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Aims The aim is to evaluate long-term effectiveness and safety of transobturator midurethral slings (TO-MUS) for treating female stress urinary incontinence (SUI). Possible risk factors for failure and complications are also evaluated. Methods A descriptive retrospective study was performed among women with SUI treated at a tertiary urogynecology unit between January 2004 and December 2006. Women with stress-predominant mixed urinary incontinence or with associated pelvic organ prolapse were also included. Postoperative follow-up was performed at 1, 6, and 12 months and yearly thereafter. Outcomes were classified as cured, improved or failed. Results Of 896 women operated on over the study period, 565 were suitable for the analysis. Of them, 327 women completed the 5-year, 225 the 7-year, and 172 the 10-year follow-up periods. Success rates were 77.6%, 73.8%, and 73.2% at 5, 7, and 10 years, respectively. On multivariate Cox regression models age, body mass index, and previous incontinence surgery were related to failure. Complications of any type were described in 24.9% of patients, although most of them were mild. Only concomitant prolapse surgery was related to intraoperative and peroperative complications and the inside-out route to an increased odds of groin pain (odds ratio = 4.0). Conclusions This study showed that TO-MUS is an effective and safe procedure in the long-term. The expected outcomes and possible side effects profile should be discussed in detail during the counseling process before opting for a treatment option.

Objective. There is scarce evidence available about the benefit of combining technetium (Tc-99(m)) and indocyanine green (ICG) for sentinel lymph node (SLN) biopsy in endometrial cancer. The aim of this study was to compare the overall and bilateral pelvic detection rates of SLNs in two retrospective cohorts: ICG exdusive vs. combined ICG+ Tc-99(m). Methods. The COMBITEC study (COMBined ICG and Technetium for SLN detection in Endometrial Cancer) consisted of a multicentre retrospective study (February 2015 June 2020) including patients diagnosed with endometrial atypical hyperplasia or early-stage endometrial carcinoma who underwent SLN biopsy by cervical injection of ICG with or without Tc-99(m) in four different referral centers in Spain. Results. A total of 180 patients were included, 51% (n = 92) in ICG group and 49% (n 88) in ICG+Tc-99(m) group. Eighty-seven percent of the patients presented endometrioid histology, and over 99% of the procedures were performed by a minimally invasive approach. Both groups were comparable regarding their basal characteristics, except for a higher body mass index in ICG+Tc-99(m) group and a bigger proportion of robotic-assisted procedures in ICG group. Overall detection rate was 92.8% without significant differences between groups (ICG: 94.6% vs ICG+Tc-99(m): 90.9%, p = .34). No significant differences were observed neither in bilateral pelvic nor aortic mapping rate. When Tc-99(m) was used, surgical procedures were significantly longer. In 7.3% of mapped patients, at least one positive SLN was found (ICG: 10.3% vs ICG+Tc-99(m): 3.9%, p = .109). Empty node packet rates and number of SLNs retrieved per patient were also similar between cohorts. Conclusion. Combining preoperative Tc-99(m) to intraoperative ICG did not improve SLN detection in endometrial cancer, but resulted in longer procedures. (C) 2021 Elsevier Inc. All rights reserved.

Background: Uterine perforation is one of the most-serious complications after a surgical abortion, and the risk of such perforation is increased in second-trimester procedures. When a uterine perf...

Simple Summary Endometrial cancer (EC) mortality is directly associated with the presence of poor prognostic factors. Molecular prognostic factors have been identified, but none are used in clinical practice due to lack of validation studies. This study aims to validate a set of 255 prognostic biomarkers previously identified in an extensive literature review and explore new prognostic applications by analyzing them in The Cancer Genome Atlas (TCGA) and Clinical Proteomic Tumor Analysis Consortium (CPTAC) databases. A total of 30 biomarkers were validated and associated to a histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), overall survival (n = 11), and recurrence-free survival (n = 5). Our results encourage further studies of understudied biomarkers such as TPX2, and validates already broadly studied biomarkers such as MSH6, MSH2, or L1CAM, among others. Finally, our results present a significant step to advance the quest for biomarkers to accurately assess the risk of EC patients. Abstract Endometrial cancer (EC) mortality is directly associated with the presence of prognostic factors. Current stratification systems are not accurate enough to predict the outcome of patients. Therefore, identifying more accurate prognostic EC biomarkers is crucial. We aimed to validate 255 prognostic biomarkers identified in multiple studies and explore their prognostic application by analyzing them in TCGA and CPTAC datasets. We analyzed the mRNA and proteomic expression data to assess the statistical prognostic performance of the 255 proteins. Significant biomarkers related to overall survival (OS) and recurrence-free survival (RFS) were combined and signatures generated. A total of 30 biomarkers were associated either to one or more of the following prognostic factors: histological type (n = 15), histological grade (n = 6), FIGO stage (n = 1), molecular classification (n = 16), or they were associated to OS (n = 11), and RFS (n = 5). A prognostic signature composed of 11 proteins increased the accuracy to predict OS (AUC = 0.827). The study validates and identifies new potential applications of 30 proteins as prognostic biomarkers and suggests to further study under-studied biomarkers such as TPX2, and confirms already used biomarkers such as MSH6, MSH2, or L1CAM. These results are expected to advance the quest for biomarkers to accurately assess the risk of EC patients.

Objectives The aims of the study were to determine the management strategies offered to women with cervical intraepithelial neoplasia 2 (CIN 2) and the attitude of colposcopists toward its histological diagnosis and to identify the criteria used to select women for conservative management. Methods Colposcopists working in Spain were invited to participate in an online questionnaire via the Spanish Gynecology and Colposcopy Societies. The survey included 42 questions covering the 3 objectives of the study. One hundred eighty-two colposcopists representing all autonomous regions in Spain responded. The response rate was 26.2%, considering the total number of members. Results Most colposcopists offer conservative management in selected cases (153/182). The preferred follow-up interval is 6 months (65%), followed by 3-4 months (30%). Observation was considered no longer appropriate after 24 months (29.5%) and 12 months (26.3%), and 24.3% expressed that it depended on women's plan to conceive. During conservative management, 93.9% always perform a cytology, 62.7% human papillomavirus testing, 96.8% colposcopy, 47.9% cervical biopsy, and 28.1% endocervical curettage. Forty-five percent consider that CIN 2 merely represents a misclassified CIN 1 or CIN 3, whereas 46.2% think that CIN 2 lesions are unlikely to regress. Most respondents considered that age older than 40 years (81.3%), human papillomavirus 16 infection (62.1%), HIV infection (76.8%), positive p16 immunostaining (60.2%), a large lesion occupying more than 50% of the cervix (87%), endocervical involvement (91.6%), and previous treatment for CIN 2-3 (77%) are contraindications for conservative management. Conclusions Management of CIN 2 remains challenging for colposcopists, and a lack of consensus still exists in clinical practice. A better understanding of the natural history of CIN 2 and its clinical outcomes is still necessary to guide clinicians in its management.

