Marzio Angelo Zullo

Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review

Functional disorders of the lower urinary tract are the most common long-term complications following radical surgery for cancer of the uterine cervix (8-80%). These disturbances were associated to the partial interruption of the autonomic fibers innervating the bladder during the resection of anterior, lateral and posterior parametrium and vaginal cuff. The pathophysiology of these changes is actually debated. The nature of the surgical damage appears to be a decentralization rather than a complete denervation and bladder dysfunctions may be either the unmasking of intrinsic detrusor activity, characterized by a loss of beta-adrenergic innervation and a consequent alfa-adrenergic hyperinnervation or the influence of remaining sympathetic innervation. No data on long-term bladder function in patients who underwent class 4 radical hysterectomy have been reported. In our experience on long-term vesical function in 38 patients with locally advanced cervical cancer treated with neoadjuvant chemotherapy and 4 Piver type radical hysterectomy, urinary symptoms were reported in 11 patients (29%), while a normal urodynamic finding was recorded in only nine patients (24%). The most common bladder dysfunction was the storage dysfunction (47%). The voiding dysfunction was present in one patient (3%) and stress urinary incontinence in 20 patients (53%). The parametrial and vaginal resections were compared among the urodynamic diagnosis The size of lateral parametria measured on the giant sections did not differ among the groups of urodynamic diagnosis, while the length of vagina removed was significantly longer in patients with detrusor dysfunctions (storage and voiding dysfunctions) than in patients with normal diagnosis or genuine stress incontinence.

GnRH analogue treatment before hysteroscopic resection of submucous myomas: A prospective, randomized, multicenter study

OBJECTIVE To evaluate the efficacy of GnRH analogue treatment before hysteroscopic resection of submucous myomas in patients with abnormal uterine bleeding. DESIGN Multicenter, prospective, randomized, clinical study. SETTING Tertiary-care university hospitals. PATIENT(S) Thirty-nine consecutive patients with submucous myomas graded as G0 or G1 according to the European Society for Gynecological Endoscopy classification (myoma size 10-35 mm). INTERVENTION(S) Patients were randomized to either direct surgery or 2 months of GnRH analogues before undergoing hysteroscopic resection of the submucous myoma. MAIN OUTCOME MEASURE(S) Operating times, fluid absorption, difficulty of the operation, surgeon satisfaction with the procedure, intra- and postoperative complications, postoperative pain, and patient satisfaction were recorded. RESULT(S) Patients treated with GnRH analogue had significantly shorter operative times (15.9+/-3.1 minutes vs. 21.3+/-4.0 minutes) and significantly reduced fluid absorption (378+/-137 mL vs. 566+/-199 mL) compared with no preoperative medical treatment. Operative difficulty and overall surgeon satisfaction were significantly better in the GnRH analogue group. Patient satisfaction was similar in the two groups. CONCLUSION(S) GnRH analogue treatment before hysteroscopic resection of G0-G1 10-35 mm submucous myomas was effective in reducing operative times, fluid absorption, and difficulty of the procedure.

Vaginal estrogen therapy and overactive bladder symptoms in postmenopausal patients after a tension-free vaginal tape procedure: a randomized clinical trial.

