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Abstract: It has been demonstrated that the forebrain cholinergic system and the extracellular regulated kinase signal transduction pathway are involved in the mechanisms of learning, encoding, and storage of information. We investigated the involvement of the cholinergic and glutamatergic systems projecting to the medial prefrontal cortex and ventral hippocampus and of the extracellular regulated kinase signal transduction pathway in the acquisition and recall of the step-down inhibitory avoidance response in the rat, a relatively simple behavioral test acquired in a one-trial session. To this aim we studied by microdialysis the release of acetylcholine and glutamate, and by immunohistochemistry the activation of extracellular regulated kinase during acquisition, encoding and recall of the behavior. Cholinergic, but not glutamatergic, neurons projecting to the medial prefrontal cortex and ventral hippocampus were activated during acquisition of the task, as shown by increase in cortical and hippocampal acetylcholine release. Released acetylcholine in turn activated extracellular regulated kinase in neurons located in the target structures, since the muscarinic receptor antagonist scopolamine blocked extracellular regulated kinase activation. Both increased acetylcholine release and extracellular regulated kinase activation were necessary for memory formation, as administration of scopolamine and of extracellular regulated kinase inhibitors was followed by blockade of extracellular regulated kinase activation and amnesia. Our data indicate that a critical function of the learning-associated increase in acetylcholine release is to promote the activation of the extracellular regulated kinase signal transduction pathway and help understanding the role of these systems in the encoding of an inhibitory avoidance memory. [Copyright &y& Elsevier]

Women with endometriosis were deemed more prone to COVID-19 infection in some reports. Considering that endometriosis-related aberrant immune response, understanding how COVID-19 vaccination influences its clinical status is crucial. The aim of this meta-analysis was the evaluate the susceptibility to COVID-19 infection and modifications of symptoms following COVID-19 vaccination in women with endometriosis. Electronic searches on EMBASE, MEDLINE, Scopus, Cochrane at CENTRAL, Scielo.br, LILACS and other databases were searched from inception to March 2024. Studies were eligible if they analyzed the incidence of infection in endometriosis women or the changes in symptoms after two doses of COVID-19 vaccine and had a control group. Four studies (2249 women) were included. No increased susceptibility to COVID-19 infection due to presence or absence of endometriosis was retrievable (risk ratio (RR) 1.42 [95% CI 0.88 to 2.27]; I 2  = 33%). Patients with endometriosis did not experience an overall worsening of symptomatology relative to controls (RR 1.58 [95% CI 0.67 to 3.75]; I 2  = 94%). An increase in the risk of dysmenorrhea worsening was noted (RR 1.88 [95% CI 1.11 to 3.17]; I 2  = 63%). No other differences regarding menstrual flow (RR 1.25 [95% CI 0.70 to 2.23]; I 2  = 78%), intermenstrual bleeding (RR 1.14 [95% CI 0.83 to 1.56]; I 2  = 39%) and pelvic pain (RR 2.55 [95% CI 0.65 to 10.05]; I 2  = 80%) compared to controls was retrievable. Therefore, mRNA vaccines do not seem to lead to worsening of symptomatology in endometriotic women. However, a slight temporary increase in dysmenorrhea may be present. Moreover, endometriosis does not seem to increase the risk of contracting COVID-19., (© 2024. The Author(s).)

Introduction: Minimally invasive surgery is considered the gold standard for the treatment of gynecological diseases. Our study aims to assess the effectiveness of the new concept of ultra-low-impact laparoscopy as a combination of low-impact laparoscopy, consisting in the use of miniaturized instruments through 3-5mm ports and low-pressure pneumoperitoneum, with regional anesthesia to evaluate the perioperative outcomes., Methods: A cross-sectional study was performed from May 2023 to December 2023, to enroll 26 women affected by benign gynecological disease and threated by mini-invasive surgical approach. The surgical procedures were performed following the low-impact laparoscopy protocol and the regional anesthesia protocol. The postoperative pain, nausea, and vomiting and the antiemetic/analgesic intake were evaluated. Postoperative surgical and anesthesiological variables were analyzed., Results: Operative time was within 90 min (41.1 ± 17.1 mean ± standard deviation (SD)) and no conversion to laparotomy or general anesthesia was required. According to VAS score, the postoperative pain during the whole observation time was less than 3 (mean). Faster resumption of bowel motility (6.5 ± 2.1 mean ± SD) and women's mobilization (3.1 ± 0.7 mean ± SD) were observed as well as low incidence of post-operative nausea and vomit. Early discharge and patient's approval were recorded. Intraoperatively pain score was assessed on Likert scale during all stages., Conclusion: Ultra-low-impact laparoscopy showed to provide a satisfying recovery experience for patients in terms of short hospital stays, cosmetic result, and pain relief, without compromising surgical outcomes. The encouraging results lead us to recruit a greater number of patients to validate our technique as a future well-established produce., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: This study aimed to evaluate the efficacy of a new biomarker, termed SIR-En, in identifying patients at risk of endometrial carcinoma among those presenting with abnormal uterine bleeding during menopause., Material and Methods: A retrospective case-control analysis was conducted on 242 women with menopausal abnormal uterine bleeding and endometrial thickness ≥ 4 mm. Peripheral blood samples were collected within 7 days before histological diagnosis. systemic inflammatory reaction (SIR) indices were calculated, including NLR, MLR, PLR, and SII. SIR-En was derived by multiplying SII and endometrial thickness. Statistical analyses, including multivariate linear regression and ROC curve analysis, were performed to assess the diagnostic capability of SIR-En., Results: Patients were categorized into endometrial hyperplasia (50 patients) and endometrial cancer (192 patients) groups. The SIR-En index was significantly higher in the carcinoma group (8710 vs. 6420; p = 0.003). The ROC curve for SIR-En had an AUC of 0.6351 (95% CI: 0.5579-0.7121). Using Youden's method, the optimal SIR-En cutoff was 13,806, showing a specificity of 0.940 and a positive predictive value of 0.957., Conclusions: Combining systemic inflammatory indices with endometrial thickness, the SIR-En index can effectively distinguish between endometrial hyperplasia and carcinoma in menopausal women with abnormal uterine bleeding. Despite the retrospective design, the identified cutoff's high specificity and positive predictive value support its potential utility in clinical practice. Further prospective studies are required to validate these findings and optimize clinical application.