Objective To determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes. Methods Prospective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010–2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. Results There were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7–17] vs, 14 [10–19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach. Conclusions The extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference. Trial registration ClinicalTrials.gov .identifier: NCT02676726

Introduction: Sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) is not indicated. However, in certain cases (size >3 cm, high grade, mass effect on mammography, or palpable mass), it may be possible to find incidental invasive carcinoma (IC) that requires an SLNB. We studied the correlation of the aforesaid factors with the probability of finding IC in the surgical specimen. Methods: Data was collected from 3 different institutions between 2010 and 2016, recording characteristics such as, but not limited to: high grade, size >3 cm, mass effect on mammography, and palpable mass. Results: On the whole, 468 “high-risk” DCIS cases were identified, 139 (29%) of which had IC. When the DCIS was high grade or the size was >3 cm, there was no significant difference in the probability of finding IC in the surgical specimen (OR = 1.13; 95% CI 0.84–1.51; OR = 1.2; 95% CI 0.85–1.40). Nevertheless, when a high grade and size (>3 cm) were combined, IC was more likely to exist (72.7 vs. 27.3%; p = 0.001). In addition, mass effect and palpation were independently associated with a significantly greater degree of IC (OR = 12.76; 95% CI 6.93–23.52). Conclusions: The results suggest that high-grade DCIS or DCIS with a size >3 cm, independently, does not require SLNB. Nonetheless, in the event that both factors are found in the same case, SLNB may be indicated. Additionally, SLNB is advisable for DCIS cases that are palpable or show a mass effect on mammography.

Procediments quirúrgics de citoreducció; Teràpia neoadjuvant; Neoplàsies d'ovari Procedimientos quirúrgicos de citorreducción; Terapia neoadyuvante; Neoplasias de ovario Cytoreduction Surgical Procedures; Neoadjuvant Therapy; Ovarian Neoplasms Objective We sought to evaluate the impact on survival of tumor burden and surgical complexity in relation to the number of cycles of neoadjuvant chemotherapy (NACT) in patients with advanced ovarian cancer (OC) with minimal (CC-1) or no residual disease (CC-0). Methods This retrospective study included patients with International Federation of Gynaecology and Obstetrics IIIC–IV stage OC who underwent debulking surgery at 4 high-volume institutions between January 2008 and December 2015. We assessed the overall survival (OS) of primary debulking surgery (PDS group), early interval debulking surgery after 3–4 cycles of NACT (early IDS group) and delayed debulking surgery after 6 cycles (DDS group) with CC-0 or CC-1 according to peritoneal cancer index (PCI) and Aletti score. Results Five hundred forty-nine women were included: 175 (31.9%) had PDS, 224 (40.8%) early IDS and 150 (27.3%) DDS. Regardless of Aletti score, median OS after PDS was significantly higher than after early IDS or DDS, but the survival difference was higher in women with an Aletti score 10, there were no differences between PDS and early IDS, but DDS was associated with decreased OS. Conclusion The benefit of complete PDS compared with NACT was maximal in patients with a low complexity score. In patients with low tumor burden, there was a survival benefit of PDS over early IDS or DDS. In women with high tumor load, DDS impaired the oncological outcome. The project that gave rise to these results received the support of a fellowship from “la Caixa” Foundation (ID 100010434). The fellowship code is LCF/BQ/EU18/11650038.

Polypropylene; Polyvinylidene fluoride; Stress urinary incontinence Polipropileno; Fluoruro de polivinilideno; Incontinencia urinaria de esfuerzo Polipropilè; Fluorur de polivinilidè; Incontinència urinària d'esforç Aims: To compare the effectiveness and safety of polypropylene (PP) and polyvinylidene fluoride (PVDF) transobturator tapes (TOT) for the treatment of female stress urinary incontinence (SUI). Methods: This is a multicentre randomized trial. Women with SUI or stress-predominant mixed urinary incontinence and scheduled for a TOT procedure were randomized to PP or PVDF slings. The primary outcome was 1-year cure or improvement rate using composite criteria. Complications were also compared. Relationships with outcomes were analyzed using multivariable logistic regressions models. Results: From April 2016 to January 2018 285 participants were randomized. PP and PVDF slings showed similar high cure or improvement rate (91.0% vs. 95.6%, p = .138). Improvement in validated questionnaires was also similar. PVDF slings were associated with a lower rate of de novo urgency incontinence (adjusted odds ratio = 0.35; 95% confidence interval = 0.15-0.80). We found no statistical differences in complications rates, although a higher incidence of long-term pain events were observed in the PP group. The study is underpowered to find differences in specific complications owing to the low number of events. Conclusion: PP and PVDF TOTs are equally effective, although PVDF is associated with fewer cases of de novo urgency incontinence. Further studies are needed to give robust conclusions on safety profiles.

To review the diagnostic and therapeutic procedures of patients diagnosed with Endometrial Stromal Sarcoma (ESS) and Undifferentiated Uterine Sarcoma (USS) at our institution and investigate their clinical outcomes and factors affecting prognosis. We retrospectively collected demographic data, preoperative diagnostic methods and therapeutic management of patients treated for ESS and UUS between January 1995 and December 2019 at Vall d’Hebron Barcelona Hospital Campus, Spain. Overall survival and disease-free survival were calculated. Cox proportional-hazards regression models were calculated. Sixty-three patients were included in the study, of which 51(81%) had a diagnosis of ESS and 12(19%) of UUS. Twenty patients (31.7%) were diagnosed after a previous non-oncologic surgery, and 12 of them (60%) suffered from tumor disruption. Cytoreductive procedures were needed in 29 patients (46%), and optimal cytoreduction was achieved in 80.9% of the patients. The median follow-up was 7.6 years (IQR = 0.99–14.31). Five-year overall survival was 57.6% (44.2–68.8) and was significantly better for low-grade ESS (LG-ESS) patients (p

PURPOSE: To combine different independent endometrial markers to classify the presence of endometriosis. METHODS: Endometrial biopsies were obtained from 109 women with endometriosis as well as 110 control women. Nine candidate biomarkers independent of cycle phase were selected from the literature and NanoString was performed. We compared differentially expressed genes between groups and generated generalized linear models to find a classifier for the disease. RESULTS: Generalized linear models correctly detected 68% of women with endometriosis (combining deep infiltrating and ovarian endometriosis). However, we were not able to distinguish between individual types of endometriosis compared to controls. From the 9 tested genes, FOS, MMP7, and MMP11 seem to be important for disease classification, and FOS was the most over-expressed gene in endometriosis. CONCLUSION(S): Although generalized linear models may allow identification of endometriosis, we did not obtain perfect classification with the selected gene candidates. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (10.1007/s10815-020-01965-6) contains supplementary material, which is available to authorized users.

