Use of botulinum toxin in aesthetic medicine and gynaecology. current approaches, controversies, and future directions

This review looks at the use of botulinum toxin in the gynaecological field with the aim of determining what needs to be further investigated to achieve a standardized application. Numerous studies have been conducted to explore how botulinum toxins (BoNT) can be applied, and it is becoming popular for treating various disorders such as chronic pelvic pain, vestibulodynia, and vaginism. However, the exact dosage and ideal location for injections still need to be clarified. The objective of this study is to point out which aspects need to be more carefully studied to ensure a consistent use of BoNT in gynaecology

When and how should peritoneal endometriosis be operated on in order to improve fertility rates and symptoms? The experience and outcomes of nearly 100 cases

Purpose: To analyze the follow-up results of patients suffering from symptomatic early-stage endometriosis after a consistent laparoscopic peritoneal stripping of the altered peritoneum (peritoneal endometriosis and surrounding inflamed tissue) was performed. This type of endometriosis is resistant to medical therapy and/or impairs fertility. Methods: Using our prospectively maintained database, we were able to identify all symptomatic women with the suspicion of only peritoneal endometriosis who underwent laparoscopy at our endometriosis center over a period of 5 years. All procedures were carried out in a standardized fashion by one single surgeon, who is highly experienced in minimal invasive surgery, and included a suspended hormonal pretreatment for 2 months. Postoperative outcomes including complications, fertility and recurrence rates were analysed. Results: Laparoscopic peritonectomy was performed on 94 women. Follow-up data were available in 87% of these cases. At the time of surgery, almost all patients tested showed signs of stage I or II endometriosis (44.7 and 48.9%, respectively). More than three-quarters of the women reported pain relief, inter alia, due to the post-surgical hormonal therapy. About one-third of the patients wanted to have children after the procedure. 62% of them became pregnant and the majority did so without the need for assisted reproductive therapy. In seven women a re-operation was performed. Conclusion: According to our data, a consistent excision of altered peritoneum followed by adjuvant hormonal therapy and multimodal concepts results in better outcomes for the patient, particularly in regards to pregnancy and recurrence rates

Optimized culture conditions for tissue explants of uterine leiomyoma

Background: Uterine leiomyomas are the most common benign tumours in women, which arise from smooth muscle cells of the uterine myometrium and usually are multicentric. In spite of their frequency pathogenesis is widely unknown, mainly due to the absence of a suitable model system. We describe the systematic optimization of culturing leiomyoma tissue explants in an economical and effective ex vivo system. Methods: Different concentrations of oxygen, different media, sera, hormones, and growth factor supplements were tested. Immunohistochemical stainings with antibodies against hormone receptors as well as specifying proliferation and apoptotic indices and real-time PCR were performed. Results: Main parameters for culturing myoma tissue explants were tested for finding an optimal protocol. Standard medium D-MEM-F12 in combination with the use of horse serum in a reduced concentration of 1% turned out to be optimal for these tissue cultures as well as the addition of estradiol and epidermal growth factor EGF to media. Reduced oxygen content in the incubator air showed no positive effect. Conclusions: For culturing tissue explants of uterine leiomyoma several conditions were optimized. The established tissue culture model allows examining the effects of known and potential therapeutic substances and the influence of immune competent cells in the process of tumour formation to find new targets for medical treatmen

Prospective comparison of loop excision under colposcopic guidance versus vitom guidance

Background: Aim of the study was to compare the quality of loop excision using a colposcope with results using the VITOM system. Results compared included cervical volume removed, intra- and postoperative complications, and positive resection margins. Methods: A total of 200 patients with histologically confirmed high-grade cervical premalignant lesions, persistent atypical cytological results and/or suspicious colposcopic findings, and cytological and histological discrepancies were included in the study. In transformation zone type 1 (T1) only a superficial cone biopsy was done, in zones type 2 and 3 (T2 and T3) a superficial outside cone biopsy or a deeper inside cone biopsy were done respectively, followed by endocervical curettage. Volume of removed tissue, complications, and positive resection margins were compared for the colposcopy and the VITOM groups. Findings: Demographic and reproductive features were similar between groups. In the VITOM group 49% of patients had zone T1, 30% had zone T2, and 21% had zone T3. In the group of patients managed by colposcopy, 48, 45, and 7% of patients had zone T1, T2 and T3 zone, respectively (p0.05). There were no significant differences in the type of procedure or the mean volume of removed tissue. Results were similar for both groups with respect to positive resection margins and complications. Conclusion: VITOM is a safe and reliable system. Results using the VITOM system are comparable to those obtained with conventional colposcopy. The potential advantage of VITOM is the broader availability of endoscopic systems in the operating theatre. © Georg Thieme Verlag KG Stuttgart · New York