Objective: Dyspareunia can severely impact the quality of life of patients with endometriosis. This symptom is often linked to a specific form of deep infiltrating endometriosis, such as rectovaginal septum endometriosis. Despite the radicality of surgery, persistence and recurrence of symptoms post-surgery are not uncommon. The aim of the present study was to determine whether adenomyosis contributes to the failure of surgical interventions for dyspareunia in these patients., Methods: A retrospective single-cohort study was conducted at the at tertiary care gynecologic center of the University Federico II of Naples, using medical records from January 2020 to July 2023. The study included patients who underwent surgery for dyspareunia associated with rectovaginal endometriosis and had a definitive histologic diagnosis. Pain and sexual quality of life were assessed using the visual analog scale (VAS) and the sexual quality of life-female (SQoL-F) questionnaire, both before and 6 months after surgery. Patients with isolated rectovaginal endometriosis were compared to those with concurrent adenomyosis., Results: A total of 94 patients were included: thirty-five in group A (endometriosis with adenomyosis) and 59 in group B (isolated rectovaginal endometriosis). Histology confirmed deep infiltrating endometriosis (DIE) in all patients. Clinical characteristics such as age, BMI, abnormal uterine bleeding, and infertility, showed no significant differences between the groups. Multiparity was more common in group A (20%) compared to group B (5.1%) (P < 0.001). Pain VAS scores decreased significantly in both groups: from 7.11 to 5.40 in group A and from 7.34 to 3.31 in group B (both P < 0.001). Sexual quality of life (SQoL) scores improved significantly: from 42 to 57 in group A and from 41 to 66 in group B (both P < 0.001). Patients in group B showed a more significant improvement. Adjusted linear regression showed no significant association between parity and the severity of dyspareunia or sexual quality of life., Conclusion: Adenomyosis appears to reduce the effectiveness of surgical treatment for dyspareunia in patients with rectovaginal septum endometriosis. Comprehensive preoperative screening for adenomyosis is recommended to improve surgical outcomes and provide appropriate counseling. Future research should further explore the impact of adenomyosis on dyspareunia and the potential benefits of adjunctive medical therapies., (© 2024 The Author(s). International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Uterine myomas are the most common gynecological disease in reproductive-aged women, present several symptoms, and require effective medical and/or surgical strategies. This study aimed to compare robotic-assisted laparoscopic myomectomy (RALM) with laparoscopic myomectomy (LM) in terms of operative times, intraoperative estimated blood loss, pre- and post-hemoglobin levels drop, and length of hospital stay. Data from 50 clinical records (25 RALM in Group A and 25 LM in Group B) of patients with uterine fibroids were collected from December 2022 to December 2023 at Gynecological Unit of DAI Materno-Infantile Federico II in Naples, Italy. Patients aged 30-49 years with symptomatic fibroids were included. Data on peri-operative outcomes, including operative time for myomectomy (OTM), overall operative time (OOT), intraoperative estimated blood loss (EBL), pre- and post-operative hemoglobin levels, and length of hospital stay were analyzed. The OTM in the presence of > 5 myomas was 59 [52-65] vs 69 min [61-96] (p < 0.001) for RALM and LM groups, respectively. Moreover, also in presence of ≤ 5 myomas, a difference was observed in the RALM group 48[43-55] compared to the LM group 53[50-61] min (p = 0.07). The OOT was also statistically significant for Group A compared to Group B (83[65-93] vs 72[56-110] min, p < 0.001). There were no significant differences between the two groups in terms of pre- and post-operative hemoglobin levels and EBL (p = 0.178). Group A demonstrated a notably shorter hospital stay 1.2 [1-2] days compared to Group B 2.9[3-3.75] days (p = 0.007). Our study suggests potential advantages of RALM over LM in terms of reduced operative times and shorter hospital stays. The standardized approach and extensive surgical experience likely contributed to the favorable outcomes of RALM., (© 2024. The Author(s).)

In women with proven infertility and deep endometriosis (DE), optimal management is controversial. To date, there is no clear evidence on the association between infertility and different stages of rASRM, nor is there clear guidance from leading scientific societies for surgical treatment of DE patients. A comprehensive literature search was conducted on the main databases for English-language trials describing the effectiveness of surgery for DE in patients with proven infertility; 16 studies were deemed eligible for inclusion in this systematic review (CRD42024498888). Quantitative analysis was not possible because of the heterogeneity of the data. A descriptive summary of the results according to location of pathology, surgical technique used, and whether assisted reproductive technology (ART) was needed or not was provided. A total of 947 infertile women were identified, 486 of whom became pregnant, with an average pregnancy rate of 51.3%. Our review suggests that surgery can be of valuable help in improving reproductive outcomes by improving the results of ART. It has not been possible to reach robust conclusions on the outcomes of surgery based on the location of DE because of the heterogeneity of evidence available to date. Overall, although some data encourage first-line surgical management, further investigation is needed to determine its effective application before or after ART failure., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 Elsevier Ltd. All rights reserved.)