Objective Paraaortic lymph node involvement is an important prognostic factor in locally advanced cervical cancer (LACC), but the anatomic limit of aortic lymphadenectomy is controversial. We assessed the impact of extraperitoneal paraaortic lymphadenectomy up to the left renal vein in patients with LACC undergoing pretherapeutic staging. Methods A retrospective, multicenter study of patients with LACC stages FIGO 2009 IB2 and IIA2-IVA treated in 10 Spanish reference hospitals in gynecological oncology between 2000 and 2016. Sites of metastatic paraaortic lymph nodes above or below the inferior mesenteric artery were evaluated. Procedural-related intraoperative and early and late complications were assessed. Results We included 634 patients undergoing paraaortic lymphadenectomy, in 616 (97.2%) of which the left renal vein was the upper limit of dissection (laparoscopy 592, robotic-assisted 24). The median surgical time was 150 min (interquartile range (IQR) 120–180), blood loss was 50 mL (range 20–80), and the length of stay was 2 days (range 2–3). Metastatic paraaortic involvement was found in 114 patients (18.5%), with infrarenal metastases in 73 (64%) of them. There were 11 patients (9.6%) with infrarenal metastases only, whereas in the remaining 62 (54.4%) patients concomitant infrarenal and inframesenteric metastases were observed. Intraoperative, early, and late postoperative complications occurred in 3.6%, 7.0%, and 4.5% of patients, respectively. Conclusions In this study of patients with LACC undergoing surgical staging, paraaortic lymphadenectomy up to the left renal vein detected skip or isolated infrarenal metastasis in 9.6% of patients, with an acceptable surgical morbidity.

Introduction: Breast cancer is one of the most frequently occurring cancers during pregnancy and its incidence is increasing. Many studies have shown poor outcomes, the causes of which remain unclear. Objectives: To analyze radiologic characteristics, histology, and prognosis factors of breast cancer during pregnancy. Methods: A total of 42 patients with breast cancer diagnosed during pregnancy (BCP) were matched with 84 patients with breast cancer of similar age who were not pregnant. Sensitivity of radiology, tumor characteristics, prognosis factors, disease-free survival, and overall survival were analyzed. Results: The sensitivity of breast ultrasound was higher than that of mammography for both groups. Ultrasound sensitivity for cancer was 95.7% in patients with BCP versus 98% in the not pregnant group, with non–statistically significant differences. Mammography sensitivity for cancer was 56.5% in patients with BCP versus 61% in the not pregnant group, with non–statistically significant differences. The stage at diagnosis according to the TNM staging system was significantly higher in patients with BCP with stage IV cancer: 16.7% in patients with BCP versus 3.7% in the not pregnant group ( p = 0.03). No statistically significant differences were observed in histologic grade, Ki-67 index, or molecular subtype. Disease-free survival and overall survival were significantly lower in patients with BCP ( p = 0.002 and p = 0.04). Multivariate analysis showed no difference when adjusting for stage and surrogate molecular subtype. Conclusion: Breast ultrasound shows a high sensitivity to detect breast cancer during pregnancy. BCP is diagnosed at a higher stage than in nonpregnant women. In our series, patients with BCP had poorer outcomes than the not pregnant group. These results were not observed when adjusting for stage.

Objectives The human papilloma virus (HPV) test is recommended in the posttreatment follow-up of cervical intraepithelial neoplasia. The aim of the study was to assess whether the intraoperative HPV (IOP-HPV) test had a similar diagnostic accuracy that HPV test performed at 6 months to predict high-grade squamous intraepithelial lesion (HSIL) recurrence. Materials and methods In a prospective cohort study, 304 women diagnosed with HSIL by biopsy and/or endocervical curettage before treatment and/or confirmation in the histological specimen were included. Immediately after surgery, HPV testing was performed. This test was compared with the test at 6 months and other predictors of recurrence. Patients were followed for 24 months. An economic analysis was performed to compare the costs of IOP-HPV and HPV test at 6 months. Results Recurrence rate of HSIL was 6.2% (19 patients). The diagnostic accuracy of the IOP-HPV test to predict HSIL recurrence at 24 months was similar to the HPV test at 6 months, with comparative sensitivities of 100% versus 86.7%, specificities of 82.0% versus 77.9%, positive predictive values of 27.1% versus 18.1%, and negative predictive values of 100% versus 99.0%. Direct economic saving per high-grade intraepithelial lesion patient was 172.8 O. Conclusions The HPV test performed after loop electrosurgical resection procedure predicted recurrence of HSIL at 24 months with a similar diagnostic accuracy than the HPV test at 6 months. The use of the IOP-HPV test in the management of HSIL will allow early detection of the risk of recurrent disease and to save costs because of potential suppression of the need of HPV and follow-up controls at 6 months.

