Renato Seracchioli

Impact of Obesity on Surgical Treatment for Endometrial Cancer: A Multicenter Study Comparing Laparoscopy vs Open Surgery, with Propensity-Matched Analysis

OBJECTIVEnTo evaluate the impact of obesity on the outcomes of surgical treatment for endometrial cancer in general and also comparing laparoscopic and open abdominal approach.nnnDESIGNnRetrospective case-control study (Canadian Task Force classification II-1).nnnSETTINGnObstetrics and Gynecology Department, University of Insubria, Varese, Catholic University of the Sacred Heart, Rome, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, and SantOrsola-Malpighi Hospital, Bologna, Italy.nnnPATIENTSnData of consecutive patients who underwent surgery for endometrial cancer in 4 centers were reviewed. Univariate and multivariable analyses were performed. Adjustment for potential selection bias in surgical approach was made using propensity score (PS) matching.nnnINTERVENTIONSnLaparoscopic or open surgical treatment for endometrial cancer.nnnMEASUREMENTS AND MAIN RESULTSnA total of 1266 patients were included, including 764 in the laparoscopy group and 502 in the open surgery group. A total of 391 patients (30.9%) were obese, including 238 (18.8%) with class I obesity, 89 (7%) with class II obesity, and 64 (5.1%) with class III obesity. The total number of complications, risk of wound complications, and venous thromboembolic events were higher in obese women compared with nonobese women. Blood transfusions, incidence/severity of postoperative complications, and postoperative hospital stay were significantly higher in the open surgery group compared with the laparoscopy group, irrespective of obesity. These differences remained significant in both multivariable analysis and PS-matched analysis. The percentage of patients who received lymphadenectomy declined significantly in patients with BMI ≥40 in both the laparoscopy and open surgery groups. Conversions from the initially intended minimally invasive approach to open surgery were 1.1% to 2.2% for women with BMI <40, but increased in those with BMI ≥40 (8.6%; pxa0=xa0.05). PS analysis showed a lower complication rate, shorter hospital stay, and greater likelihood of receiving lymphadenectomy in obese women in the laparoscopic group.nnnCONCLUSIONnLaparoscopy for endometrial cancer retains its advantages over open surgery, even in obese patients. However, operating on obese patients can be challenging regardless of the surgical approach taken, especially in casesxa0of morbid adiposity.

Laparoscopic vs. open treatment of endometrial cancer in the elderly and very elderly: An age-stratified multicenter study on 1606 women

UNLABELLEDnObjective To investigate in depth the effect of increasing age on the peri-operative outcomes of laparoscopic treatment for endometrial cancer, compared to open surgery, with stratification of patients according to the different definitions of elderly age used in the literature.nnnMETHODSnData of consecutive patients who underwent surgery for endometrial cancer staging at six centers were reviewed and analyzed according to surgical approach (laparoscopic or open), different definitions of elderly and very elderly age (≥65years, ≥75years, ≥80years), and class of age (<65; ≥65-<75; ≥75-80; ≥80years). Multivariable analysis to correct for possible confounders and propensity-score matching to minimize selection bias were used.nnnRESULTSnA total of 1606 patients were included: 938 and 668 patients received laparoscopic and open surgery, respectively. With increasing age, fewer patients received laparoscopy (P<0.001 with ANOVA). The percentage of patients who received lymphadenectomy declined significantly in both groups for age ≥80years. Blood transfusions, incidence and severity of post-operative complications, and hospital stay were significantly lower among patients who had laparoscopy both in younger (<65years) and elderly (whether defined as ≥65 or ≥75years) patients, with no effect of age on any of the characteristics analyzed (nnnANOVAnP>0.05). The same tendency was observed among very-elderly patients (≥80years). Multivariable and propensity score-matched analysis confirmed these findings.nnnCONCLUSIONSnLaparoscopy for staging endometrial cancer retains its advantages over open surgery even in elderly and very-elderly patients. Our data strongly suggest that minimally-invasive surgery is advantageous even among subjects ≥80years.