Background: Hereditary breast and ovarian cancer syndrome (HBOC) predisposes women to an increased risk mainly of breast and tubo-ovarian cancer. The aim of the study is to investigate whether being diagnosed with HBOC syndrome is itself a risk factor for sexual dysfunction., Methods: An ad hoc questionnaire, including baseline demographic and clinical data, and the Sexual Function Questionnaire 28 (SFQ28) were administered to HBOC female carriers (study group) and to a control group., Results: After propensity score matching (1:1), we enrolled 202 women, 101 in the study group and 101 in the control group. In a multivariate analysis, we finally found that menopausal status was the only risk factor for a significant low score in the domains Desire (HR 0.66; CI95% 0.47-0.93; p = 0.017), Arousal (Lubrication) (HR 0.52; CI95% 0.34-0.80; p = 0.003), Arousal (Cognitive) (HR 0.64; CI95% 0.44-0.95; p = 0.027), and Orgasm (HR 0.33; CI95% (0.16-0.70; p = 0.004), independent of risk-reducing surgery for gynecological malignancy. Psycho-oncology support is a protective factor for the Enjoyment domain (HR 1.38; CI95% 1.05-1.81; p = 0.022)., Conclusions: HBOC syndrome itself does not affect SFQ28 domains, while menopausal status significantly influences sexual health, with potential mitigating effects of psycho-oncological support.

We have developed a biopsy technique aimed at preoperative evaluating the extent of Paget's vulvar disease in order to plan subsequent radical vulvar surgery. The aim is to find all possible lesion sites that are not visible macroscopically, to obtain a clear evaluation of the disease spread and to tailor the radical surgical procedure to remove even microscopic lesions, avoiding recurrences and excessively destructive surgery, adopting as conservative an approach as possible. We used this procedure for the first time to establish the radicality of the surgical intervention in a 68-year-old patient initially suffering from a single invasive vulvar Paget's lesion., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2024 Della Corte, Ascione and Bifulco.)

Vulvar carcinoma is a rare cancer affecting the genital tract, constituting 4% of gynecological tumors. Vulvar squamous cell carcinoma (VSCC) is the most common type. Diagnosis relies on biopsy during vulvoscopy, plus imaging such as ultrasonography (USG), magnetic resonance imaging (MRI) and positron emission tomography (PET). This review aims to lay out a thorough overview as to the current preoperative management of VSCC, both in case of vulvar and lymph node involvement. The data research was conducted using the following databases: MEDLINE, EMBASE, Web of Sciences, Scopus, ClinicalTrial.gov, OVID and Cochrane Library from 2010 to 2024. The selection criteria included only original articles. Seventeen studies were assessed for eligibility. A concordance rate of 62.3% for vHSIL and 65.2% for carcinoma at vulvoscopy, with a sensitivity of 98%, specificity of 40%, PPV (Positive Predictive Value) of 37% and NPV (Negative Predictive Value) of 98% in identifying malignant lesions was found. Regarding the reliability of PET for staging and assessing lymph node involvement, a mean SUV (Standardized Uptake Value) for malignant vulvar lesions of 8.4 (range 2.5-14.7) was reported. In the case of MRI, useful for the evaluation of loco-regional infiltration and lymph node involvement, the ratio of the short-to-long-axis diameter and the reader's diagnostic confidence for the presence of lymph node metastasis yielded accuracy of 84.8% and 86.9%, sensitivity of 86.7% and 87.5%, specificity of 81.3% and 86.2%, PPV of 89.7% and 87.5% and NPV of 76.5% and 86.2%, respectively. A long lymph node axis >10 mm and a short diameter >5.8 mm were found to be predictors of malignancy. At USG, instead, the two main characteristics of potentially malignant lymph nodes are cortical thickness and short axis length; the combination of these ultrasound parameters yielded the highest accuracy in distinguishing between negative and positive lymph nodes. Despite the heterogeneity of the included studies and the lack of randomized clinical trials, this review provides a broad overview of the three imaging tools used for the presurgical management of VSCC. Nowadays, although MRI and PET represent the gold standard, ultrasound evaluation is taking on a growing role, as long as it is carried out by expert sonographer. The management of this rare disease should be always performed by a multidisciplinary team in order to precisely stage the tumor and determine the most suitable treatment approach.

Background: To date hysteroscopy is the gold standard technique for the evaluation and management of intrauterine pathologies. The cervical canal represents the access route to the uterine cavity. The presence of cervical stenosis often makes entry into the uterine cavity difficult and occasionally impossible. Cervical stenosis has a multifactorial etiology. It is the result of adhesion processes that can lead to the narrowing or total obliteration of the cervical canal., Purpose: In this review, we summarize the scientific evidence about cervical stenosis, aiming to identify the best strategy to overcome this challenging condition., Methods: The literature review followed the scale for the quality assessment of narrative review articles (SANRA). All articles describing the hysteroscopic management of cervical stenosis were considered eligible. Only original papers that reported data on the topic were included., Results: Various strategies have been proposed to address cervical stenosis, including surgical and non-surgical methods. Medical treatments such as the preprocedural use of cervical-ripening agents or osmotic dilators have been explored. Surgical options include the use of cervical dilators and hysteroscopic treatments., Conclusions: Cervical stenosis can present challenges in achieving successful intrauterine procedures. Operative hysteroscopy has been shown to have the highest success rate, particularly in cases of severe cervical stenosis, and is currently considered the gold standard for managing this condition. Despite the availability of miniaturized instruments that have made the management of cervical stenosis more feasible, it remains a complex task, even for experienced hysteroscopists., (© 2023. The Author(s).)

Introduction: Hemostasis is an important step in all surgical procedures. Mechanical methods of hemostasis have been gradually abandoned in favor of electrosurgery. The aim of this systematic review was to evaluate the effectiveness of electrosurgical instruments utilized in minimally invasive gynecological procedures., Material and Methods: We performed a systematic review, including randomized controlled trials, prospective and retrospective studies, comparing the outcomes of different energy devices (EDs) used in laparoscopic gynecologic surgeries. We extracted data about blood loss (BL), mean operative time, post-operative pain, hospital stay and complications associated with each electrosurgical device., Results: We included 30 studies reporting comparative outcomes concerning conventional (bipolar and monopolar) and innovative EDs (Harmonic scalpel, LigaSure, Plasma kinetic gyrus, Thunderbeat, EnSeal, Marseal, Caiman and ALAN). New EDs were found to be more efficient in complex surgeries due to less intraoperative BL and shorter operative time. No significant decrease in hospital stay, post-operative pain or complications was found with the use of new energy instruments., Conclusions: Although new electrosurgical devices seem an appealing and safer option, there is still insufficient evidence for one vessel-sealing technology to be considered superior to another. Therefore, monopolar and conventional bipolar (CB) are still widely used in laparoscopic gynecology.

