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Objective: The objective of this study was to investigate surgical outcomes and complications of hysterectomy for benign conditions other than prolapse in elderly patients and to define predictors of prolonged hospitalization. Design: Retrospective analysis of prospectively collected data. Setting: This study was conducted in an academic research center. Patients: We utilized our institution surgical database to identify patients aged 60 years or more (“elderly”) who underwent hysterectomy for benign conditions other than pelvic organ prolapse during a 20-year period (January 2000–December 2019). Methods: Length of stay (LOS) of more than 2 days (90th percentile of LOS) was defined as prolonged hospitalization. Patient demographics, comorbid conditions, and surgical approach (vaginal hysterectomy (VH), laparoscopic hysterectomy (LH), and abdominal hysterectomy (AH)) were identified. Patients treated via LH or VH were also grouped as minimally invasive surgery (MIS). Multivariable logistic regression was used to identify factors associated with prolonged LOS. Results: Overall, 334 patients were included in this study, 262 (78.4%) of whom underwent LH, 42 (12.6%) VH, and 30 (9.0%) AH. Median LOS was 2 days (1–8), and 63 (18.8%) patients required prolonged LOS. Compared to AH, median hospital stay was shorter in MIS group (2 days vs. 3 days, p < 0.001). No admission variables were associated with prolonged LOS. The only independent predictors of prolonged LOS were AH (odds ratio 24.82, 95% CI 4.84–127.16) and operative time (odds ratio for 30 mins increased 11.34, 95% CI 1.63–78.78). Compared to those who underwent VH, patients having LH had a higher rate of concomitant salpingo-oophorectomy (96.6% vs. 61.9%, p < 0.001). Limitations: Retrospective single-center study design, number of patients with prolonged hospitalization, and the setting (tertiary minimally invasive gynecology referral center), which might have reduced the generalizability of our results are the limitations of this study. Conclusions: The abdominal route of hysterectomy was found as the main driver of prolonged hospitalization, reinforcing the benefits of MIS for benign hysterectomy in elderly patients with non-prolapsed uteri; the higher chance of performing concomitant salpingo-oophorectomy supports the laparoscopic approach as the first option for these patients.

Surgery is the mainstay of treatment in the management of early-stage cervical cancer. Until the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial, minimally invasive radical hysterectomy was the recommended approach to treat patients with early-stage disease. The results of the LACC trial questioned the adoption of minimally invasive surgery in cervical cancer. In comparison with the open approach, minimally invasive surgery correlated with worse disease-free and cancer-specific survival. Similarly, other retrospective studies highlighted this correlation, thus corroborating the results of the LACC trials. In the present review, we evaluated current evidence and further prospective of the adoption of minimally invasive radical hysterectomy in cervical cancer. Moreover, we sought to assess some unsolved issues regarding the role of minimally invasive surgery in early-stage cervical cancer patients.

Although it is known that hysterectomy (HY) alone cannot resolve apical prolapse, vaginal hysterectomy (VH) remains the most common surgical procedure for this issue. In recent years, various procedures for uterine conservation have been proposed to avoid the surgical risks of HY. Furthermore, most women with symptomatic pelvic organ prolapse (POP) prefer uterine conservation in the absence of considerable benefit in uterine removal. In 2017, we proposed a new technique for hysteropexy and anterior vaginal native tissue repair (NTR) in women with cystocele and apical prolapse. The objective of this study is to assess the efficacy and safety of this new procedure after at least 5 years of follow-up. We included only patients with stage II or greater prolapse of the anterior vaginal wall and a concomitant stage II uterine prolapse in accordance with Pelvic Organ Prolapse Quantification (POP-Q) system. A Patient Global Impression of Improvement (PGI-I) score ≤ 2 in addition with the absence of POP symptoms was defined as subjective success. A descensus with a maximum point of less than −1 in any compartment was considered objective cure. A total of 102 patients who fulfilled the inclusion criteria were enrolled. At 60 months follow-up, 90 out of 102 patients (88%) were subjectively cured, whereas 88 out of the 102 (86%) patients were objectively cured. Subjective and objective cure rates persisted during the entire study period. Uni- and multivariate analysis of possible predictive factors associated with recurrence of prolapse showed that only a preoperative point C > 0 cm and BMI ≥ 25 kg/m2 were risk factors for failure. In conclusion, our study showed that hysteropexy with anterior vaginal native tissue repair may be an effective and safe option for the treatment of anterior vaginal prolapse and concomitant stage II uterine prolapse by at least 5 years of follow-up.