Teixit cancerígen; Càncer d'ovaris; Proteòmica Tejido canceroso; Cáncer de ovarios; Proteómica Cancer tissue; Ovarian cancer; Proteomics High-grade serous ovarian cancer (HGSC) remains the most common and deadly subtype of ovarian cancer. It is characterized by its late diagnosis and frequent relapse despite standardized treatment with cytoreductive surgery and platinum-based chemotherapy. The past decade has seen significant advances in the clinical management and molecular understanding of HGSC following the publication of the Cancer Genome Atlas (TCGA) researchers and the introduction of targeted therapies with anti-angiogenic drugs and poly(ADP-ribose) polymerase inhibitors in specific subgroups of patients. We provide a comprehensive review of HGSC, focusing on the most important molecular advances aimed at providing a better understanding of the disease and its response to treatment. We emphasize the role that proteomic technologies are now playing in these two aspects of the disease, through the identification of proteins and their post-translational modifications in ovarian cancer tumors. Finally, we highlight how the integration of proteomics with genomics, exemplified by the work performed by the Clinical Proteomic Tumor Analysis Consortium (CPTAC), can guide the development of new biomarkers and therapeutic targets. This work was supported by the PhD4MD collaborative research program between the Vall d’Hebron Research Institute (VHIR) and the Centre for Genomic Regulation (CRG). The CRG/UPF Proteomics Unit is part of the Spanish Infrastructure for Omics Technologies (ICTS OmicsTech) and it is a member of the ProteoRed PRB3 consortium which is supported by grant PT17/0019 of the PE I + D + i 2013–2016 from the Instituto de Salud Carlos III (ISCIII) and ERDF. We acknowledge support from the Spanish Ministry of Science and Innovation (CTQ2016-80364-P) and “Centro de Excelencia Severo Ochoa 2013–2017”, SEV-2012-0208; the “Secretaria d’Universitats i Recerca del Departament d’Economia i Coneixement de la Generalitat de Catalunya” (2017SGR595 and 2017SGR1661), from the Instituto de Salud Carlos III (PI15/02238, PI18/01017, CPII18/00027) and from the Ministerio de Economia y Competitividad y Fondos FEDER (RTC-2015-3821). We also acknowledge the support of the Spanish Ministry of Science and Innovation to the EMBL partnership, the Centro de Excelencia Severo Ochoa and the CERCA Programme/Generalitat de Catalunya.

Cáncer de cuello de útero; Supervivencia libre de enfermedad; Metástasis linfática Càncer de coll de l'úter; Supervivència lliure de malaltia; Metàstasi limfàtica Cervical Cancer; Disease-Free Survival; Lymphatic Metastasis Objective The prognostic impact of surgical paraaortic staging remains unclear in patients with locally advanced cervical cancer (LACC). The objective of our study was to evaluate the results of the surgical technique of preoperative aortic lymphadenectomy in LACC related to tumor burden and disease spread to assess its influence on survival. Methods Data of 1,072 patients with cervical cancer were taken from 11 Spanish hospitals (Spain-Gynecologic Oncology Group [GOG] working group). Complete aortic lymphadenectomy surgery (CALS) was considered when the lymph nodes (LNs) were excised up to the left renal vein. The extent of the disease was performed evaluating the LNs by calculating the geometric means and quantifying the log odds between positive LNs and negative LNs. The Kaplan-Meier method was used to estimate the survival distribution. A Cox proportional hazards model was used to account for the influence of multiple variables. Results A total of 394 patients were included. Pathological analysis revealed positive aortic LNs in 119 patients (30%). LODDS cut-off value of −2 was established as a prognostic indicator. CALS and LODDS

Objective. Pre-operative immunohistochemical (IHC) biomarkers are not incorporated in endometrial cancer (EC) risk classification. We aim to investigate the added prognostic relevance of IHC biomarkers to the ESMOESGO-ESTRO risk classification and lymph node (LN) status in EC. Methods. Retrospective multicenter study within the European Network for Individualized Treatment of Endometrial Cancer (ENITEC), analyzing pre-operative IHC expression of p53, L1 cell-adhesion molecule (L1CAM), estrogen receptor (ER) and progesterone receptor (PR), and relate to ESMO-ESGO-ESTRO risk groups, LN status and outcome. Results. A total of 763 EC patients were included with a median follow-up of 5.5-years. Abnormal IHC expression was present for p53 in 112 (14.7%), L1CAM in 79 (10.4%), ER-in 76 (10.0%), and PR-in 138 (18.1%) patients. Abnormal expression of p53/L1CAM/ER/PR was significantly related with higher risk classification groups, and combined associated with the worst outcome within the 'high and advanced/metastatic' risk group. In multivariate analysis p53-abn, ER/PR-and ESMO-ESGO-ESTRO 'high and advanced/metastatic' were independently associated with reduced disease-specific survival (DSS). Patients with abnormal IHC expression and lymph node metastasis (LNM) had the worst outcome. Patients with LNM and normal IHC expression had comparable outcome with patients without LNM and abnormal IHC expression. Conclusion. The use of pre-operative IHC biomarkers has important prognostic relevance in addition to the ESMO-ESGO-ESTRO risk classification and in addition to LN status. For daily clinical practice, p53/L1CAM/ER/ PR expression could serve as indicator for surgical staging and refine selective adjuvant treatment by incorporation into the ESMO-ESGO-ESTRO risk classification. (c) 2021 The Authors. Published by Elsevier Inc. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/). sion was present for p53 in 112 (14.7%), L1CAM in 79 (10.4%), ER- in 76 (10.0%), and PR- in 138 (18.1%) patients. Abnormal expression of p53/L1CAM/ER/PR was significantly related with higher risk classification groups, and combined associated with the worst outcome within the 'high and advanced/metastatic' risk group. In multivariate analysis p53-abn, ER/PR- and ESMO-ESGO-ESTRO 'high and advanced/metastatic' were independently associated with reduced disease-specific survival (DSS). Patients with abnormal IHC expression and lymph node metastasis (LNM) had the worst outcome. Patients with LNM and normal IHC expression had comparable outcome with patients without LNM and abnormal IHC expression. Conclusion. The use of pre-operative IHC biomarkers has important prognostic relevance in addition to the ESMO-ESGO-ESTRO risk classification and in addition to LN status. For daily clinical practice, p53/L1CAM/ER/ PR expression could serve as indicator for surgical staging and refine selective adjuvant treatment by incorpora