The clinical implementation of liquid biopsy has dramatically modified the analytical paradigm for several solid tumors. To date, however, only circulating free DNA (cfDNA) has been approved in clinical practice to select targeted treatments for patients with colorectal cancer (CRC), non-small cell lung cancer (NSCLC), and breast cancer (BC). Interestingly, emerging liquid biopsy analytes in peripheral blood, including circulating tumor cells (CTC), miRNA, and extracellular vesicles (EVs), have been shown to play a crucial role in the clinical management of solid tumor patients. Here, we review how these blood-based biomarkers may positively impact early diagnosis, prognosis, and treatment response in ovarian cancer (OC) patients., Competing Interests: Declaration of Competing Interest The authors declare no conflict of interest., (Copyright © 2024 Elsevier B.V. All rights reserved.)

Introduction: Minimally invasive procedures performed in laparoscopy, such as salpingectomy for ectopic pregnancy, can be combined with a minimally invasive anesthesia. The aim of this study was to assess the feasibility and the intraoperative and postoperative outcomes of laparoscopic surgery for ectopic pregnancy under spinal anesthesia (SA) compared to general anesthesia (GA) from the point of view of the surgeon, anesthesiologist, and patient., Methods: A retrospective cohort study was performed at DAI Materno Infantile of AOU Federico II of Naples, analyzing all medical records of women who met the inclusion criteria between April 2020 and April 2023. Eighty-two women (35 under SA in group A and 47 under GA in group B) undergone elective or emergency laparoscopic salpingectomy for ectopic tubal or ovarian pregnancy were included., Results: Patients in group A reported less pain at 0 h (adjusted mean difference: -1.5; 95% CI: -2.3 to -0.7; p &lt; 0.001) and after 6 h (adjusted mean difference: -1.1; 95% CI: -2.0 to -0.3; p = 0.01) while no statistically significant differences between the two groups at 12 and 24 h after surgery. No differences were observed among the type of analgesic and during the postoperative observation time, except for paracetamol at 0 h in group B. A faster resumption of bowel motility, patient's mobilization, and a shorter hospital stay were observed in group A compared to group B. Also greater odds of returning faster to daily activities emerged in group A (adjusted OR: 5.39; 95% CI: 1.77-16.37). A greater number of patients in group A were satisfied with the entire procedure compared to those of group B (33 [94.3%] vs. 37 [78.7%]). The general surgeon satisfaction was always very good or excellent in group A. Finally, all surgical steps were well tolerated in group A., Conclusion: In specific settings, SA is a feasible and safe procedure for the laparoscopic treatment of ectopic pregnancy., (© 2023 S. Karger AG, Basel.)

Purpose: Uterine leiomyomas are benign uterine tumors. The choice of surgical treatment is guided by patient's age, desire to preserve fertility or avoid "radical" surgical interventions such as hysterectomy. In laparotomy, the issue of extracting the fibroid from the cavity does not arise. However, in laparoscopy and robotic surgery, this becomes a challenge. The aim of the present study was to determine the optimal surgical approach for fibroid extraction following laparoscopic or robotic myomectomy in terms of postoperative pain, extraction time, overall surgical time, scar size, and patient satisfaction., Methods: A total of 51 patients met the inclusion criteria and were considered in our analysis: 33 patients who had undergone the "ExCITE technique" (Group A), and 18 patients a minilaparotomy procedure (Group B), after either simple myomectomy, multiple myomectomy, supracervical hysterectomy, or total hysterectomy. The diagnosis of myoma was histologically confirmed in all cases., Results: Regarding the postoperative pain evaluation, at 6 h, patients reported 4 [3-4] vs 6 [5.3-7] on the VAS in Group A and B, as well as at 12 h, 2 [0-2] vs 3.5 [2.3-4] in Group A and B, respectively: both differences were statistically significant (p < 0.001). No statistically significant difference at 24 h from surgery was found. All patients in Group A were satisfied with the ExCITE technique, while in Group B only 67% of them. The length of the hospital stay was significantly shorter in Group A as compared to Group B (p = 0.007). In terms of the operative time for the extraction of the surgical specimen, overall operative time, and the scar size after the surgery, there was a statistically significant difference for those in Group A., Conclusion: The ExCITE technique does not require specific training and allows the surgeon to offer a minimally invasive surgical option for patients, with also an aesthetic result. It is a safe and standardized approach that ensures tissue extraction without the need for mechanical morcellation., (© 2023. The Author(s).)

Purpose: To evaluate the agreement rate between hysteroscopy and pathological examination in case of chronic endometritis., Methods: A retrospective observational study carried out at Gynecology and Obstetrics Department, Puerta de Hierro Hospital, Autónoma University of Madrid, Spain, from January 2021 to June 2022 was performed by obtaining data from 115 medical records of women who underwent office hysteroscopies that was compared with the findings of final histological examination of endometrial biopsy. Cohen's kappa index was used to evaluate this agreement rate. In addition, sensitivity, specificity, positive and negative predictive value and diagnostic accuracy were obtained., Results: The agreement between hysteroscopic findings and histological examination showed a modest result with a Cohen's kappa index of 34%. In addition, we obtained a specificity of 70% and a sensitivity of 64%. The positive and negative predictive value were 60.8% and 73.4%, respectively. An excellent agreement rate (100%) between histological and hysteroscopic results was observed in presence of hyperemia and micropolyps., Conclusion: Although the sample size is not as large as that of other studies published so far, the first glance of our experience is that hysteroscopic signs are not yet sufficient to make an accurate diagnosis of chronic endometritis, thus requiring a histopathological confirmation to make it., (© 2023. The Author(s).)