Minorly skilled gynecologists are less likely to repair obstetric anal sphincter injuries (OASIS), and this can lead to higher rate of de novo onset of pelvic floor dysfunction (PFD). The aim of this study was to understand the impact of surgeon skills in OASIS repair on de novo incidence of PFDs.An observational prospective cohort study performed between January 2019 and December 2020. We included 116 women with OASIS. At 6-weeks from delivery, women were divided into two groups in relation to the onset of PFDs. Characteristics were compared; categorical and continuous variables were assessed with chi-squared test and the Mann-Whitney rank-sum test respectively. Factors involved in PFDs development were analysed with explorative univariate analysis; significant (p0.05) or approaching significance (p≤0.10) variables were included in multivariable analysis.Seventy-six women (76/116; 65.5%) reported at least one PFD symptom and anal incontinence was the most prevalent (44.73%; 34/76). OASIS management by a skilled gynaecologist resulted protective for PFDs [aOR 0.33 (0.13-0.61)]. Skilled surgeon reported fewer PFDs than less skilled surgeon (4% vs 82.4%; p0.0001). Operative delivery was more performed (32.5% vs 15.8%; p= 0.03) and severe OASIS resulted more prevalent (60% vs 17.1%; p0.0001) among women without PDFs, even if these didn't affect the incidence of de novo PFDs [aOR 1.03 (0.23-1.45) and 0.83 (0.13-1.45), respectively].Surgeons skilled in OASIS repair resulted the only protective factor for incidence of de novo PFDs in women with OASIS at 6 weeks of follow up. Improvement of training in OASIS repair is necessary.

To compare scar quality associated with metal staples or tissue adhesive for closure of the skin incision at repeat cesarean delivery (CD).Single-center Randomized Controlled Trial (ClinicalTrial.gov ID: NCT04302597), including women undergoing repeat CD using metal staples or 2- octylcyanoacrylate for closure of the skin incision. Patients were randomized to have skin closure following CD with either staples or tissue adhesive. Scar quality was evaluated 2 and 6 months postoperatively using the Vancouver Scar Scale, the Patient and Observer Scar Assessment Scale (POSAS), and a visual analog scale.Of the 66 patients who were recruited, 55 successfully completed the study. The duration of surgery was comparable in both groups. A partial wound dehiscence occurred in one patient who had tissue adhesive closure. No difference in subjective and objective scar cosmesis rating was found between tissue adhesive and staples groups at either 2 months or 6 months.In women undergoing CD, stapled wounds and those closed with tissue adhesive result in equivalent cosmetic appearance of the scar.

Introduction and hypothesis Few studies in literature have assessed the long-term durability and mesh-related complications of mid-urethral slings (MUSs). The aim of this study is to assess the efficacy and safety of retro-pubic tension-free vaginal tape (TVT) 20 years after implantation for the treatment of female stress urinary incontinence (SUI). Methods A prospective observational study was conducted in two urogynaecologic units in two countries. All the patients involved were consecutive women with urodynamically proven pure SUI treated by TVT. The patients underwent preoperative clinical and urodynamic evaluations. Subjective outcomes, objective outcomes and adverse events were recorded during the follow-up period. Results Fifty-two patients underwent a TVT surgical procedure. Twenty years after surgery, 32 out of 36 patients (88.8%) declared themselves cured (p = 0.98). Similarly, 33 out of these 36 patients (91.7%) were objectively cured (p = 0.98). No significant deterioration of subjective and objective cure rates was observed over time (p for trend 0.50 and 0.48). Fifteen of the 36 patients (41.6%) at the 20-year follow-up reported the onset of de novo overactive bladder (OAB) (p = 0.004). No significant vaginal bladder or urethral erosion or de novo dyspareunia was recorded and no patient required tape release or resection during this period. The cause of death of seven out of ten women who died in the last year of the follow-up period was coronavirus disease 19 (COVID 19). Conclusions The 20-year results of this study showed that TVT is a highly effective and safe option for the treatment of SUI. The impact of COVID 19 on the mortality rate of elderly women has drastically reduced the number of eligible patients for future evaluations in our region.