Objective:To evaluate whether the frequency of overactive bladder (OAB) symptoms increases in menopause patients after a tension-free vaginal tape (TVT) procedure, and to determine if topical estrogen therapy can help prevent these symptoms. Design:After undergoing a preoperative assessment, enrolled patients were randomly allocated to receive TVT plus postoperative vaginal estrogen therapy (ET group) or TVT without adjunctive medical treatment (No ET group). The pre- and postoperative assessments included: acquisition of a urogynecologic history with standardized questions regarding urinary function (including a 10-grade visual analogue scale score), urogynecologic clinical examination, and urodynamic assessment. Follow-up assessments were performed at 1, 3, and 6 months after surgery. Results:Fifty-six of 59 patients were evaluable; 28 received topic vaginal estrogen after surgery (ET group) and 28 did not receive adjunctive medical treatment (No ET group). The overall OAB syndrome rate in menopause patients (No ET group) was 7% (2 of 28 patients) at baseline and 32% (9 of 28 patients) 6 months after surgery (P = 0.04). At the 6-month follow-up assessment, the incidence of urinary urgency was 4% (1 of 28 patients) and 29% (8 of 28 patients) in the ET and No ET groups, respectively (P = 0.01). Differences in frequency and nocturia were not statistically significant. Analysis of the visual analogue scale scores revealed that at the 6-month follow-up assessment, urgency significantly improved in the ET group compared with the No ET group (0.23 ± 1.0 vs 2.30 ± 3.7, respectively; P = 0.02). Conclusions:The TVT procedure seems to increase the frequency of OAB syndrome in menopause patients. Vaginal estriol therapy significantly reduces symptoms of urinary urgency, has a high rate of patient satisfaction, and can be used to treat postmenopausal women for at least 6 months after a TVT procedure.

Neoadjuvant Chemotherapy Followed by Radical Surgery in Patients Affected by FIGO Stage IVA Cervical Cancer

BackgroundConcomitant chemoradiotherapy represents the standard treatment for patients affected by locally advanced cervical cancer. Survival rates in patients affected by FIGO stage IVA disease remain poor. Some authors have suggested that neoadjuvant chemotherapy followed by radical surgery might be a valid alternative to standard treatment. The objective of this study was to analyze the feasibility and results obtained by neoadjuvant chemotherapy in patients affected by stage IVA disease.MethodsEighteen patients affected by FIGO stage IVA cervical cancer were treated with 175 mg/m2 paclitaxel and 75 mg/m2 cisplatin every 21 days for three courses followed by radical surgery when feasible.ResultsAll patients were subjected to the three planned chemotherapy courses. Two patients achieved a complete clinical response, and 10 patients achieved a partial clinical response. Ten patients were subjected to anterior pelvic exenteration, whereas the remaining eight patients were treated with chemotherapy, radiotherapy, and concomitant chemoradiotherapy. The estimated 3-year and 5-year overall survival rates were 47.4% and 31.6%, respectively. Patients eligible for surgery benefited from significantly longer survival rates.ConclusionsNeoadjuvant chemotherapy followed by radical surgery is feasible in approximately half of patients affected by FIGO stage IVA cervical cancer. Overall survival rates appear similar to those reported with concomitant chemoradiotherapy. Patients who are amenable to radical surgery after chemotherapy may benefit from long-term survival rates.

A comparison of three different entry techniques in gynecological laparoscopic surgery: a randomized prospective trial

OBJECTIVE Laparoscopic entry techniques vary and still remain debated. We conducted a randomized control trial to compare three entry techniques. STUDY DESIGN Women aged 18-70 years, nominated for laparoscopic surgery at University of Rome Campus Bio-Medico, were randomized into three different groups: Veress needle (VER), Direct trocar insertion (DIR) and Open technique (OP). For each group, minor complications (extra-peritoneal insufflation, trocar site bleeding, omental injury and surgical site infection), failed entry and time of entry of the main trocar were evaluated. Major complications were also considered. Between-group comparisons were performed using chi-square test. Significance P value was <0.05. RESULTS A series of 595 consecutive procedures were included: 193 in the VER group, 187 in the DIR group and 215 in the OP group. Minor complications occurred in 36 cases: extraperitoneal insufflation (n=6) in the VER group only, site bleeding (n=2 in the VER group, n=2 in the DIR group and n=1 in the OP group), site infection (n=5 in the VER and n=6 in OP group), and omental injury (n=6 in the VER group and n=3 in the DIR group). Failed entry occurred in 4 cases of the VER group and 1 case of the DIR group. Mean time of entry was 212.4, 71.4 and 161.7s for the VER, DIR and OP groups respectively. Among major complications, one bowel injury resulted following the Veress technique. CONCLUSIONS In our series, DIR and OP entry presented a lower risk of minor complications compared with VER. In addition, time of entry was shorter in DIR than with OP entry.