Alcohol consumption and risk of uterine myoma: A systematic review and meta analysis

Background: The published data about alcohol consumption and uterine myoma are scanty and controversial: some studies found positive association whereas other studies showed no association. Objectives: To conduct a systematic review and meta-analysis to determine whether alcohol is a risk factor for myoma. Search strategy: A MEDLINE/EMBASE search was carried out, supplemented by manual searches of bibliographies of the selected studies. Selection criteria: Articles published as full-length papers in English. In the review we included all identified studies. Otherwise, the inclusion criteria for studies included in the meta-analysis were: a) case-control or cohort studies, reporting original data; b) studies reporting original data on the association between alcohol consumption and myoma; c) diagnosis of myoma was ultrasound or histological confirmed and/or clinically based. Data collection and analysis: A total of 6 studies were identified for the review and 5 studies were included in the meta-analysis. The primary outcome was the incidence of uterine myoma in ever versus never alcohol drinkers and when data were available, we also analyzed categories of alcohol intake. We assessed the outcomes in the overall population and then we performed a subgroup analysis according to study design. Pooled estimates of the odds ratios (OR) with 95% confidence interval (CI) were calculated using random effects models. Main results: The summary OR (95%CI) of myoma forever versus never alcohol intake was 1.12 (0.94-1.34) with significant heterogeneity. The summary OR for current versus never drinking was 1.33 (1.01-1.76) with no heterogeneity. Conclusions: Ever alcohol consumption is not associated with myoma risk. Based on the data of two studies, current alcohol drinkers had a slightly borderline increased risk of diagnosis of myoma. In consideration of the very limited number of studies and the suggestion of a potential increased risk among current drinkers, further studies are required

Pressurized intraperitoneal aerosol chemotherapy with cisplatin and doxorubicin or oxaliplatin for peritoneal metastasis from pancreatic adenocarcinoma and cholangiocarcinoma

Background: Systemic chemotherapy for pancreatic adenocarcinoma (PDAC) and cholangiocarcinoma (CC) with peritoneal metastases (PM) is affected by several pharmacological shortcomings and low clinical efficacy. Pressurized intraperitoneal aerosol chemotherapy (PIPAC) is expected to maximize exposure of peritoneal nodules to antiblastic agents. This study aims to evaluate safety and efficacy of PIPAC for PM of PDAC and CC origin. Methods: This is a retrospective analysis of consecutive PDAC and CC cases with PM treated with PIPAC at two European referral centers for peritoneal disease. We prospectively recorded from August 2016 to May 2019 demographic, clinical, surgical, and oncological data. We performed a feasibility and safety assessment and an efficacy analysis based on clinical and pathological regression. Results: Twenty patients with PM from PDAC (14) and CC (six) underwent 45 PIPAC administrations. Cisplatin–doxorubicin or oxaliplatin were administered to eight and 12 patients, respectively. We experienced one intraoperative complication (small bowel perforation) and 18 grade 1–2 postoperative adverse events according to Common Terminology Criteria for Adverse Events version 4.0. A pathological regression was recorded in 50% of patients (62% in the cisplatin–doxorubicin cohort and 42% in the oxaliplatin one). Median survival from the first PIPAC was 9.7 and 10.9 months for PDAC and CC, respectively. Conclusion: PIPAC resulted feasible and safe without relevant toxicity issues, with both cisplatin–doxorubicin and oxaliplatin. The pathological response observed supports the evidence of antitumoral activity. Despite the study limitations, these outcomes are encouraging, recommending PIPAC in prospective, controlled trials in the palliative setting or the first line chemotherapy for PM from PDAC and CC