Cervical cancer (CC) is the fourth most common cancer among women worldwide. The aim of this study is to focus on the state of the art of CC prevention, early diagnosis, and treatment and, within the latter, the role of surgery in the various stages of the disease with a focus on the impact of the LACC study (Laparoscopic Approach to Cervical Cancer trial) on the scientific debate and clinical practice. We have discussed the controversial application of minimally invasive surgery (MIS) for tumors < 2 cm and the possibility of fertility-sparing surgery on young women desirous of pregnancy. This analysis provides support for surgeons in the choice of better management, including patients with a desire for offspring and the need for sentinel node biopsy (SNB) rather than pelvic lymphadenectomy for tumors < 4 cm, and without suspicious lymph nodes' involvement on imaging. Vaccines and early diagnosis of pre-cancerous lesions are the most effective public health tool to tackle cervical cancer worldwide.

Background: Hyperthermic intraperitoneal chemotherapy (HIPEC) after cytoreductive surgery has been extensively studied in patients with peritoneal carcinomatosis, and it holds promise as a therapeutic strategy, but its role remains elusive. The aim of this study was to assess the existing evidence for the use or not of HIPEC in primary debulking surgery (PDS), interval debulking surgery (IDS), and recurrent ovarian cancer (ROC), evaluated in terms of survival rates and post-surgical morbidity., Methods: Medline, Pubmed, Cochrane, and Medscape were systematically searched for any article comparing the use of HIPEC treatment with any other therapy in patients with ovarian cancer in PDS, IDS, and ROC. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines were followed. We only considered English-language published studies., Results: We included 14 studies, including two RCTs with a total of 1813 women, published between 2003 and 2023 with a recruitment period between 1998 and 2020. In PDS, there were no differences in progression-free survival (PFS) between HIPEC and controls [MD -5.53 months [95% CI -19.91 to 8.84 months]; I 2 = 96%]. Conversely, in patients treated with NACT, pooled results showed a significant survival advantage in terms of progression-free survival (PFS) and overall survival (OS) in the combined HIPEC plus IDS group rather than surgery alone [PFS: MD 4.68 months (95% CI 3.49 to 5.86 months, I 2 = 95%); OS: MD 11.81 months (95% CI 9.34 to 14.27 months); I 2 = 97%]. Concerning ROC patients, pooled MD did not show either a significant PFS difference between intervention and controls [MD 2.68 months (95% CI 433 to 9.70 months); I 2 = 95%], and OS significant difference (MD 6.69 months [95% CI -9.09 to 22.47 months]; I 2 = 98%). Severe post-operative complications (≥grade 3) were available in 10 studies, accounting for 1108 women. Overall, there was a slightly but significantly increased risk with the combined approach compared to controls [RR 1.26 (95% CI 1.02 to 1.55); I 2 = 0%]., Conclusions: The combination of HIPEC with cytoreductive surgery prolongs OS and PFS in advanced epithelial ovarian cancer after NACT with acceptable morbidity. However, additional trials are still needed to determine the effectiveness of HIPEC in primary and recurrence settings. In the era of personalized medicine, the correlation between the efficacy of HIPEC and biological and molecular findings represents a challenge for the future of ovarian cancer.

Background and Objectives : Meigs syndrome is represented by a benign adnexal tumor, ascites, and hydrothorax. Even though the ovarian mass is often characterized by a fibroma-like origin, cancer antigen-125 (CA-125) serum levels could be elevated as in the development of ovarian cancer. Here, we present the case of a patient with Meigs syndrome and increased CA-125. Materials and Methods : We performed systematic research for articles including similar cases in PubMed, EMBASE, and Scopus in February 2023, adopting the string of idioms: "Meigs syndrome AND Cancer antigen 125", and following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results : Eligible records were 25. Hydrothorax was right-sided in 10 cases over 25; left-sided in two patients over 25. Concerning ascites, two patients showed more than 6 L of ascitic fluid, whereas three patients had 6 L or less. CA-125 elevation ranged from 149 IU/mL to 3803 IU/mL. Adnexal mass histotypes were: struma ovarii (12 cases), thecomas (two cases), fibrothecomas (five cases), fibromas (five cases), and one sclerosing stromal tumor (SST). Conclusions : In postmenopausal women with elevated CA-125 serum levels and an adnexal mass suspicious for malignancy at ultrasound (US), ascites and pleural effusion, surgery, and histopathological examination are necessary. MS is a diagnostic option, with an excellent prognosis after exeresis of the mass.

