Pierfrancesco Bolis

Randomized clinical trial of two laparoscopic treatments of endometriomas: cystectomy versus drainage and coagulation

OBJECTIVE To assess the efficacy of two laparoscopic methods for the management of endometriomas with regard to pain relief, pregnancy rate, and disease recurrence. DESIGN Prospective, randomized clinical trial. SETTING Tertiary care hospital. PATIENT(S) Sixty-four patients with advanced stages of endometriosis. INTERVENTION(S) Patients were randomly allocated at the time of laparoscopy to undergo either cystectomy of the endometrioma (group 1) or drainage of the endometrioma and bipolar coagulation of the inner lining (group 2). MAIN OUTCOME MEASURE(S) Pain relief and pregnancy rate. RESULT(S) Thirty-two patients were enrolled in each group. The 24-month cumulative recurrence rates of dysmenorrhea, deep dyspareunia, and nonmenstrual pelvic pain were lower in group 1 than in group 2 (dysmenorrhea: 15.8% versus 52.9%; deep dyspareunia: 20% versus 75%; nonmenstrual pelvic pain: 10% versus 52.9%). The median interval between the operation and the recurrence of moderate to severe pelvic pain was longer in group 1 than in group 2 (19 months [range, 13.5-24 months] versus 9.5 months [range, 3-20 months]). The 24-month cumulative pregnancy rate was higher in group 1 than in group 2 (66.7% versus 23.5%). CONCLUSION(S) For the treatment of ovarian endometriomas, a better outcome with a similar rate of complications is achieved with laparoscopic cystectomy than with drainage and coagulation.

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.

Female Urinary Incontinence During Intercourse: A Review on an Understudied Problem for Women's Sexuality

INTRODUCTION Coital urinary incontinence is a frequently underreported symptom, with a relevant impact on womens sexuality and quality of life. AIM This article will review the available evidence on incidence, pathophysiology, and treatment of coital urinary incontinence with the attempt to present the current state of the art. METHODS PubMed was searched for reports about coital urinary incontinence that were published from 1970 to 2008, and the most relevant articles were reviewed. MAIN OUTCOME MEASURES Review on epidemiology, pathophysiology, diagnosis, and treatment of coital incontinence. RESULTS The incidence of coital incontinence in incontinent women has been reported to range between 10% and 27%. At present, some evidence suggests an association between urinary leakage at penetration and urodynamic stress (USI) incontinence as well as urinary leakage during orgasm and detrusor overactivity (DO). When treatment for these conditions are based upon urodynamic findings, pelvic floor muscle training, surgery, and pharmacotherapy show satisfactory cure rates. CONCLUSIONS Coital urinary incontinence deserves much more attention in clinical practice: women should be specifically interviewed for this disturbance because it has a very negative impact on their sexuality. If a reliable urodynamic diagnosis is made, coital urinary incontinence at penetration can be cured in more than 80% of cases by surgery in the presence of USI. The form of coital incontinence during orgasm is curable by antimuscarinic treatment in about 60% of cases when associated with DO.

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.

Incisional hernia in gynecologic oncology patients: a 10-year study

Objective To evaluate the independent contribution of clinical and constitutional factors in the development of early and late incisional hernias in women undergoing surgery for uterine cancer. Methods Over 10 years, patients undergoing extended abdominal hysterectomy for cervical or endometrial malignancies through a vertical incision were followed for the identification of incisional hernias. Logistic regression and survival analyses were used for statistics. Results Four hundred fifty-five women were included in the study, 77 of whom (16.9%) developed incisional hernias. The median (range) body mass index was higher in women who developed an incisional hernia than in those who did not (28 [19–44] kg/m2 versus 24 [16–41] kg/m2; P < .01). The frequencies of diabetes (14.3% versus 4.8%; P < .01), wound sepsis (10.4% versus 1.3%; P < .05), and fascial closure with interrupted sutures (70.1% versus 55.6%; P < .05) were significantly higher in women with incisional hernia than in those without. Multiple logistic regression revealed that, after adjustment for confounding variables, the only factors associated with incisional hernia formation within 1 year from the operation were body mass index above 27 kg/m2 (odds ratio [OR] 3.68; 95% confidence interval [CI] 1.38, 9.81; P < .01) and wound infection (OR 5.05; 95% CI 1.39, 18.37; P < .01), whereas the factors associated with incisional hernia formation at least 3 years after surgery were diabetes (OR 6.68; 95% CI 2.02, 22; P < .01) and wound infection (OR 8.55; 95% CI 1.54, 47.5; P < .01). For hernia developing after 5 years (OR 8.32; 95% CI 1.41, 55.65; P < .05) and 8 years (OR 49.52; 95% CI 2.72, 907.14; P < .01), the only significant association was found with diabetes. Conclusion Late incisional hernia formation does not depend on conditions present at the time of operation or on surgical technique. Other factors such as diabetes seem to play an important role in the development of late incisional hernia.