Use of Laparoscopic and Laparotomic J-Plasma Handpiece in Gynecological Malignancies: Results From A Pilot Study in A Tertiary Care Center

Introduction: The J-Plasma has recently been introduced into the surgical community with different intrinsic characteristics aimed to further reduce the thermal effect and enhance precision when compared to standard radiofrequency. This study aimed to investigate the role of this new technology in different conditions of gynecological carcinomatosis characterized by the indication for regional peritonectomy and/or ablation, either in laparotomy (LPT) or in laparoscopy (LPS), in the context of a modern personalized approach to the surgical management of gynecological malignancies. Material and Methods: From January 2019 to April 2019, 12 patients were selected for this prospective pilot study at the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS in Rome. In this single surgeon experience, the inclusion criteria were: histologically proven advanced ovarian/endometrial cancer, primary or interval debulking surgery, and intraoperative indication for regional peritonectomy. Six patients were treated by LPS (Group 1) and 6 by LPT (Group 2). Results: In Group 1 the indication for debulking surgery was in 4 cases an interval debulking surgery and 2 advanced endometrial cancer. All patients in Group 2 underwent primary debulking surgery for advanced ovarian cancer. The whole cohort achieved a complete tumor excision after surgery. The median OT and median EBL were 195 min and 100 ml in Group 1, and 420 min and 500 ml in Group 2. The median hospital stay was 4 days in Group 1 and 13 days in Group 2, respectively. No intra and postoperative complications were registered within 60 days after surgery. Conclusions: J-Plasma allows to approach delicate maneuvers on viscera, mesentery, and blood vessels with a high degree of safety and precision thanks to its limited vertical and lateral thermal spread, favoring the surgeon to push ever higher the cytoreduction/morbidity tradeoff. The use of J-Plasma in cytoreductive surgery could also increase the range of possible minimally invasive procedures, narrowing the technical distance with the open technique and thus contributing to designing a personalized surgical strategy for each patient in different scenarios of peritoneal carcinomatosis

Fertility-sparing approach in women affected by stage i and low-grade endometrial carcinoma: An updated overview

Endometrial cancer (EC) is a deleterious condition which strongly affects a woman’s quality of life. Although aggressive interventions should be considered to treat high-grade EC, a conservative approach should be taken into consideration for women wishing to conceive. In this scenario, we present an overview about the EC fertility-sparing approach state of art. Type I EC at low stage is the only histological type which can be addressed with a fertility-sparing approach. Moreover, no myometrium and/or adnexal invasion should be seen, and lymph-vascular space should not be involved. Regarding the pharmaceutical target, progestins, in particular medroxyprogesterone acetate (MPA) or megestrol acetate (MA), are the most employed agent in conservative treatment of early-stage EC. The metformin usage and hysteroscopic assessment is still under debate, despite promising results. Particularly strict and imperious attention should be given to the follow-up and psychological wellbeing of women, especially because of the double detrimental impairment: both EC and EC-related infertility consequences

Molecular markers and endometrial cancer

Non

Comparison between Laparoscopic and Robotic Approach for Sentinel Lymph Node Biopsy in Endometrial Carcinoma Women

Robotic surgery has been approved as an alternative to laparoscopy to improve surgical outcomes. There is neither a consensus nor a systematic assessment of the literature about the superiority of the robotic approach over the laparoscopic one for sentinel lymph node (SLN) biopsy in endometrial carcinoma (EC) women. Therefore, a systematic review and meta-analysis was performed to compare the laparoscopic and robotic approaches for SLN biopsy in EC patients. Five electronic databases were queried from their inception to May 2022 for peer-reviewed studies, comparing such approaches in SLN biopsy in EC patients. The rate of detected SLN, dissected SLN, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time were compared between the laparoscopic and robotic approaches for SLN biopsy in EC patients. Odds ratios with 95% confidence intervals were calculated when possible. Two studies with 660 EC women (364 who had undergone laparoscopy, and 296 who had robotic surgery) were included. No assessed outcome showed significant differences between the two approaches. In conclusion, the laparoscopic and robotic approaches for SLN biopsy in EC patients appeared to not differ, in terms of SLN detection, intraoperative and postoperative complications, conversion to laparotomy, number of dissected SLN, and SLN identification and dissection time