Introduction/Background* Enhanced Recovery After Surgery (ERAS) reduces complication rates after surgery, decreases length of hospital stay (LOS) and reduces costs. A correct implementation of the ERAS protocol and adherence to all ERAS items contribute to better outcomes in gynecological oncology surgery. The aim of this survey is to acquire a comprehensive picture of the current status of implementation of the ERAS protocol among European centers. Methodology A 45-item questionnaire survey, investigating ERAS practice preferences in pre-, intra-, and post-operative management was launched between December 2020 and May 2021. An on-line questionnaire link was e-mailed to the national representatives (NATREPs) of the European Network of Young gynecologic oncologists (ENYGO), who then shared the survey with their centers. In order to avoid duplicate data, NATREPs selected one referral person from the highest volume centers performing complex surgery per country. Two weeks later a reminder was sent to non-responders. Result(s)* A total of 116 responses were collected. 73% of centers were academic/teaching hospitals. Overall, 70% of respondents reported that ERAS was implemented at their institution. The median LOS for advanced ovarian cancer surgery was between 5-7 days according to 63% of respondents. 81% of respondents reported a median LOS between 2-4 days among patients who underwent surgery for early-stage gynecological cancer. An overall compliance rate between 60% and 80% was reported by 44,29% of centers. ERAS items with well adherence to the guidelines were: deep vein thrombosis prophylaxis, antibiotic prophylaxis, prevention of hypothermia and early mobilization. Regarding preoperative ERAS items, 28% of respondents reported bowel preparation as ‘sometimes–normally’ performed. 60% of respondents described ERAS implementation as a challenge and 76% reported being reluctant to change clinical practice. Conclusion* This European survey of ERAS in gynecologic oncology surgery shows that there is still a lack of implementation of the ERAS protocol across Europe and European centers need to increase ERAS gynecologic oncology guideline compliance to improve patient outcomes. Therefore, European centers need a further protocol and guidelines that encompass the way of ERAS implementation

Introduction/Background* Enhanced recovery after surgery (ERAS) programs in advanced ovarian cancer (AOC) surgery have been developed in the last few years. The PROFAST randomized controlled trial showed that ERAS was associated with a decrease on length of stay and readmission. Here, we present the results of a secondary outcome, cost analysis, of the PROFAST trial. Methodology The PROFAST trial was a prospective, interventional randomized clinical trial that enrolled women undergoing surgery for either suspected or diagnosed advanced ovarian cancer, at a reference hospital in gynecologic oncology in Barcelona (Spain). Patients were treated following either an ERAS protocol or conventional management (CM) protocol. The primary outcome was to evaluate reduction in length of stay (LOS). One of the secondary outcomes was to perform cost analysis betweem both groups. Cost estimations were performed by two strategies: gross counting (cost of inpatient care, intensive care unit and surgery care), and microcosting (costs associated to image testing and laboratory). In both cases, costs were based on 2014 cost data. A sensitivity analysis of cost savings in different scenarios was performed. This trial was registered at ClinicalTrials.gov (NCT02172638). Result(s)* From June 2014 to March 2018, 110 women were recruited, of which eleven were excluded. The ERAS group comprised 50 patients, and the CM group, 49 patients. LOS. Although mean overall cost per patient was higher in ERAS vs CM (14347 € vs 12597€), ERAS cost distribution was skewed by two patients that accounted for 48% of total intensive care unit costs. Comparing median costs, ERAS costs were significantly lower than CM costs (7642€/patient vs 8594€/patient, P=.0275). Decrease in hospital readmission rates led to higher readmission costs in the CM group (Total costs 6126€ v 125725€, P=.028). Sensitivity analysis showed that, in the worst predicted scenario (median LOS corresponding to 12 days), 1146 €/patient would be saved if ERAS protocols were applied. Conclusion* Besides of achieving lower LOS and fewer readmission rates, implementation of an ERAS program in AOC surgery leads to valuable hospital savings. Therefore, ERAS should be the standard practice for AOC surgeries.

Introduction/Background* The combination of improved survival and delaying child bearing increases the trend of early cervical cancer diagnosis in women without a fulfilled gestational wish. Fertility preservation surgery (FSS) becomes a necessary treatment option for young women. The aim of this study is to analyze the impact of tumor size on surgical and oncological outcomes of FSS in early cervical cancer in Spain. Methodology A multicenter, retrospective cohort study of early cervical cancer (IA2- IB1, FIGO 2009) patients with gestational desire who underwent FSS was carried out at the departments of gynecology of 12 tertiary care hospitals between 01/2005 and 01/2019 throughout Spain. The data were registered in an on-line database. All analyses were performed using STATA 15 statistical software Result(s)* A total of 111 patients who underwent trachelectomy were included, 82 (73.9%) of them with tumors Median follow-up was 55.7 months in patients group Cox regression was performed to identify different predictor factor for recurrence. Only tumor size ( Conclusion* This study shows a real world data of a large number of trachelectomies performed in patients with early cervical cancer after negative lymphnode assessment. Selection criteria should be rigorous especially for patients with tumor ≥ 2 cm due to its worse oncological outcomes. Options may be discussed with the patient to reach a balance between the risk of recurrence and the best fertility results

Introduction/Background* Endometrial cancer (EC) is the most common gynecological cancer in developed countries. There are no screening tools for its early diagnosis, and the diagnostic process starts with the apparition of related symptoms, mainly, abnormal vaginal bleeding (AVB). It is estimated that ~7M women with AVB will undergo the diagnostic process every year in Europe, and from those, 9% will have EC. Importantly, the current diagnostic process relies on the pathological examination of an endometrial biopsy that is always obtained by minimally-invasive to invasive methods. This overdiagnosis creates a big burden to the healthcare systems, so the development of non-invasive tools for EC diagnosis would revolutionize this scenario. Our aim is to approach a non-invasive diagnosis by the identification of protein biomarkers to accurately diagnose EC in liquid cervical cytologies. Methodology The discovery phase consisted of a shotgun label-free proteomic approach. It included 60 patients (20 EC, 20 controls suffering AVB without endometrial or cervical pathology, and 20 controls without endometrial pathology but cervical pathology). The levels of a statistically significant set of 75 proteins (110 peptides) from the discovery phase were measured in a verification phase including 234 (107 non-EC; 127 EC) patients by LC-MSMS/PRM. Analysis was performed using MaxQuant, Skyline, SPSS and R software. Result(s)* The discovery study permitted to determine a total number of 2,888 proteins in our samples. Statistical analysis identified 75 potential proteins differently expressed between EC and non-EC patients to be further assessed and verified. Verification phase revealed the potential of 58 proteins measured in cervical cytologies to reach a non-invasive diagnosis of EC. Specifically, 16 proteins achieved an AUC > 0.75, and 3 proteins an AUC > 0.8. Additionally, an ELISA assay of the best performing protein was tested reproducing the results obtained by mass-spectrometry and reaching an AUC=0.927 in this dataset. Conclusion* We identified protein biomarkers in liquid cervical cytologies to diagnose EC patients with a diagnostic power up to 92%. These results are promising for a subsequent development of an early and non-invasive screening tool for EC. This tool is expected to change the standard of care in EC diagnosis.