Adenomyosis: What the Patient Needs

A panel of experts in the field of endometriosis expressed their opinions on management options in a 28-year-old patient, attempting pregnancy for 1xa0year, with severe cyclic pelvic pain and with clinical examination and imaging techniques suggestive of adenomyosis. Many questions this paradigmatic patient may pose to the clinician are addressed, and all clinical scenarios are discussed. A decision algorithm derived from this discussion is also proposed.

Comparison between the stripping technique and the combined excisional/ablative technique for the treatment of bilateral ovarian endometriomas: A multicentre RCT

STUDY QUESTIONnIs the combined excisional/ablative technique for the treatment of ovarian endometriomas better than the traditional stripping technique in terms of recurrence rate?nnnSUMMARY ANSWERnThere is no evidence that the combined excisional/ablative technique is better than the traditional stripping technique, as similar recurrence rates were observed for the two techniques.nnnWHAT IS KNOWN ALREADYnThe stripping technique is associated with better results compared with ablative, non-excisional techniques for the treatment of ovarian endometriomas. Excisional techniques, such as stripping, have, however, been associated with reduced ovarian reserve as evaluated with anti-Mullerian hormone, and surgical techniques that better preserve the ovarian reserve are needed.nnnSTUDY DESIGN, SIZE, DURATIONnA prospective, multicentre, randomized blinded clinical trial was carried out on 51 patients with bilateral endometriomas larger than 3 cm. For each patient, serving as her own control, one ovary was randomized to the stripping technique and the contralateral to the combined excisional/ablative technique. Patients were enrolled between January 2013 and April 2014.nnnPARTICIPANTS/MATERIALS, SETTING, METHODSnPatients of reproductive age with pelvic pain and/or infertility affected by bilateral endometriomas larger than 3 cm were included (n = 51). The patients underwent laparoscopic removal of endometriomas with two different surgical techniques performed at either side after random assignment: complete removal by stripping on one side versus the combined technique, consisting of partial excisional cystectomy followed by completion with ablative surgery using bipolar coagulation, on the other side. Post-operative follow-up was performed at 1, 3 and 6 months after surgery for the evaluation of endometrioma recurrence (primary outcome) and of antral follicle count (AFC) and ovarian volumes (OVs) to assess ovarian reserve (secondary outcome).nnnMAIN RESULTS AND THE ROLE OF CHANCEnRecurrence rates were 5.9% for the stripping technique versus 2.0% for the combined technique (odds ratio 3.00; 95% confidence interval: 0.24-157.5; P = 0.62). AFC in the ovaries treated with the stripping technique did not differ significantly from AFC in ovaries treated with the combined technique at all follow-up visits, whereas OV was significantly lower after the combined technique at the 6-month follow-up visit (P = 0.04).nnnLIMITATIONS, REASONS FOR CAUTIONnA major limitation of this study is the small sample size and particularly for ovarian reserve, the secondary outcome, for which no formal sample size calculation was performed. The lower-than-expected recurrence rates in the present series may be related to the shorter follow-up in our study compared with most studies in the literature. Further studies with larger sample sizes and longer follow-up are needed to confirm the findings of this study. The combined technique using CO2 laser energy instead of bipolar coagulation should also be evaluated.nnnWIDER IMPLICATIONS OF THE FINDINGSnThe traditional excisional technique, i.e. the stripping technique, should still be considered the gold standard approach for the surgical treatment of endometriomas.nnnSTUDY FUNDING/COMPETING INTERESTSnNo commercial funding was received. The authors report no relevant conflict of interest.nnnTRIAL REGISTRATION NUMBERnANZCTR number ACTRN12614000653662.nnnTRIAL REGISTRATION DATEn23 June 2014.nnnDATE OF FIRST PATIENTS ENROLMENTn1 January 2013.

Cyproterone acetate vs leuprolide acetate in combination with transdermal oestradiol in transwomen: a comparison of safety and effectiveness.