Prospective study to assess risk factors for pelvic floor dysfunction after delivery

Background. To identify obstetric risk factors for de novo pelvic floor disorders after vaginal delivery. Methods. Antenatally asymptomatic women who delivered vaginally were interviewed on urinary, anal and sexual disorders antenatally, 6 and 12 months postpartum. Results. Of 967 women, 336 were included for final analysis. Urinary symptoms occurred in 27 and 23% of women at 6 and 12 months postpartum: univariate analysis showed a significant relation to the use of epidural analgesia (p =0.04) and to a second stage of labour >1 h (p =0.02), the latter was confirmed significant by multivariate analysis. Anal incontinence occurred in 7.1 and 6.8% of women at 6 and 12 months postpartum, respectively. Dyspareunia was reported by 24% at 6 months, decreasing to 8% at 12 months (p <0.0001). Conclusions. Our study shows that a second stage longer than 1 h is associated with the development of postpartum urinary incontinence. Except for dyspareunia, pelvic floor dysfunction rarely resolves spontaneously.

Surgical treatment for female stress urinary incontinence: what is the gold-standard procedure?

In the last few years, the Burch colposuspension and the fascial slings were often defined from the pages of the most relevant journals of general medicine, as gold-standard procedures for the surgical treatment of stress urinary incontinence (SUI), whereas mid-urethral slings (tension-free vaginal tape (TVT) and tension-free vaginal tape obturator) were attributed a marginal and almost experimental role in this field. This poorly reflect the current scenario of the surgical management of SUI: Recently, a number of meta-analysis have demonstrated that TVT is significantly more effective if compared to colposuspension and that it is followed by significantly lower perioperative morbidity if compared to pubovaginal slings. It is not realistic to suggest to general practitioners that the surgical gold standard for SUI includes the performance of a wide laparotomy, long hospital stays and a high risk of long-lasting intermittent self-catheterisation. This would inevitably discourage women from embarking on surgical treatment, which instead could actually improve their quality of life.

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.

Sexual Function after Radical Hysterectomy for Early-Stage Cervical Cancer: Is There a Difference between Laparoscopy and Laparotomy?

INTRODUCTION Surgical treatment for cervical cancer is associated with a high rate of late postoperative complications, and in particular with sexual dysfunction. AIM To evaluate sexual function in women who underwent radical hysterectomy (RH), in comparison with a control group of healthy women, using a validated questionnaire (Female Sexual Function Index [FSFI]). Then we tried to evaluate the possible differences between laparoscopic RH and abdominal RH in terms of their impact on sexuality. METHODS Consecutive sexually active women, who underwent RH for the treatment of early-stage cervical cancer between 2003 and 2007, were enrolled in this study (cases) and divided into two groups, according to the surgical approach. All women were administered the FSFI. The results of this questionnaire were compared between patients who underwent laparoscopic RH (LPS group) vs. women who underwent laparotomic RH (LPT group). The cases of RH were also compared with a control group of healthy women, who were referred to our outpatient clinic for a routine gynecologic evaluation. MAIN OUTCOME MEASURES FSFI questionnaire on six domains of female sexuality (desire, arousal, lubrication, orgasm, satisfaction, pain). RESULTS A total of 38 patients were included. We also enrolled 35 women as healthy controls. FSFI score was significantly higher in the healthy controls vs. the cases of RH. In the LPS group, the total score and all the domains of the FSFI were lower in comparison with the healthy controls, whereas three of the six domains (arousal, lubrication, orgasm) and the total score of FSFI were lower in the LPT group if compared with the controls. There were no significant differences between LPS and LPT group. CONCLUSIONS RH worsens sexual function, regardless of the type of surgical approach. In our experience, laparoscopy did not show any benefit on womens sexuality over the abdominal surgery for cervical cancer.