Introduction/Background* There is scarce evidence available about the benefit of combining technetium (99mTc) and indocyanine green (ICG) for sentinel lymph node (SLN) biopsy in endometrial cancer. The aim of this study was to compare the overall and bilateral pelvic detection rates of sentinel lymph nodes in two retrospective cohorts: ICG exclusive vs. combined ICG+99mTc. Methodology Multicentre retrospective study (November 2015-June 2020) including patients diagnosed with endometrial atypical hyperplasia or early-stage endometrial carcinoma who underwent sentinel lymph node biopsy by cervical injection of ICG with or without 99mTc in four different referral centers in Spain. Result(s)* A total of 180 patients were included, 51% (n=92) in ICG group and 49% (n=88) in ICG+99mTc group. Eighty-six percent of the patients presented endometrioid histology, and over ninety-nine percent of the procedures were performed by a minimally invasive approach. Both groups were comparable regarding their basal characteristics, except for a higher body mass index in ICG+99mTc group and a bigger proportion of robotic-assisted procedures in ICG group. Overall detection rate was 92.8% and similar between groups (ICG: 94.6% vs ICG+99mTc: 90.9%, p=.34). No significant differences were observed neither in bilateral pelvic nor aortic mapping rate. When 99mTc was used, surgical procedures were significantly longer. In 6.7% of patients, at least one positive SLN was found (ICG:9.8% vs ICG+99mTc:3.4%, p = .164). Empty node packet rates and number of SLNs retrieved per patient were also similar between cohorts. Conclusion* Combining preoperative 99mTc to intraoperative ICG did not improve SLN detection in endometrial cancer, but resulted in longer procedures.

Introduction/Background* The surgical approach of minimally invasive surgery (MIS) for paraaortic staging lymphadenectomy (PALND) in gynecologic malignancies is controversial. The STELLA-2 trial was designed to determine whether the extraperitoneal approach for PALND results in a lower rate of surgical complications compared to the transperitoneal approach. Methodology Prospective randomized multicenter study of patients with early-stage endometrial or ovarian cancer who underwent PALND as part of the staging process between June 2012 and January 2019. Patients were randomized to PALND by MIS (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥ 500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. Secondary end points included the number of lymph nodes retrieved, the operative time, the length of hospital stay, and oncologic outcome (overall survival and disease-free survival). A post-hoc analysis to compare all possible approaches (transperitoneal or extraperitoneal, robotic-assisted or laparoscopic) was performed. ClinicalTrials gov id:NCT02676726). Result(s)* Of 209 women randomized, 103 in the extraperitoneal group and 100 in the transperitoneal group underwent PALND. Differences in the composite outcome between both groups (transperitoneal 26.0% vs extraperitoneal 18.4%: P=.195) were not found. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7-17] vs 14 [10-19]: P=.026). Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. The post-hoc multivariable analysis revealed that age (OR: 1.05, 95% CI: 1.00-1.09), body mass index (OR: 1.09, 95% CI: 1.03-1.16), and waist-hip ratio (OR: 1.66, 95% CI: 1.12-2.47) were found to independently increase the risk of PALND complications, while extraperitoneal robotic approach (OR: 0.13, 95% CI 0.02-0.64) was an independent protective factor for complication occurrence. Conclusion* Extraperitoneal approach is a safe procedure for PALND in the minimally invasive surgical staging of women diagnosed with early-stage endometrial or ovarian malignancy. Moreover, in the post-hoc analysis, robotic-assisted extraperitoneal PALND was associated with fewer surgical complications.

Introduction/Background* In advanced ovarian cancer surgery, there is rather limited published evidence, drawn from a small sample, providing information about risk factors for anastomotic leak. Methodology In our previous work, Twelve pre-/intraoperative variables were analysed as potential independent risk factors for anastomotic leak. A predictive model was created to stablish the risk of anastomotic leak for a given patient. Result(s)* The validation of our proposed predictive model will emerge from the collaborative research performed by 12 centers: 6 from Spain, 2 from United Kingdom, 1 from Italy, 1 from France and 2 from Germany. Conclusion* Due to the low incidence of AL in ovarian cancer patients, a restrictive stoma policy based on the presence of risk factors should be the actual recommendation. The AL risk for each patient can be predicted by our multivariate model.

Introduction/Background* Patients with high-grade endometrial carcinoma (EC) have an increased risk of lymph node metastasis (LNM). Preoperative serum CA125 and imaging findings have been incorporated in multiple risk stratification models to predict LNM and advanced disease in EC and are widely used in clinical practice. However, data on their predictive value in high-grade EC are limited. We therefore aim to determine the predictive value of CA125 combined with preoperative computed tomography (CT) imaging in high-grade EC for LNM. Methodology Retrospective multicentre cohort study including patients (n=334) with preoperative high-grade EC and available CA125. Clinical data including imaging results, primary surgical treatment and final International Federation of Gynaecology and Obstetrics (FIGO) stage were recorded. CA125 was considered elevated at >35 IU/L. Result(s)* Patients with high-grade EC (n=334) and elevated CA125 more often presented with advanced FIGO stage (III-IV), 64.2% (95/148) versus 18.8% (35/186) in patients with normal CA125 (p Multivariate analysis (table 2) showed that elevated CA125, histological deep (>50%) myometrial invasion, and cervical involvement independently predict histological LNM (p Conclusion* This study demonstrates that elevated CA125 in patients with high-grade EC is an important prognostic marker for the predication of LNM and advanced stage disease. In patients with preoperative normal CA125, the additional value of CT imaging was limited with respect to the prediction of LNM. We therefore recommend to incorporate CA125 in routine preoperative work-up for risk stratification in high-grade EC.

