Russalina Mavrova

Influences of Different Hysterectomy Techniques on Patients' Postoperative Sexual Function and Quality of Life

INTRODUCTION Hysterectomy ranks among the most frequently performed gynecological surgical procedures. At the time of operation, the majority of patients are premenopausal and sexually active. Hence, detailed counseling about the effects of hysterectomy on postoperative sexuality and quality of life can be regarded as an integral part of preoperative counseling. However, available data on these subjects are limited and contradictory. AIM The aim of this study was to assess quality of life and sexuality following three common hysterectomy procedures-total laparoscopic hysterectomy (TLH), supracervical laparoscopic hysterectomy (SLH), and vaginal hysterectomy (VH)-in premenopausal patients using the European Quality of Life Five-Dimension Scale (EQ-5D) and Female Sexual Function Index (FSFI). MAIN OUTCOME MEASURES Preoperative and postoperative EQ-5D and FSFI scores were compared using the Wilcoxon signed-rank test. Kruskal-Wallis analysis and Mann-Whitney U-test with post hoc Bonferroni correction were used to assess differences among the three subgroups. METHODS All premenopausal patients who underwent TLH, SLH, or VH without adnexectomy due to benign uterine disorders between April 2011 and June 2013 at the Department of Gynaecology and Obstetrics of Saarland University Hospital were enrolled in this observational cohort study. Sexuality and quality of life status were assessed preoperatively and 6 months postoperatively using two standardized validated questionnaires: the FSFI, a multidimensional, self-reported instrument for the assessment of female sexual function, and the EQ-5D, a standardized, validated instrument to measure an individuals health status. RESULTS Of 402 eligible patients, 237 completed the study. Patient characteristics and preoperative FSFI and EQ-5D scores did not differ among the three hysterectomy subgroups. Postoperative FSFI and EQ-5D scores were significantly higher (P ≤ 0.01) than preoperative scores for all procedures but did not differ among the groups. CONCLUSIONS In this cohort of premenopausal women, hysterectomy without adnexectomy performed due to benign uterine pathologies had significant positive effects on postoperative sexual function and quality of life, regardless of the surgical technique used.

Five minutes of extended assisted ventilation with an open umbilical trocar valve significantly reduces postoperative abdominal and shoulder pain in patients undergoing laparoscopic hysterectomy.

OBJECTIVE Residual carbon dioxide contributes substantially to pain following laparoscopic surgery. We evaluated the effects of extended assisted ventilation (EAV) with an open umbilical trocar valve for five additional minutes following laparoscopic hysterectomy on postoperative abdominal and shoulder pain levels. We also examined whether a combination of EAV and trocar site infiltration (TSI) with lidocaine could further reduce postoperative pain levels. STUDY DESIGN In this prospective randomized trial, the effectiveness of EAV and EAV/TSI in reducing postoperative abdominal and shoulder pain were compared with that of a standard treatment regime in 283 patients undergoing laparoscopic hysterectomy (total or supracervical). Pain levels were evaluated by self-assessment questionnaire using a numeric rating scale (NRS) and by postoperative piritramid requirement, a surrogate parameter for postoperative analgesic drug requirement. The incidence of nausea and vomiting was also assessed. RESULTS Compared with the standard treatment regime, EAV reduced abdominal pain levels significantly at 3h (NRS score, 3.21 ± 1.56 vs. 4.73 ± 1.71) and 24h (3.82 ± 1.49 vs. 4.95 ± 1.68) postoperatively (both p < 0.01). EAV also significantly reduced shoulder pain at 24h (EAV vs. control, 4.28 ± 1.51 vs. 5.14 ± 1.49) and 48 h (3.64 ± 1.66 vs. 4.22 ± 1.43) postoperatively (both p < 0.01). Patients in the EAV group had significantly lower piritramid requirements compared with standard treatment at 3h post-operatively (4.28 ± 2.09 mg vs. 6.31 ± 2.21 mg; p<0.01). EAV/TSI showed no additional benefit in terms of pain reduction compared with EAV alone. Incidences of postoperative nausea and vomiting were not reduced by EAV or EAV/TSI. CONCLUSION EAV was found to be an effective and safe method to reduce postoperative pain levels in patients undergoing laparoscopic hysterectomy.