To retrospectively compare the effectiveness and safety of 1‐year administration of transdermal oestradiol (TE) with cyproterone acetate (CPA) or leuprolide acetate (Leu) in transwomen.

Endometriosis in Adolescence: Practical Rules for an Earlier Diagnosis.

Dysmenorrhea, cyclic pelvic pain, and acyclic pelvic pain are common in adolescent girls, and at least 10% of these girls are at risk for subsequent development of endometriosis. In this article we highlight practical tips for the management of dysmenorrhea and chronic pelvic pain and how to diagnose endometriosis as early as possible and detect patients at risk for developing the disease in the future. We suggest five practical rules for managing adolescents with dysmenorrhea and chronic pelvic pain: (1) Never underestimate the pain; (2) Always consider endometriosis as a possible cause of severe cyclic pain; (3) Obtain a detailed and accurate history before performing clinical evaluation and pelvic sonography; (4) Treat the pain with hormonal therapies (combined oral contraceptives or progestogen-only pill) and analgesics (acetaminophen and nonsteroidal anti-inflammatory drugs); and (5) Plan frequent follow-up visits to re-evaluate the patient. [Pediatr Ann. 2016;45(9):e332-e335.].

The Effect of a Uterine Manipulator on the Recurrence and Mortality of Endometrial Cancer: A Multi-Centric Study by the Italian Society of Gynecological Endoscopy.

BACKGROUND: Although widely adopted, the use of a uterine manipulator during laparoscopic treatment of endometrial cancer represents a debated issue, and some authors hypothesize that it potentially may cause an increased risk of relapse, particularly at specific sites. OBJECTIVE: Our aim was to evaluate the risk and site of disease recurrence, overall survival, and disease‐specific survival in women who had laparoscopic surgery with and without the use of a uterine manipulator. STUDY DESIGN: Data were reviewed from consecutive patients who had laparoscopic surgery for endometrial cancer staging in 7 Italian centers. Subjects were stratified according to whether a uterine manipulator was used during surgery; if so, the type of manipulator was identified. Multivariable analysis to correct for possible confounders and propensity score that matched the minimize selection bias were utilized. The primary outcome was the risk of disease recurrence. Secondary outcomes were disease‐specific and overall survival and the site of recurrence, according to the use or no use of the uterine manipulator and to the different types of manipulators used. RESULTS: We included 951 patients: 579 patients in the manipulator group and 372 patients in the no manipulator group. After a median follow‐up period of 46 months (range,12–163 months), the rate of recurrence was 13.5% and 11.6% in the manipulator and no manipulator groups, respectively (P=.37). Positive lymph nodes and myometrial invasion of >50% were associated independently with the risk of recurrence after adjustment for possible confounders. The use of a uterine manipulator did not affect the risk of recurrence, both at univariate (odds ratio, 1.18; 95% confidence interval, 0.80–1.77) and multivariable analysis (odds ratio, 1.00; 95% confidence interval, 0.60–1.70). Disease‐free, disease‐specific, and overall survivals were similar between groups. Propensity‐matched analysis confirmed these findings. The site of recurrence was comparable between groups. In addition, the type of uterine manipulator and the presence or not of a balloon at the tip of the device were not associated significantly with the risk of recurrence. CONCLUSION: The use of a uterine manipulator during laparoscopic surgery does not affect the risk of recurrence and has no impact on disease‐specific or overall survival and on the site of recurrence in women affected by endometrial cancer.

High cytokine expression and reduced ovarian reserve in patients with Hodgkin lymphoma or non-Hodgkin lymphoma