Objective. To determine the factors related with diverting ileostomy performance after colorectal resection and anastomosis, in advanced ovarian cancer cytoreductive surgery. Methods. We have previously demonstrated the risk factors associated with anastomotic leak after colorectal anastomosis: Advanced age at surgery, low serum albumin level, additional bowel resections, manual anastomosis and distance of the anastomosis from the anal verge. However, use of diverting ileostomy is strongly variable and depends on individual surgeon preferences and training. Eight hospitals participated in this retrospective study. Data of 695 patients operated for ovarian cancer with primary colorectal anastomosis were included (January 2010-June 2018). Fourteen pre-/intraoperatively defined variables were identified and analysed as justification factors for use of diverting ileostomy. Results. The rate of diverting ileostomy in the entire cohort was 19.13% (133/695; range within individual centers 4.6-24.32%). Previous treatment with bevacizumab [OR 2.8 (1.3-6.1); p=0.01]; additional bowel resections [OR 3.0 (1.8-5.1); p

PURPOSE: There is a gap in knowledge regarding the impact of micrometastases (MIC) and isolated tumor cells (ITCs) found in the sentinel lymph nodes of patients with endometrial cancer. Here, we present a meta-analysis of the published literature on the rate of MIC and ITCs after lymphatic mapping and determine trends in postoperative management. METHODS: Literature search of Medline and PubMed was done using the terms: micrometastases, isolated tumor cells, endometrial cancer, and sentinel lymph node. Inclusion criteria were: English-language manuscripts, retrospectives, or prospective studies published between January 1999 and June 2019. We removed manuscripts on sentinel node mapping that did not specify information on micrometastases or isolated tumor cells, non-English-language articles, no data about oncologic outcomes, and articles limited to ten cases or less. RESULTS: A total of 45 manuscripts were reviewed, and 8 studies met inclusion criteria. We found that the total number of patients with MIC/ITCs was 286 (187 and 99, respectively). The 72% of patients detected with MIC/ITCs in sentinel nodes received adjuvant therapies. The MIC/ITCs group has a higher relative risk of recurrence of 1.34 (1.07, 1.67) than the negative group, even if the adjuvant therapy was given. CONCLUSION: We noted that there is an increased relative risk of recurrence in patients with low-volume metastases, even after receiving adjuvant therapy. Whether adjuvant therapy is indicated remains a topic of debate because there are other uterine factors implicated in the prognosis. Multi-institutional tumor registries may help shed light on this important question.

Uterine angioleiomyoma is a rare type of leiomyoma variant and there are few cases reported in the literature. The definitive diagnosis is usually obtained only after the histopathologic examination because there are no specific imaging criteria for this disease. The objective of this article is to review published cases about this clinical condition. We report a case of giant angioleiomyoma superinfected by S. agalactiae with the development of latero-cervical distant metastasis in a premenopausal woman. Firstly, the case herein reported was orientated as an endometrial stroma sarcoma in the peri-operative histologic examination by frozen sections. It was treated with laparotomic total hysterectomy, bilateral salpingo-oophorectomy, inframesocolic omentectomy and pelvic and paraaortic lymph node dissection. Postoperative definitive anatomopathological analyses using a proper immunohistochemical panel revealed a case of uterine angioleiomyoma. We also review other case reports published about this clinical condition. We present the first case reported in the literature, in our knowledge, of a giant angioleiomyoma superinfected by S. agalactiae with the development of distant septic metastases. Immunohistochemistry permitted the definitive diagnosis of angioleiomyoma. Treatments previously reported are hysterectomy or tumor resection and any patient recurred. The definitive diagnosis is usually obtained after the definitive histopathologic examination since the use of immunohistochemical study has an important role in this regard. Complete surgical removal of the lesion is the treatment of choice, with no recurrent cases reported to date.

Objectives The PI3K/AKT/mTOR pathway is frequently overactivated in endometrial cancer (EC). We assessed the efficacy of ABTL0812, a novel first-in-class molecule presenting a unique mechanism of action inhibiting this pathway. Methods We investigated the effects of ABTL0812 on proliferation, cell death and modulation of intracellular signaling pathways in a wide panel of endometrioid and non-endometrioid cell lines, an inducible PTEN knock-out murine model, and two patient-derived xenograft murine models of EC. Then, TRIB3 expression was evaluated as potential ABTL0812 pharmacodynamic biomarker in a Phase 1b/2a clinical trial. Results ABTL0812 induced an upregulation of TRIB3 expression, resulting in the PI3K/AKT/mTOR axis inhibition and autophagy cell death induction on EC cells but not in healthy endometrial cells. ABTL0812 treatment also impaired PTEN knock-out cells to progress from hyperplasia to cancer. The therapeutic effects of ABTL0812 were demonstrated in vivo. ABTL0812 increased TRIB3 mRNA levels in whole blood samples of eight EC patients, demonstrating that TRIB3 mRNA could be used as a pharmacodynamic biomarker to monitor the ABTL0812 treatment. Conclusions ABTL0812 may represent a novel and highly effective therapeutic agent by inducing TRIB3 expression and autophagy in EC patients, including those with poorer prognosis.

OBJECTIVES The data available on vaginal intraepithelial neoplasia (VAIN) and infection by HIV are scarce. We therefore aimed to review the clinical presentation, management, and survival outcomes of VAIN in this group of women. MATERIALS AND METHODS This is an observational cohort study of women diagnosed with VAIN for a 23-year period. Clinical characteristics and outcomes were analyzed according to women's HIV infection status. Disease-free and progression-free survival were compared between groups. RESULTS Twenty-two of 87 women were HIV positive (25.3%) compared with the HIV-negative group, HIV-positive women were younger (median age = 39 vs 57 years, p < .001) and more frequently smokers (p < .001). They also presented with multifocal and multicentric disease more often (p = .004 and p = .033, respectively) in relation to infection by human papillomavirus. All HIV-positive women were receiving antiretroviral treatment. The median time from the diagnosis of HIV to the development of VAIN was 14 years (range = 1-22 years). There were no significant differences in survival outcomes between groups. CONCLUSIONS HIV-positive women are at an increased risk of developing VAIN and frequently present at a younger age with multifocal and multicentric disease. Vaginal intraepithelial neoplasia lesions can develop many years after the initial diagnosis of HIV infection reason why prolonged surveillance is essential to enable prompt diagnosis and treatment.

Background: Second primary malignancies (SPM) in the lung are not common in breast cancer (BC) patients. EGFR-mutant lung cancer (LC) is a separate molecular subset, and the co-existence of EGFR-mutant LC and BC has not been explored. We hypothesized that EGFR-mutant LC patients could have higher rates of primary BC than those with EGFR-wild type (WT). Methods: We collected data on clinical and molecular characteristics and outcomes of female patients with LC and a previous or simultaneous history of primary BC treated in our hospital from 2008 to 2014. Results: Data on treatment, follow-up, and EGFR mutation status were available for 356 patients. 17.7% (11/62) of patients with EGFR mutations had BC, compared to 1.02% (3/294) of EGFR-WT patients (p < 0.001). Both tumors were metachronous in 81.8%, with LC diagnosed 9 years after the diagnosis of BC. 5 of the 6 (83.3%) BC patients treated with radiotherapy developed LC in an area within the radiation field. No EGFR mutations were detected in BC tissue and no HER2 expression was detected in LC samples. Conclusion: SPM in the lung and breast occur more frequently among EGFR-mutant compared to EGFR-WT LC patients. Radiotherapy for BC may increase the risk of developing primary LC.

