation? Results of an artificial neural network analysis.

BACKGROUND International official guidelines recommend urodynamic (UDS) evaluation in patients with pelvic organ prolapse (POP). However, the real benefit of this examination is still the subject of heated and controversial debate. Therefore, we aimed to assess the correlation between urinary symptoms and UDS findings in women with POP through the implementation of a sophisticated computer-based technology in the outpatient workup. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study was performed in a single, tertiary, urogynaecologic referral department, enrolling consecutive women seeking care for pelvic floor dysfunctions. INTERVENTION Patients underwent clinical and urodynamic evaluation. Data regarding baseline characteristics, symptoms, anatomic, and urodynamic findings were gathered for each patient. Multiple linear regression (MLR) and artificial neural networks (ANNs) were performed to design predicting models. RESULTS AND LIMITATIONS A total of 802 women with POP were included. POP quantification stages and baseline data poorly correlated to final UDS findings. Stress urinary incontinence and overactive bladder were both independently associated to each UDS diagnosis, including detrusor overactivity (DO), urodynamic stress incontinence (USI), and mixed urinary incontinence (USI plus DO). Receiver operating characteristic comparison confirmed that ANNs were more accurate than MLR in identifying predictors of UDS diagnosis, but none of these methods could successfully overcome UDS. Case-control studies are needed to confirm our findings. CONCLUSIONS Despite the current debate based on the actual value of UDS in women with POP, even the implementation of ANN, a sophisticated computer-based technology, does not permit an accurate diagnosis just on the basis of symptoms or avoiding UDS. Therefore, in women with POP, especially if scheduled for surgery, UDS should be considered as mandatory, since misleading counselling could result in unpleasant unexpected events.

Infectious morbidity after total laparoscopic hysterectomy: does concomitant salpingectomy make a difference?

The study was aimed to test the hypothesis that preservation of the fallopian tubes at the time of total laparoscopic hysterectomy (TLH) increases the risk for postoperative infection. The study group consisted of 137 consecutive women undergoing TLH with conservation of the ovaries, who had concomitant bilateral total salpingectomy at the time of TLH. The control group included 145 women who had had TLH without salpingo‐oophorectomy before the study period. Women undergoing bilateral total salpingectomy at the time of TLH had a lower rate of infectious morbidity compared with those who had TLH alone (3/137 versus 14/145, P = 0.01). Multivariable analysis showed that bilateral total salpingectomy at the time of TLH and blood loss are independent predictors of infectious morbidity.

Risk factors for cervical intraepithelial neoplasia recurrence after conization: a 10-year study

OBJECTIVE To evaluate the risk factors potentially involved in the development of cervical intraepithelial neoplasia (CIN) recurrence after cervical conization in a long-term follow-up period. STUDY DESIGN Consecutive patients with histologically proven CIN who had undergone either cold knife conization or a loop electrosurgical excision procedure were enrolled and scheduled for serial follow-up examinations over a 10-year period. Data were stored in a digital database. Multivariate analysis was performed to identify factors for recurrence. RESULTS Between January 1999 and December 2009, 282 patients fulfilled the inclusion criteria and were included in the final statistical analysis. After a median follow-up of 26.7 months (range 6-100), 64 (22.7%) women developed histologically confirmed recurrence. The 2-year recurrence-free survival was 83.7% and 66.7% for women with negative and positive margins, respectively (p=0.008). The 5-year recurrence-free survival was 75.4% and 50.3% for patients with negative and positive margins, respectively (p=0.0004). Positive surgical margin was the most important independent predictor of recurrence [HR 2.5 (95%CI 1.5-4.5), p=0.0007; Wald 11.338]. After multinomial logistic regression the indication for conization based on persistent CIN1 was the only independent predictor for negative margin [OR 0.3 (95%CI 0.1-0.7), p=0.008]. CONCLUSIONS Our study demonstrated that the surgical margin status represents the most important predictor for CIN recurrence after conization. After excisional therapy, close follow-up is mandatory for the early detection of recurrent disease. The identification of risk factors for recurrence may guide clinical decision-making on expectant management versus re-intervention.