Tranexamic acid (TA) has been proposed for preventing or treating primary postpartum haemorrhage (PPH), which is the leading cause of maternal morbidity and mortality worldwide. We conducted a systematic literature search to the TA role in managing PPH in vaginal and caesarean delivery. Twenty-seven randomised controlled trials (RCTs) (33,302 women) were identified. Three RCTs investigated TA for preventing PPH after vaginal delivery and 22 after caesarean section. None demonstrated a preventive effect on secondary clinical outcomes related to blood loss. Two trials evaluated TA for treating PPH after vaginal and caesarean delivery. Only the WOMAN trial showed that 1 g of TA is effective. In conclusion, TA is considered useful and is recommended or advised for treating PPH. Conversely, available evidence on the prophylactic role is still limited, and this use is not supported. Further investigation is recommended. In this regard, stronger and more reliable outcomes than blood loss should be considered.

A multicenter cross-sectional survey study involving four Italian University Hospitals was performed to test the hypothesis that negative affect and positive affect (affective dimensions) mediate the association between risk perception (perceived risk of infection and death; cognitive dimensions) and the feeling of work exhaustion (WE) among obstetrics healthcare providers (HCPs) during the Coronavirus Disease 2019 (COVID-19) pandemic. Totally, 570 obstetrics HCPs were invited to complete the 104-item IPSICO survey in May 2020. A theoretical model built on the tested hypothesis was investigated by structural equation modelling. The model explained 32.2% of the WE variance. Only negative affect mediated the association between cognitive dimensions and WE and also the association between WE and psychological well-being before the pandemic, experiences of stressful events, female gender, and dysfunctional coping. Non-mediated associations with WE were observed for work perceived as a duty, experience of stressful events, support received by colleagues, and the shift strategy. Only previous psychological well-being, support by colleagues, and shift strategies were inversely associated with WE. Based on study results, monitoring negative than positive affect appears superior in predicting WE, with practical implications for planning psychological interventions in HCPs at the individual, interpersonal, and organizational levels.

Study objective: There is great consensus that the implementation of ERAS approach is beneficial for surgical patients, but there is paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The present survey was aimed at gathering detailed information on perioperative management of DE patients undergoing sigmoid/rectal (discoid or segmental) resection within SEGI group. Design: Baseline survey. Setting: National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). Patients: The study did not involve patients. Interventions: A 63-item questionnaire, covering ERAS items for gynecologic/elective colorectal surgery, was sent to SEGI centres. Only questionnaires from centres reporting to perform ≥10 sigmoid/rectal resections per year were considered for the present analysis. Measurements and main results: Thirty-three/38 (86.8%) questionnaireswere analysed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6%, respectively, for pre-operative, intra-operative, and post-operative items. The proportion of overall agreement was 56.6%. Pre-operative diet, fasting and bowel preparation, correction of anaemia, avoidance of peritoneal drains, post-operative feeding and early mobilization were the most controversial. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p=0.044 and p=0.003, respectively) and gynecologist's/surgeon's experience (p=0.042 and p=0.022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centres reporting ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p=0.081) and gynecologist's/surgeon's experience (p=0.294). Conclusion: This is the first study conducted on a national scale for DE. The present survey reveals a sub-optimal compliance to the ERAS recommendations, and underline the need for improving the quality of peri-operative care in DE patients undergoing sigmoid/rectal resection. The present study is a first step to build a consistent structured reporting platform for the SEGI units and facilitate a wide implementation and standardization of ERAS protocol for DE patients in Italy.