To evaluate the clinical value of postreatment plasmatic levels of the squamous cell carcinoma antigen (SCC-Ag) as a survival independent prognostic factor in patients with LACC.Retrospective, multicenter study including LACC patients (FIGO 2009 stages IB2, IIA2-IVA) managed at the Gynecology Oncological Units corresponding to eight reference hospitals in Spain between 2000 and 2016. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off values of postreatment SCC-Ag levels in prediction of survival. Survival curves were calculated by using the Kaplan-Meier method and were compared with the log-rank test. Cox models were used to analyze different factors in terms of their prognosis predictive value.The study included 447 patients with a median follow-up time of 53 months (IQR 26-101) and median pre- and postreatment SCC-Ag levels of 3.4 ng/ml (IQR 1.2-11) and 0.8 ng/ml (IQR 0.5-1.2), respectively. The cut-off level of pretreatment SCC-Ag was 11.75 ng/ml (sensibility 37.5%; specificity 80.5%) and that of postreatment SCC-Ag was 1.24 ng/ml (sensibility 34.6%; specificity 83.1%). In a multivariate Cox regression analysis, factors that were independent predictors of OS were: FIGO stage (HR 2.12; 95%CI 1.18-3.8; p = 0.011), paraaortic lymph node involvement (HR 3.56; 95%CI 2.04-6.2; p0.0001), postreatment SCC-Ag level ≥ 1.2 ng/ml (HR 1.95; 95%CI 1.11-3.44; p = 0.02) and incomplete response to treatment (HR 4.5; 95%CI 2.5-8.11; p0.0001).Postreatment plasmatic SCC-Ag level ≥ 1.2 ng/ml was an independent risk factor for the survival of patients with LACC. Further factors influencing survival included: paraaortic lymph node involvement, advanced disease and poor response to concomitant chemoradiotherapy.

Objective: To evaluate the reliability of sagittal abdominal diameter (SAD)—a surrogate of visceral obesity—in MRI, and its accuracy to predict the surgical morbidity of aortic lymphadenectomy. Design: A multicentre reliability (phase 1) and accuracy (phase 2) cohort study. Setting: Three Spanish referral hospitals. Population: High-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional vs. robotic-assisted laparoscopy, and transperitoneal vs. extraperitoneal technique. Methods: Retrospective analysis of data from the STELLA-2 randomized controlled trial. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, the renal vein, and the inferior mesenteric artery) and selected the most reliable one. In phase two, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Main Outcome Measures: surgical morbidity was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty. Results: In phase one, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD was the most reliable one. In phase two, we included 136 patients. Umbilical SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than BMI and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56 and specificity: 0.80). Conclusions: Umbilical SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.

Objective To demonstrate the step-by-step surgical technique of robotic-assisted transabdominal cerclage, highlighting a new posterior compartment approach. Design Stepwise explanation of a surgical technique using surgical video. Setting The procedure was performed at the Obstetrics and Gynecology Department, Hospital Vall d'Hebron in Barcelona, Spain, a tertiary medical center. The local institutional review board considers that case reports are exempt from research approval. Patient(s) A 26-year-old non-pregnant patient, with a history of cervical incompetence, three second-trimester losses, and vaginal cerclage failure during her previous pregnancy. Intervention(s) Robotic-assisted transabdominal cerclage placement was performed. An 8-mm, 30° scope; monopolar scissors; and Maryland bipolar graspers were used. A uterine manipulator was used for better exposure. First, a bladder flap was created, and the uterine vessels were identified and skeletonized. Next, a window between the uterine vessels and the uterine cervix at the level of the cervical-isthmic junction was created bilaterally. At the posterior compartment, the dissection of the root of the uterosacral ligaments was carefully performed. A retrocervical pocket was created with monopolar scissors and sharp dissection. The procedure was finished with the Mersilene tape placement. First, the tape was passed through the window created in the right broad ligament, with a posterior-to-anterior direction, the retro cervical pocket, and finally through the left broad ligament. The knot was placed anteriorly and reperitonization was performed. In addition to this operation, robotic-assisted transabdominal cerclage was successfully performed in another six patients with good surgical and obstetrics outcomes. Main outcome measure(s) Intraoperative technique to ensure successful robot-assisted abdominal cerclage placement. Result(s) The patient became pregnant six months following the robotic-assisted transabdominal cerclage. Her pregnancy was closely followed up at the High-Risk Obstetric Unit, and she had no complications during pregnancy. An elective cesarean section was performed at 36 weeks with a healthy newborn baby that was discharged with the mother three days after delivery. Conclusion(s) The development of a retro cervical pocket during robotic-assisted transabdominal cerclage can be performed safely and effectively. It may help prevent displacement of the Mersilene tape during endoscopic knotting.

Enhanced Recovery After Surgery (ERAS) programs include multiple perioperative care elements, which when implemented together are designed to improve recovery after surgery with subsequent reduction in hospital length of stay (LOS). The aim of this study is to examine the impact of ERAS protocol compliance on LOS in patients undergoing advanced ovarian cancer surgery within the context of a randomized clinical trial. Patients were enrolled in a prospective, consecutive, interventional randomized clinical trial between June 2014 and March 2018. Women with either suspected or confirmed advanced ovarian cancer with International Federation of Gynecology and Obstetrics (FIGO) stages IIB–IVA and recurrent ovarian cancer, who underwent cytoreduction surgery, were randomly assigned to either a conventional management (CM) protocol or an ERAS protocol. Demographic items, preoperative clinical data, and surgical characteristics of patients were recorded, as were LOS and ERAS protocol compliance. Negative binomial regression was used to model the relation between length of stay and ERAS protocol compliance. We included 49 patients in the CM group and 50 patients in the ERAS group. The overall rate of ERAS compliance was 92%. We observed that increasing ERAS protocol compliance was associated with shorter median LOS, and in patients who underwent higher complex surgeries, the length of stay reduction was greater. This study identifies a correlation between increasing ERAS protocol compliance and decreasing LOS in ovarian cancer surgery. This finding underlines the necessity to implement as many ERAS protocol elements as possible to achieve optimal clinical outcome improvements.