Stromal Fibroblasts Induce CCL20 through IL6/C/EBPβ to Support the Recruitment of Th17 Cells during Cervical Cancer Progression

Cervical cancer is a consequence of persistent infection with human papillomaviruses (HPV). Progression to malignancy is linked to an inflammatory microenvironment comprising T-helper-17 (Th17) cells, a T-cell subset with protumorigenic properties. Neoplastic cells express only low endogenous levels of the Th17 chemoattractant CCL20, and therefore, it is unclear how Th17 cells are recruited to the cervical cancer tissue. In this study, we demonstrate that CCL20 was predominantly expressed in the stroma of cervical squamous cell carcinomas in situ. This correlated with stromal infiltration of CD4(+)/IL17(+) cells and with advancing International Federation of Gynecology and Obstetrics (FIGO) stage. Furthermore, we show that cervical cancer cells instructed primary cervical fibroblasts to produce high levels of CCL20 and to attract CD4/IL17/CCR6-positive cells, generated in vitro, in a CCL20/CCR6-dependent manner. Further mechanistic investigations identified cervical cancer cell-derived IL6 as an important mediator of paracrine CCL20 induction at the promoter, mRNA, and protein level in fibroblasts. CCL20 was upregulated through the recently described CCAAT/enhancer-binding protein β (C/EBPβ) pathway as shown with a dominant-negative version of C/EBPβ and through siRNA-mediated knockdown. In summary, our study defines a novel molecular mechanism by which cervical neoplastic cells shape their local microenvironment by instructing fibroblasts to support Th17 cell infiltration in a paracrine IL6/C/EBPβ-dependent manner. Th17 cells may in turn maintain chronic inflammation within high-grade cervical lesions to further promote cancer progression.

Postoperative Quality of Life and Sexual Function in Premenopausal Women Undergoing Laparoscopic Myomectomy for Symptomatic Fibroids: A Prospective Observational Cohort Study.

Introduction Uterine leiomyomas are the most common benign gynecologic tumors. To date laparoscopy myomectomy is the gold standard for treatment of symptomatic fibroids in reproductive-aged women. Detailed counseling about the effects of this procedure on postoperative sexuality and quality of life is important in these patients. However, available data on these subjects are limited and contradictory. The aim of this study was to assess sexual function and quality of life in premenopausal women undergoing laparoscopic myomectomy for symptomatic uterine fibroids. Material and Methods All premenopausal women who underwent laparoscopic myomectomy for symptomatic fibroids between April 2012 and August 2014 at a tertiary university center were enrolled in this prospective observational cohort study. Sexual function and quality of life were assessed for the pre- and postoperative (six months post-operatively) state using two validated questionnaires, the Female Sexual Function Index (FSFI) and the European Quality of Life Five-Dimension Scale (EQ-5D). Results Ninety-five of the 115 (83%) eligible patients completed the study. Overall a significant improvement in quality of life and sexual function was observed in the study cohort: Median FSFI (28 (18.7–35.2)) and EQ-5D scores (1 (0.61–1) after laparoscopic myomectomy were significantly higher than preoperative scores (21.2 (5.2–33.5); 0.9 (0.2–1); p ≤ 0.01). The number, position and localization of the largest fibroids were not correlated with pre- or postoperative sexual function or quality of life. Conclusion Laparoscopic myomectomy might have positive short-term effects on postoperative quality of life and sexual function in premenopausal women suffering from symptomatic fibroids.

Learning curves for laparoscopic hysterectomy after implementation of minimally invasive surgery.

To evaluate the learning process for total laparoscopic hysterectomy (TLH) and laparoscopic supracervical hysterectomy (LSH) for benign uterine pathologies among surgeons inexperienced in laparoscopy.

Photobiomodulation therapy in breast cancer-related lymphedema: a randomized placebo-controlled trial.

The aim of our study was to examine the effects of photobiomodulation therapy (PBMT) in the treatment of breast cancer‐related lymphedema using a compactly designed treatment regime consisting of eight therapy sessions in combination with a cluster laser device covering a total area size of 78.54 cm² over the axillary.

Estrogen, progesterone, and Her-2/neu receptor expression discrepancy in primary tumors and in-breast relapse in patients with breast cancer.