Objectives: Laparoscopic subtotal hysterectomy (LSH) is a possible treatment for patients with benign uterine disease. Once the hysterectomy has been completed, morcellation and extraction of the corpus uteri is a crucial step of the procedure. We here present a case series to evaluate the feasibility of the in-bag transvaginal specimen retrieval following LSH. Study design: We report a case series of consecutive patients who underwent LSH followed by in-bag transvaginal specimen retrieval. LSH was accomplished in a standard fashion. Once the uterus was detached from the cervix, a 2cm posterior colpotomy was performed laparoscopically with a monopolar hook under direct view to insert a specimen retrieval bag into the abdomen. The corpus uteri was placed into the bag and transvaginal contained manual morcellation was performed. The colpotomy was then sutured transvaginally. Baseline patients' characteristics and surgical data were collected. Postoperative complications, same-hospital readmissions, and reoperations were registered if occurred within 30days from surgery. Results: Patients' median age and BMI were 45,5 and 22,7, respectively. Median operative time was 71.5min (range 34-143) and uterus weight ranged from 60g to 470g (median 210g). The estimated blood loss was 100mL (median) and no blood transfusion was required. No conversions to open surgery, nor intraoperative complications occurred. Median hospital stay was 2days (1-3) and no postoperative complications within 30days from surgery were recorded. Conclusions: LSH followed by in-bag transvaginal specimen extraction is a promising technique and might be considered a reliable and safe option to further reduce the invasiveness of the procedure.

OBJECTIVE To compare outcomes after hysterectomy and hysterectomy plus sentinel node mapping (SNM) in endometrial cancer (EC) patients. MATERIALS AND METHODS This is a retrospective study, collecting data of EC patients treated between 2006 and 2016 in nine referral centers. RESULTS The study population included 398 (69.5%) and 174 (30.5%) patients having hysterectomy and hysterectomy plus SNM. As the results of the adoption of a propensity-score matched analysis, we selected two homogeneous cohort of patients (150 having hysterectomy only vs. 150 having hysterectomy plus SNM). The SNM group had a longer operative time, but did not correlate with length of hospital stay and estimated blood loss. Overall severe complication rates were similar between groups (0.7% in the hysterectomy group vs. 1.3% in the hysterectomy plus SNM group; p = 0.561). No lymphatic-specific complication occurred. Overall, 12.6% of patients having SNM were diagnosed with disease harboring in their lymph nodes. Adjuvant therapy administration rate was similar between groups. Considering patients having SNM, 4% of patients received adjuvant therapy on the basis of nodal status alone; all the other patients received adjuvant therapy also on the basis of uterine risk factors. Five-year disease-free (p = 0.720) and overall (p = 0.632) survival was not influenced by surgical approach. CONCLUSIONS Hysterectomy (with or without SNM) is a safe and effective method for managing EC patients. Potentially, these data support the omission of side specific lymphadenectomy in case of unsuccessful mapping. Further evidence is warranted in to confirm the role SNM in the era of molecular/genomic profiling.

Background: The aim of our study was to compare the number of lymph nodes removed during indocyanine green (ICG)-guided laparoscopic/robotic pelvic lymphadenectomy with standard systematic lymphadenectomy in endometrial cancer (EC) and cervical cancer (CC). Methods: This is a multicenter retrospective comparative study (Clinical Trial ID: NCT04246580; updated on 31 January 2023). Women affected by EC and CC who underwent laparoscopic/robotic systematic pelvic lymphadenectomy, with (cases) or without (controls) the use of ICG tracer injection within the uterine cervix, were included in the study. Results: The two groups were homogeneous for age (p = 0.08), Body Mass Index, International Federation of Gynaecology and Obstetrics (FIGO) stages (p = 0.41 for EC; p = 0.17 for CC), median estimated blood loss (p = 0.76), median operative time (p = 0.59), and perioperative complications (p = 0.66). Nevertheless, the number of lymph nodes retrieved during surgery was significantly higher (p = 0.005) in the ICG group (n = 18) compared with controls (n = 16). Conclusions: The accurate and precise dissection achieved with the use of the ICG-guided procedure was associated with a higher number of lymph nodes removed in the case of systematic pelvic lymphadenectomy for EC and CC.