Anterior Colporrhaphy Plus Inside-out Tension-free Vaginal Tape for Associated Stress Urinary Incontinence and Cystocele

STUDY OBJECTIVE To reveal the efficacy and feasibility of concomitant anterior colporrhaphy and tension-free vaginal tape-obturator to treat stress urinary incontinence (SUI) and concomitant cystocele. DESIGN Controlled trial without randomization (Canadian Task Force classification II-1). SETTING University hospitals in Rome, Italy. PATIENTS Fifty consecutive patients with SUI associated with symptomatic cystocele were enrolled into the study. Exclusion criteria were: uterine prolapse greater than or equal to 1, rectocele greater than or equal to 1, overactive bladder, overactive bladder symptoms, intrinsic urethral sphincter deficiency, urinary retention, previous anti-incontinence and/or prolapse surgery, neurologic bladder, psychiatric disease, body mass index greater than 30, and elevated intraabdominal pressure. The preoperative evaluation consisted of: complete history, physical examination, 3-day voiding diary, and urodynamic testing. The International Consultation on Incontinence Questionnaire Short Form (ICIQ-UI SF) was used to subjectively quantify the patient perception of SUI symptom severity. INTERVENTIONS All patients underwent an ultralateral anterior colporrhaphy plus tension-free vaginal tape-obturator. MEASUREMENTS AND MAIN RESULTS In all, 43 (91%) and 46 (92%) patients were objectively cured for cystocele and SUI, respectively. The median operating time, blood loss, and hospitalization were 43 minutes (range 35-56), 64 mL (range 40-148), and 1 day (range 1-2), respectively. Overall early postoperative complication rate was 16%, although all were minor. Only 1 patient, at 12-month follow-up, developed tape erosion that required surgical removal. The ICIQ-UI SF questionnaire scores were 13.4 +/- 6.8 and 3.5 +/- 3.2 (p <.01) between preoperative and 12-month follow-up, respectively. CONCLUSION Concomitant tension-free vaginal tape-obturator plus ultralateral anterior colporrhaphy are feasible and safe procedures for the treatment of SUI and with associated cystocele with a high success rate and low intraoperative and postoperative complications rate.

Ultrasonographic Evaluation of Postoperative Ovarian Cyst Formation after Laparoscopic Excision of Endometriomas

STUDY OBJECTIVE To evaluate, by means of serial transvaginal ultrasound (US) examinations, the ovary after laparoscopic excision of endometriomas with the stripping technique. DESIGN Prospective, controlled, single-blind clinical trial (Canadian Task Force classification II-1). SETTING Tertiary care university hospital. PATIENTS Forty-seven patients, from 21- to 35-years old, undergoing laparoscopic excision of a monolateral ovarian endometrioma. INTERVENTION The patients underwent serial US scans performed by a blinded observer during the first, third, and sixth menstrual cycle after surgery. MEASUREMENTS AND MAIN RESULTS At the first follow-up US examination, an abnormal finding, namely the presence of an ovarian cyst on the operated ovary, was diagnosed in five of 47 patients (10.6%; p = .03 when compared with the nonoperated ovary). In the remaining 42 patients (89.4%), no gross abnormalities were evident. No differences were present between the two ovaries as to ovarian volume or follicular development pattern. During the third follow-up US, in 47 patients (100%) no gross abnormalities were present. CONCLUSION The US follow-up of ovaries operated on for endometriomas by laparoscopy demonstrates that the evidence of an ovarian cyst in the early postoperative period is not an uncommon event. This finding, occurring in approximately 10% of cases, seems to be a transient one occurring during ovarian healing after surgery, since no evidence of such anomaly was present on subsequent US scans. Therefore, treatment for US evidence of recurrence of an ovarian endometrioma should be deferred for at least 3 to 6 months if the diagnosis of recurrence is made in the early postoperative period. Apart from this finding, the operated ovary is indistinguishable from the contralateral one, even 1 month after surgery.