Purpose: To assess the impact of preoperative endocervicoscopy on obstetric outcomes and complications in women undergoing LEEP for CIN2 + ., Methods: This was a retrospective cohort study carried out between October 2012 and April 2018. All women had undergone cervical length measurement at T0 (before LEEP), T1 (6 months after LEEP), and T2 (at 20 weeks of pregnancy) through transvaginal ultrasound examination after LEEP for CIN2 + . A total of 528 patients fulfilled our inclusion criteria and contributed to the final analysis: 288 had undergone endocervicoscopy before the excisional procedure (Group A), while the remaining 240 (Group B) did not., Results: Patients who did not undergo endocervicoscopy showed a greater amount of tissue excised at LEEP compared to those of Group A (6.7% vs 31.9% in Group A and B, p < 0.01, respectively). A statistically relevant difference was detected in the lesion margins involvement: negative in 93.8% in Group A compared to 65.6% in Group B. The cervicometry before the treatment resulted in similar between the two groups, while a statistically significant difference was noted after 6 months (37.5 ± 2.9 mm in Group A vs 35.1 ± 3.8 mm in Group B, p < 0.01) and at 20th week pregnancy (36.9 ± 5.3 mm in Group A vs 33.5 ± 5.6 mm in Group B, p < 0.01). The number of pregnancies after LEEP as well as the difference in the elapsed time (in months) did not result in a statistical significance between the two groups. The threatened preterm labor (TPL) and the threatened miscarriage showed a statistically significant difference in incidence between the two groups (4,2% and 4.2% in Group A vs 15.3% and 25% in Group B, p < 0.01, respectively)., Conclusion: Endocervicoscopy reduces the size of the LEEP sample and in particular its depth, saving healthy cervical tissue, and guarantees the total eradication of the lesion as the resection margins are negative in almost all cases, allowing for a reduction of the rate of TPL and threatened miscarriage in women with CIN2 + , especially with Type 2 or 3 cervical squamocolumnar junction (SCJ)., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: To describe a conservative laparoscopic treatment of an advanced case of interstitial pregnancy diagnosed in a woman at 14 weeks of gestational age., Design: A video case report with demonstration of diagnostic workup and laparoscopic management of rare subtypes of ectopic pregnancy., Setting: University tertiary care hospital., Patient(s): A 32-year-old nulliparous woman at 14 weeks of gestational age, presented with moderate abdominal pain. She reported a history of irregular periods; however, no risk factor for ectopic pregnancy was identified. The human chorionic gonadotropin level was 7,345 mIU/mL. Transvaginal ultrasound revealed an empty uterine cavity and a complex heterogeneous mass of 6 cm on the left cornual region. The myometrial thickness surrounding the gestational sac was 4 mm., Intervention(s): There were several critical strategies for this laparoscopic approach. To reduce intraoperative bleeding, the peritoneum was opened, the ureters were identified, and bulldog clamps were used to temporarily reduce uterine vascularization. An intramyometrial injection of vasopressin was performed. After the first cornuostomy attempt, we had to perform a cornual resection to achieve complete removal of the ectopic mass. Multilayer uterine sutures and anatomical restoration to prevent adhesion were then accomplished. Institutional review board approval was not required for this case report as per our institution's policy; patient consent was obtained for publication of the case., Main Outcome Measure(s): Description of laparoscopic management of huge interstitial pregnancy., Result(s): The overall operation time was 55 minutes, and the estimated blood loss was 55 mL. A successfully conservative treatment was achieved with no short-term complications. Postoperative ultrasound showed a normal uterus, and complete regression of human chorionic gonadotropin level was achieved 2 weeks after surgery., Conclusion(s): Interstitial ectopic pregnancy presents a high risk of maternal mortality considering that the interstitial part of the tube, because of its thickness, has a great capacity to expand before rupture. Despite the dimension of the lesion, in our case, the tube was still intact and the patient was in a stable clinical condition. Although cornuostomy is a more conservative solution, in these cases, cornual resection should be preferred. Through the accomplishment of reproducible key steps, laparoscopic removal of interstitial pregnancy is a feasible method and can be proposed even for advanced cases of interstitial pregnancies., (Copyright © 2023 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.)

Background: In the past, some pregnant women have been recommended to be in activity restriction because of the presumed increased risk of preterm birth due to the increased release of catecholamines, which might stimulate myometrial activity, during exercise and aerobic activity., Objective: This study aimed to test the hypothesis that in women with singleton pregnancy and arrested preterm labor, activity restriction would reduce the rate of preterm birth at <37 weeks of gestation., Study Design: This was a parallel-group nonblinded randomized trial conducted at a single center in Italy. Eligible patients were those with a diagnosis of arrested preterm labor, defined as not delivering after 48 hours of hospitalization for threatened preterm labor, with transvaginal ultrasound cervical length ≤25 mm, no other symptoms of possible uterine contractions, and cervical dilatation <3 cm at pelvic examination. Inclusion criteria were singleton pregnancies between 24 0/7 and 33 6/7 weeks of gestation. Participants were randomized in a 1:1 ratio to either activity restriction at the time of discharge or no activity restriction. Women in the intervention group were recommended activity restriction, defined as the following: pelvic rest, prohibition of sexual activity, and reduction of work and/or nonwork activity. The primary endpoint was preterm birth at <37 weeks of gestation., Results: A total of 120 participants were included in the trial; 60 patients were enrolled in the activity restriction group and 60 in the control group. Preterm birth at <37 weeks of gestation occurred in 15 of 60 women (25.0%) in the activity restriction group and 23 of 60 women (38.3%) in the control group (relative risk, 0.65; 95% confidence interval, 0.38-1.12). There was no significant between-group difference in the incidence of preterm birth at <32 weeks and in neonatal outcomes, but the trial was not powered for these outcomes., Conclusion: In singleton gestations with arrested preterm labor, activity restriction, including pelvic rest, prohibition of sexual activity, and reduction of work and/or nonwork activity, does not result in a lower rate of preterm birth at <37 weeks. Given the evidence on the lack of benefits, use of activity restriction in this population should be discouraged., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Laparoscopic excision of endometrioma and subsequent hemostasis have detrimental effects on ovarian reserve., Objectives: To evaluate which hemostatic approach after stripping cystectomy shows less damage on ovarian reserve., Search Strategy: Embase, MEDLINE, Scopus, Scielo.br, LILACS, Cochrane Library at the CENTRAL Register of Controlled Trials, Clinicaltrials.gov, CINAHL, conference abstracts, and International Clinical Trials Registry Platform were searched from inception until April 2022., Selection Criteria: Randomized controlled trials of women undergoing laparoscopic endometrioma excision that compared at least two hemostatic approaches., Data Collection and Analysis: Relevant data were extracted and tabulated. Network meta-analysis based on random-effects model for mixed multiple treatment to rank hemostatic strategies using the surface under the cumulative ranking curve area (SUCRA) was performed. Quality assessment was performed using Cochrane criteria. The primary outcome was serum antimullerian hormone levels 3 months after surgery., Main Results: Ten studies, including 748 women, were selected. Suturing the ovary with barbed suture (SUCRA, 82.80%) seem the most effective strategy to avoid antimullerian hormone reduction. Similarly, for ultrasonographic antral follicular count, barbed (SUCRA, 30.70%) and simple suture (SUCRA, 30.70%) were ranked the best choices. Ovarian suturing with simple suture demonstrated lower follicle-stimulating hormone levels (SUCRA, 88.70%)., Conclusions: Suturing the ovary, with simple or barbed suture, seems the most effective approach to keep ovarian reserve higher., (© 2022 International Federation of Gynecology and Obstetrics.)