OBJECTIVEnTo investigate the ovarian reserve in female lymphoma patients and the potential relationships with the cytokine network.nnnDESIGNnAge-matched control study.nnnSETTINGnWomens university hospital.nnnPATIENT(S)nSeventy-three lymphoma patients (57 with classic Hodgkin lymphoma [HL] and 16 with non-Hodgkin lymphoma [NHL]), approaching our center for ovarian tissue cryopreservation (study group) were compared with 25 age-matched healthy volunteers (control group).nnnINTERVENTION(S)nMeasurements of antimüllerian hormone (AMH), soluble interleukin-2 receptor (SIL-2R), interleukin-6 (IL-6), interleukin-8 (IL-8) and tumor necrosis factor α (TNF-α) levels.nnnMAIN OUTCOME MEASURE(S)nThe AMH and cytokine levels of the lymphoma patients and the healthy volunteers were compared. Correlations between AMH with SIL-2R, IL-6, and IL-8 levels were performed.nnnRESULT(S)nThe AMH showed significant lower concentrations in lymphoma patients than in the control group. Higher significant concentrations in lymphoma patients than in control group were found for SIL-2R and IL-6. No differences were observed comparing HL and NHL groups and within the stages of HL group for AMH and all the cytokines analyzed. Finally, significant inverse correlations were observed in lymphoma patients between AMH and SIL-2R, IL-6, and IL-8 levels, but not with TNF-α levels. Positive correlations between SIL-2R with IL-6, and IL-6 with IL-8 were also shown.nnnCONCLUSION(S)nIn patients with HL or NHL at baseline the cytokine network is particularly active and the ovarian reserve is reduced. A strong negative correlation between AMH and SIL-2R, IL-6, and IL-8 has been also evidenced.

PELVIC FLOOR MUSCLE DYSFUNCTION AT 3D/4D TRANSPERINEAL ULTRASOUND IN PATIENTS WITH DEEP INFILTRATING ENDOMETRIOSIS: A PILOT STUDY.

Pelvic floor muscle (PFM) dysfunction seems to play an important role in the pathophysiology of pelvic pain, including that associated with deep infiltrating endometriosis (DIE). The aim of this study was to evaluate the static and dynamic morphometry of the PFM using three‐dimensional (3D) and four‐dimensional (4D) transperineal ultrasound in women with DIE compared with asymptomatic healthy women.

Impaired Lipid Profile is a Risk Factor for the Development of Sexual Dysfunction in Women

INTRODUCTIONnDyslipidemia is a common risk factor for cardiovascular disease which may contribute to sexual dysfunction in women.nnnAIMSnTo assess the impact of dyslipidemia compared with other metabolic alterations on female sexual function.nnnMETHODSnIn total, 466 women were enrolled in the study, of which 256 were postmenopausal. Dyslipidemia was defined based on high-density lipoprotein, low-density lipoprotein, or triglycerides levels. Women completed the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale (FSDS), and the Middlesex Hospital Questionnaire (MHQ). Biochemical and anthropometric measurements were performed and the Framingham risk score (FRS) was calculated for each subject.nnnMAIN OUTCOME MEASUREMENTSnFSFI, FSDS, and MHQ scores, prevalence of FSD and FRS.nnnRESULTSnMedian age of the population enrolled was 51.5 (range 42.0-58.0) years. The overall prevalence of FSD, according to FSFI and FSDS scores, was 24%. A significantly higher prevalence of FSFI (P = .001) and FSDS (P = .006) pathological scores were found in women with dyslipidemia compared with the control group. The prevalence of FSD was significantly higher in dyslipidemic women (P = .001). Women with dyslipidemia had significantly higher total scores in areas of depression, somatization, and obsession in the MHQ questionnaire compared with control women. Multivariate analysis showed that dyslipidemia (OR:1.7, CI 1.1-2.9, P = .037), postmenopausal status (OR:2.7, CI 1.5-4.7, P = .001), higher education (OR:0.6; CI 0.3-0.9, P = .038), and somatization (OR:1.7, CI 1.0-2.8, P = .045) were independently associated with FSD. The FRS was higher in dyslipidemic women (P = .001) and in those with FSD (P = .001), being associated with an almost doubled risk of developing FSD.nnnCONCLUSIONnOur results indicate that dyslipidemia is an independent risk factor for FSD irrespective of postmenopausal status. Also, psychopathological alterations such as somatization are strongly associated with sexual dysfunction. The direct correlation between FSFI score and FRS suggest the importance of cardiovascular integrity in female sexual health.