Salpingoscopy during laparoscopy using a small-caliber hysteroscope introduced through an accessory trocar.

Salpingoscopy is an endoscopic technique that allows the direct visualization of the tubal mucosa. The status of the tubal mucosa is the best prognostic factor when evaluating patients with tubal infertility. Salpingoscopy, performed during laparoscopy, has not reached wide acceptance due the costly, non-user-friendly, dedicated instrumentation needed. In this article, a simplified technique to perform salpingoscopy at the time of laparoscopy is reported, using a standard 2.9-mm diagnostic hysteroscope, with a 3.7-mm single-flow diagnostic sheath, introduced through an accessory port. Salpingoscopy, with this new technique, was performed in 13 patients with tubal infertility. The tubes were successfully cannulated in all patients, for a total of 24 tubes evaluated (2 patients had a single tube). Salpingoneostomy and salpingoovarolysis were completed after salpingoscopy only when the tubal mucosa was normal. In 1 patient with severe tubal damage, salpingectomy of the single remaining tube was performed. Salpingoscopy added a mean of 15 minutes to surgical time. Intrauterine pregnancies were obtained, after salpingoneostomy, fimbrioplasty, or adhesiolysis, in 5 of 12 patients (42%), with a mean follow-up of 9 months. The simplified technique of salpingoscopy, with a diagnostic hysteroscope introduced through an accessory trocar at the time of laparoscopy, adds important information on the reproductive potential of patients with tubal disease.

Suburethral sling in autoimmune patients: complications, quality of life, and success rate

Introduction and hypothesisSuburethral sling procedures are a mainstay for the surgical treatment of stress urinary incontinence (SUI). The interaction between the sling and the host is fundamental for the success of the procedure. Patients affected by autoimmune disease present with an overactive immune system; this should theoretically increase rejection risk.MethodsThe data from 19 autoimmune patients affected by SUI were retrospectively collected. Primary outcome consisted of evaluating whether tape-related complications may occur more frequently. Secondary outcome measures were assessment of objective and subjective cure of SUI. Changes from baseline were analyzed using the Mann–Whitney and Fisher tests.ResultsSuccess rate, evaluated at 12-month follow-up, was 89.5%. No tape erosion or urinary retention was observed; chronic pelvic pain and dyspareunia rates were 5.26% and 15.4%, respectively. One patient developed de novo urgency.ConclusionsAccording to our experience, the suburethral sling is a safe procedure with low complication rates comparable to those reported in the literature.

2, 3-Diphosphoglycerate in normal and pathologic pregnancy: Relationship to neonatal weight

2,3-Diphosphoglycerate levels were assayed in 154 pregnant women in third trimester (61 normal, 52 diabetic, 19 with gestational hypertension, 7 with fetal macrosomia, and 15 with idiopathic fetal underdevelopment). A correlation was found between 2,3-diphosphoglycerate levels and birth weight (absolute and relative birth weight or birth weight expressed as percentile), which was negative in normal patients evaluated in the last 7 days before delivery (r = 0.38; p = 0.04) and positive in diabetic patients (evaluated in the third trimester and in the last 7 days before delivery) and in patients with gestational hypertension (evaluated in the third trimester) (r and p values differ according to whether birth weight is expressed as absolute, relative, or a percentile). No correlation was found between 2,3-diphosphoglycerate levels and birth weight in patients with neonatal underdevelopment or macrosomia of unknown origin. On the basis of these results we hypothesize that in some conditions the fetus can influence maternal 2,3-diphosphoglycerate levels and hence its own oxygen supply and growth in utero.