Objective: The surgical management of polycystic ovary syndrome (PCOS) represents an unclear option compared to medical therapy, and it is necessary to deepen the role of minimally invasive surgery, represented by laparoscopic ovarian drilling (LOD) and transvaginal hydrolaparoscopy (THL), for the treatment of PCOS in infertile women resistant to drug therapy and to establish its success in terms of ovulation and pregnancy rates., Methods: A search was performed in the main electronic databases (MEDLINE, EMBASE, Web of Science, PubMed, and the Cochrane Library) from 1994 to October 2022 in order to evaluate the role of surgery in patients with PCOS resistant to pharmacological treatment. Only original scientific articles in English were included., Results: Seventeen studies were analyzed in this review. In all analyzed studies, more than 50% of the population underwent spontaneous ovulation after surgical treatment without great differences between the two surgical techniques (LOD and THL). More than 40% of patients delivered, with a higher rate after LOD, although eight ectopic pregnancies and sixty-three miscarriages were reported. A lower risk of adhesion formation after THL has been reported. No clear data regarding the effect of surgery on the regularization of the menstrual cycle has been described. A reduction in LH and AMH serum levels as well as the LH/FSH ratio compared to preoperative levels for both surgical techniques has been described., Conclusions: Despite the scarcity and heterogeneity of data, surgical therapy could be considered an effective and safe approach in the management of PCOS patients with resistance to pharmacological treatment who desire to become pregnant.

Radiation therapy (RT) is the standard of care in patients with locoregional or isolated vaginal recurrence who never underwent irradiation. It is often associated with brachytherapy (BT), whereas chemotherapy (CT) is a rare treatment option. We systematically searched the PubMed and Scopus databases in February 2023. We included patients with relapsed endometrial cancer, describing the treatment of locoregional recurrence, and reporting at least one outcome of interest-disease-free survival (DFS), overall survival (OS), recurrence rate (RR), site of recurrence, and major complications. A total of 15 studies fulfilled the inclusion criteria. Overall, 11 evaluated RT only, 3 evaluated CT, and 1 analyzed oncological outcomes after administration with a combination of CT and RT. In total, 4.5-year OS ranged from 16% to 96%, and DFS ranged from 36.3% to 100% at 4.5 years. RR ranged from 3.7% to 98.2% during a median follow-up of 51.5 months. Overall, RT showed a 4.5-year DFS from 40% to 100%. CT revealed 36.3% DFS at 4.5 years. RT showed a 4.5-year OS ranging from 16% to 96%, whereas CT revealed a 27.7% OS rate. It would be appropriate to test multi-modality regimens to evaluate outcomes and toxicity. EBRT and BT are the most employed options to treat vaginal recurrences.

Borderline ovarian tumor (BOT) accounts for 15-20% of all epithelial ovarian tumors. Concerns have arisen about the clinical and prognostic implications of BOT with exophytic growth patterns. We retrospectively reviewed all cases of BOT patients surgically treated from 2015 to 2020. Patients were divided into an endophytic pattern (with intracystic tumor growth and intact ovarian capsule) and an exophytic pattern (with tumor growth outside the ovarian capsule) group. Among the 254 patients recruited, 229 met the inclusion criteria, and of these, 169 (73.8%) belonged to the endophytic group. The endophytic group showed more commonly an early FIGO stage than the exophytic group (100.0% vs. 66.7%, p < 0.001). Furthermore, tumor cells in peritoneal washing (20.0% vs. 0.6%, p < 0.001), elevated Ca125 levels (51.7% vs. 31.4%, p = 0.003), peritoneal implants (0 vs. 18.3%, p < 0.001), and invasive peritoneal implants (0 vs. 5%, p = 0.003) were more frequently observed in the exophytic group. The survival analysis showed 15 (6.6%) total recurrences, 9 (5.3%) in the endophytic and 6 (10.0%) patients in the exophytic group ( p = 0.213). At multivariable analysis, age ( p = 0.001), FIGO stage ( p = 0.002), fertility-sparing surgery ( p = 0.001), invasive implants ( p = 0.042), and tumor spillage ( p = 0.031) appeared significantly associated with recurrence. Endophytic and exophytic patterns in borderline ovarian tumors show superimposable recurrence rates and disease-free survival.

Non-invasive prenatal screening (NIPS) in twin gestations has been shown to have high detection rates and low false-positive rates for trisomy 21, as seen in singleton pregnancies, although there have been few large cohort twin studies, genome-wide studies in particular, to date. In this study, we looked at the performance of genome-wide NIPT in a large cohort consisting of 1244 twin pregnancy samples collected over a two-year period in a single laboratory in Italy. All samples underwent an NIPS for common trisomies, with 61.5% of study participants choosing to undergo genome-wide NIPS for additional fetal anomalies (namely, rare autosomal aneuploidies and CNVs). There were nine initial no-call results, all of which were resolved upon retest. Based on our NIPS results, 17 samples were at high risk for trisomy 21, one for trisomy 18, six for a rare autosomal aneuploidy, and four for a CNV. Clinical follow-up was available for 27 out of 29 high-risk cases; a sensitivity of 100%, a specificity of 99.9%, and a PPV of 94.4% were noted for trisomy 21. Clinical follow-up was also available for 1110 (96.6%) of the low-risk cases, all of which were true negatives. In conclusion, we found that NIPS was a reliable screening approach for trisomy 21 in twin pregnancies.

