Roberto Ricciardi

Ten years of HPV vaccines: State of art and controversies

The human papillomavirus (HPV) represents one of the most common sexually transmitted infections and it has been related to cervical cancer. The HPV vaccines prevent infection with certain species of HPV associated with the development of cervical cancer or genital warts. We carried out a PubMed search up to 2015 evaluating all randomized studies published in literature. This review discusses the current status of HPVs vaccines on the global market, efficacy, safety profiles, controversies and future vaccine developments. Three HPVs vaccines are currently on the global market: bivalent, quadrivalent and ninevalent. Bivalent and quadrivalent vaccines can protect against almost 70% of cervical HPV-related cancerous and precancerous conditions and the ninevalent vaccine, instead, provides a protection against almost 90%. The use of vaccinations raised several controversies in the last years and, currently, is not possible to establish which type of vaccine is most effective, however all of them are safe.

Does extensive upper abdomen surgery during primary cytoreduction impact on long-term quality of life?

Objectives The objective of this study was to evaluate the feasibility in terms of safety and quality of life in a sample of Italian patients affected by advanced ovarian cancer and submitted to either extensive upper abdomen or standard surgery, through validated questionnaires. Methods From January 2006 to November 2011, a prospective, observational study was conducted to compare quality of life in patients affected by advanced ovarian cancer and submitted to primary cytoreduction in the Division of Gynecology of the University Campus Bio-Medico of Rome. After surgery patients were stratified into 2 groups (group A: standard surgery or group B: extensive upper abdomen surgery). All patients were submitted to standard chemotherapy. At completion of treatment, during the first follow-up visit, all eligible patients were asked to fill in Quality of Life Questionnaire-C30 (QLQ-C30) (version 3.0) and European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire-OV28 (QLQ-OV28) questionnaires. Results Eighty-nine patients were enrolled into our study. Nine were excluded, so finally 80 patients were considered in this study. Group A included 40 patients and underwent standard surgery (pelvic surgery); group B, included 40 patients and underwent extensive upper abdomen surgery. There were no statistical differences in terms of major surgical complication rates (15% vs 10%). We registered same times of beginning of chemotherapy (median, 19 vs 21 days) and no severe related toxicities. Quality-of-life scores of both questionnaires were comparable between groups, with the exception of Global Health Status in QLC-30. Conclusions Upper abdomen surgery is a feasible and safe therapeutic option. Patients present same times of beginning of chemotherapy without an increase in chemorelated toxicities and experience the same general quality of life.

Learning curves of a resident surgeon performing transobturator tape procedures for stress urinary incontinence

To evaluate the number of procedures necessary for an untrained resident surgeon to learn transobturator tension‐free vaginal tape (TVT‐O) procedures for treatment of stress urinary incontinence (SUI).

Reply to: Is there only CO2

We were honored to receive comments by Prof. Mynbaev [1] regarding our recent publication entitled: ‘‘Influence of pneumoperitoneum pressure on surgical field during robotic and laparoscopic surgery: a comparative study’’ [2]. The aim of our study was the evaluation of surgical field modifications related to variations in CO2 insufflation pressure, both during laparoscopic and robotic surgery. The two surgical procedures are technically very similar, both involving the use of the pneumoperitoneum to determine the distension of the abdominal cavity. Although these techniques are considered minimally invasive, intraabdominal CO2 insufflation is the cause of hemodynamic changes and metabolic effects; in particular, insufflation pressure and duration of pneumoperitoneum lead to damage of the mesothelium and adhesions formation, with clinical subsequences [3]. ‘‘The higher the pressure, the better the view’’ is a remark classically heard from laparoscopic surgeons [4]. This axiom is only true within limits; working space increment related to increase in insufflation pressure, in fact, is much more evident at lower than higher intra-abdominal pressures. This can be explained by the mechanical properties of the abdominal wall. The abdominal wall becomes progressively less compliant at higher levels of deformation (stretch) [5]. Song et al. [6, 7] described anisotropic mechanical properties of the abdominal wall on the basis of the orientation of stiff connective tissue fibers. As explained in physiology textbooks, muscle-containing tissues have active and passive states where muscle tone greatly influences mechanical properties [8]. The stretching of muscles also influences the maximum force their sarcomeres can generate [9]. This makes the abdominal wall a nonlinear, anisotropic, dynamic, and difficult-to-describe mechanical entity. With our study, we demonstrated that the values of intra-abdominal pressure used to obtain the pneumoperitoneum do not significantly affect the display of the abdomino-pelvic cavity in robotic surgery, differently from laparoscopic procedures where higher pressure are needed in order to perform adequate surgery. This finding is particularly significant especially at low CO2 pressure (5 mmHg), and it has considerable implications both in terms of intraoperative cardiocirculatory parameters and of peritoneal damage with consequent influence on the postoperative recovery. According to our study, Prof. Mynbaev suggested that there is an impact of pre-stretching of the abdominal wall in a case where initially we have evaluated a high insufflation pressure (15 mmHg) and then lower pressures (10 and 5 mmHg) which may bias our results. To support this hypothesis, they cited the study by Vlot et al. [10]. With this trial the authors examined the effect of pre-stretching on CO2 pneumoperitoneum volume in 24 pigs. In all animals, working-space dimensions were assessed at 0, 5, 10, and 15 mmHg. Working space was reassessed in a second run of insufflation up to 5 mmHg. All the measurements were made using CT images. Pre-stretching of the abdominal wall by a previous stepwise insufflation with This reply refers to the comment available at doi:10.1007/s00404-015-3876-x.