To the Editor: Estrogen and progesterone receptors have increasing importance in the management of breast malignancy. 60–70% of primary breast tumors are ER and PR positive. This results in a good prognosis for the patients (1) and allows the use of endocrine therapy which is now a standard in the adjuvant treatment of hormone receptor-positive invasive breast cancers. The hormone receptors are determined by immunohistochemistry on paraffin sections. Her-2/neu is a transmembrane tyrosine kinase receptor which belongs to the family of the EGFR. The most common reason of Her-2/neu overexpression in breast cancer is an amplification of the erbB2 gene. This results in a poor prognosis and occurs in 15–25% of all invasive breast cancers (2). The overexpression of Her-2/neu can be determined using immunohistochemistry and/or fluorescence in situ hybridization. Patients with Her-2/neu overexpressive breast cancer can be treated with the humanized antibody Trastuzumab. Some studies have reported hormone-receptor status discordance rates of 10–54% between primary and recurrent breast tumors (3–8). The mechanisms of change of hormone receptor and Her-2/neu expression have not been explicitly identified. Possible explanations include tumor heterogeneity, genetic instability, or errors in the determination of the receptors. Retrospective analysis was performed on 68 patients diagnosed with an in-breast relapse at the University Breast Center, Homburg/Saar, Germany, between 2001 and 2011. We evaluated the patient’s age at primary diagnosis and relapse, the tumor entity, the TNM stage, the initial grading and the grading at relapse, the ER-, PRand Her-2/neu status in primary cancer and relapse, the therapy received after the primary diagnosis. Primary and recurrent hormone receptor and Her-2/neu receptor data were obtained retrospectively using chart reviews or pathology reports. Sixty-one out of 68 patients showed an invasive carcinoma (89.7%) and seven cases a ductal carcinoma in situ. The patients had received surgical treatment or biopsy between 1982 and 2010 at University Breast Center, Homburg/Saar, in Germany. The age of patients ranged from 31 to 86. The mean time to the first recurrence of breast cancer was 7.7 years after the primary diagnosis. Thirty-three women were premenopausal and 35 were postmenopausal at the time of the first diagnosis. Overall, 64.7% of the primary breast cancers were positive for ER and PR. Only a few patients (3%) were Her-2/neu-positive at the time of the primary diagnosis. At this point of time, 31 patients were lymph node-negative, 32.4% had positive axillary lymph nodes and in 15 cases the nodal status was unknown. Patients had been treated either by lumpectomy in 47 cases or radical mastectomy in 21 cases plus axillary excision in form of axillary dissection in 50 cases or sentinel node dissection in seven cases. Most of the patients had received an adjuvant systemic therapy. Previous therapies included endocrine therapy for 40 out of 68 patients, previous chemotherapy for 38 out of 68 patients and previous radiotherapy for 35 out of 68 patients. Discordance rates between primary and locally recurrent lesions, were 23.5% for ER, 34% for PR, and 7% for Her-2/neu. In 13 cases, there was a switch from ER positive in the primary carcinoma to ER negative in in-breast relapse and in three cases the receptor changed from ER negative to ER positive. 25% of patients showed a PR-switch from positive receptor status in the primary carcinoma to a negative status in cancer relapse, and in 9% the PR status changed from negative to positive. The Her-2/neu receptor status shifted from negative to positive in four out of five patients comparing primary tumor and in-breast Address correspondence and reprint requests to: Russalina Mavrova, Saarland university Homburg Gynecology, obstretics and reproductive medicine, Kirrbergerstr. 100, Homburg Saarland 66421, Germany, or e-mail: r_mavrov@yahoo.de

Abdominal Hysterectomy: Postoperative Care

Optimal postoperative care is an important step of surgical treatment, especially after open surgery as in case of abdominal hysterectomy, which can be associated with various postoperative complications. A standardized management is recommended to minimize postoperative complications and avoid a prolonged hospitalization of the patient. In this chapter we point out the most common complications of abdominal hysterectomy and give an overview of preventive and treatment options.

Abdominal Hysterectomy: Indications and Contraindications

Hysterectomy is the most common non-obstetric gynecologic procedure and remains the gold standard for treatment of benign uterine pathologies and part of the surgical treatment of gynecologic malignancies. Many guidelines have been published regarding the best technique to perform hysterectomy and although overall recommendations endorse a vaginal or minimal invasive approach whenever feasible, the largest proportions of hysterectomies worldwide are performed via laparotomy. This chapter gives an overview of the indications and contraindications of abdominal hysterectomy and introduces factors which influence the choice of the route of hysterectomy.