Adhesion formation following gynecological surgery remains a challenge. The adoption of minimally invasive surgical approaches, such as conventional or robotic-assisted laparoscopy combined with meticulous microsurgical principles and the application of adhesion-reducing substances, is able to reduce the risk of de novo adhesion formation but do not eliminate it entirely. Myomectomy is the most adhesiogenic surgical procedure and postoperative adhesions can have a significant impact on the ability to conceive. Therefore, when surgery is performed as infertility treatment, attention should be paid to whether the benefits outweigh the risks. Among several factors, the size and the location of fibroids are the most accountable factors in terms of adhesion development and post surgical infertility; therefore, the search for effective strategies against adhesion formation in this setting is of paramount importance. The purpose of this review is to evaluate the incidence and factors of adhesion formation and the best preventive measures current available., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Mercorio, Della Corte, Boccia, Palumbo, Reppuccia, Buonfantino, Cuomo, Borgo, Zitiello, De Angelis, Laganà, Bifulco and Giampaolino.)

Purpose: To evaluate the impact of endocervical and decidual polypectomy on obstetrical outcomes of pregnant women., Methods: MEDLINE, Scopus, ClinicalTrials.gov, Scielo, EMBASE, Cochrane Library at the CENTRAL Register of Controlled Trials, and LILACS were searched from inception to April 2021. No language or geographical restrictions were applied. Inclusion criteria regarded observational studies concerning pregnant women with a cervical lesion who underwent cervical polypectomy. Co-primary outcomes were incidence of late pregnancy loss and preterm birth in women with endocervical or decidual polypectomy as well as polypectomy versus expectant management. Random effect meta-analyses to calculate risk ratio (RR) with 95% confidence interval (CI) were performed. Quality assessment of included papers was performed using Newcastle-Ottawa Scale criteria., Results: Three studies, with data provided for 3097 women, were included in quantitative analysis, with comparisons between endocervical and decidual polyps extracted from two studies and 156 patients. After a first trimester endocervical or decidual polypectomy, no significant differences were found for late pregnancy losses (RR 0.29 [95% CI 0.05, 1.80], I 2  = 11%). Risk for preterm birth was significantly higher for decidual polyps' removal (RR 6.13 [95% CI 2.57, 14.59], I 2  = 0%). One paper compared cervical polypectomy vs expectant management, with increased incidence of late pregnancy loss (4/142 vs 5/2799; p < 0.001) and preterm birth (19/142 vs 115/2799; p < 0.001) in women subjected to polypectomy., Conclusions: Evidence regarding the removal of cervical polyps in pregnancy is extremely limited. However, the removal of either decidual or endocervical polyps seems associated with increased risk of pregnancy loss and preterm birth, with increased preterm birth risk following endocervical rather than decidual polypectomy., (© 2022. The Author(s).)

Hereditary women's syndromes due to inherited mutations result in an elevated risk of developing gynecological cancers over the lifetime of affected carriers. The BRCA 1 and 2 mutations, Lynch syndrome (LS), and mutations in rare hereditary syndromes increase this risk and require more effective management of these patients based on surveillance and prophylactic surgery. Patients need counseling regarding risk-reducing surgery (RRS) and the time required to perform it, considering the adverse effects of premenopausal surgery and the hormonal effect on quality of life, bone density, sexual activity, and cardiological and vascular diseases. Risk-reducing salpingo-oophorectomy (RRSO) is the gold standard for BRCA-mutated patients. An open question is that of endometrial cancer (EC) risk in patients with BRCA1/2 mutation to justify prophylactic hysterectomy during RRSO surgical procedures. RRS provides a 90-95% risk reduction for ovarian and breast cancer in women who are mutation carriers, but the role of prophylactic hysterectomy is underinvestigated in this setting of patients. In this review, we evaluate the management of the most common hereditary syndromes and the benefits of risk-reducing surgery, particularly exploring the role of prophylactic hysterectomy., Competing Interests: The authors declare no conflicts of interest.

Background: Since February 2020, the spread of Coronavirus Disease 2019 (COVID-19) in Italy has induced the government to call for lockdown of any activity apart from primary needs, and changing the lives of each of us. All that has dramatically impacted the management of patients affected by cancer. Patients with vulvar cancer (VC) represent a particularly frail population because they are elderly and affected by multiple comorbidities. The aim of this study is to evaluate the clinical impact of the SARS-CoV-2 infection on VC patients in terms of delay or impossibility of carrying out the scheduled treatment. Methods: The medical records of patients affected by vulvar tumors, referred to "DAI Materno-Infantile" of AOU Federico II of Naples between February 2020 and January 2022 were retrospectively analyzed. The presence of a positive reverse transcription-polymerase chain reaction (RT-PCR) in nasopharyngeal swab defined the positivity to SARS-CoV-2. Results: Twenty-four patients with VC were analyzed and scheduled for treatment. The median age was 70.7 years (range: 59-80). Seven (29.2%) patients were diagnosed with SARS-CoV-2 infection: In three (42.8%) patients, the treatment was delayed with no apparent consequences, in four (57.2%), the treatment was delayed or changed due to cancer progression and, of these four, one died due to respiratory complications of COVID-19, and one died due to oncologic disease progression. Conclusion: COVID-19 caused, in most cases, significant delays in oncologic treatments and high mortality in our series of patients affected by VC.

Despite wide screening campaigns and early detection, cervical cancer remains the fourth most common cancer among women. Radical hysterectomy, whether by open, laparoscopic or by robotic-assisted techniques, is the mainstay treatment. However, for adequate surgical results and good oncological prognosis, a gynecological surgeon should be trained to perform those procedures. The learning curve of radical hysterectomy, especially by laparoscopy, is influenced by several factors. The LACC trial, the decrease in cervical cancer incidence and radical hysterectomy procedures have widely reduced the learning curve for surgeons. This article mainly discusses the learning curve of laparoscopic radical hysterectomy for cervical cancers, and how several factors are influencing it negatively, with the need to have medical authorities reset specific surgical training programs and allocate them to special oncological centers.