STUDY OBJECTIVE To investigate the postoperative morbidity of laparoscopic hysterectomy (LH) for endometriosis/adenomyosis in terms of operative outcomes and complications. DESIGN Retrospective multicentric cohort study. SETTING Eight European minimally invasive referral centers. PATIENTS Data from 995 patients with pathologically confirmed endometriosis and/or adenomyosis who underwent LH without concomitant urological and/or gastroenterological procedures from January 2010 to December 2020. INTERVENTIONS Total laparoscopic hysterectomy. MEASUREMENTS AND MAIN RESULTS Demographic patients' characteristics, surgical outcomes, and intraoperative and postoperative complications were evaluated. We considered major postoperative surgical-related complications any grade 2 or more events (Clavien-Dindo score) that occurred within 30 days from surgery. Univariate analysis and multivariable models fit with logistic regression were used to estimate the adjusted odds ratio (OR) and corresponding 95% CI for major complications. Median age at surgery was 44 years (28-54) and about half of them (505, 50.7%) were on medical treatment (estro-progestins, progestin or GnRh-analogues) at the time of surgery. In association with LH, posterior adhesiolysis was performed in 387 (38,9%) cases and deep nodule resection in 302 (30,0%). Intraoperative complications occurred in 3% of the patients and major postoperative complications were registered in 93 (9.3%). The multivariable analysis showed an inverse correlation between the occurrence of Clavien-Dindo >2 complications and age (OR 0.94, 95%CI 0.90-0.99), while previous surgery for endometriosis (OR 1.62, 95%CI 1.01-2.60) and intraoperative complications (OR 6.49, 95%CI 2.65-16.87) were found as predictors of major events. Medical treatment at the time of surgery has emerged as a protective factor (OR 0.50, 95%CI 0.31-0.81). CONCLUSION LH for endometriosis/adenomyosis is associated with non-negligible morbidity. Knowing the factors associated with higher risks of complications might be used for risk stratification and could help clinicians during preoperative counseling. The administration of estro-progestin or progesterone preoperatively might reduce the risks of postoperative complications following surgery.

OBJECTIVE To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer. METHODS This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting. RESULTS Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p��

We performed a retrospective cohort study, namely "Surgery and ART for Endometriomas" (SAFE) trial (Clinical Trial ID: NCT03717870), including women who underwent laparoscopic cystectomy for endometrioma before first IVF and compared their reproductive outcomes with the ones of women without endometriosis and with unexplained infertility, tubal factor or male factor infertility. We found that women who underwent previous laparoscopic cystectomy for endometrioma had higher FSH and LH levels between the 2nd and 5th day of the cycle before IVF, required higher doses of gonadotrophins for ovarian stimulation and had a lower number of retrieved oocytes compared with other types of infertility. Nevertheless, pregnancy and delivery rates remain comparable to other causes of infertility. In addition, differences in ovarian stimulation parameters between endometriosis and other types of infertility lost significance with the increase of women's age. These pieces of information can be considered useful to make adequate counselling about reproductive outcomes for infertile women with ovarian endometriomas and allow a proper decision-making approach shared with the patient.IMPACT STATEMENTWhat is already known on this subject? Although endometriomas are common findings in infertile women, whether they should be surgically removed before an in vitro fertilisation (IVF) is a long-lasting debate, and current evidence does not offer a robust background to draw firm recommendations.What do the results of this study add? Women who underwent previous laparoscopic cystectomy for endometrioma need higher doses of gonadotrophins for ovarian stimulation and have a lower number of retrieved oocytes, compared with other types of infertility. Pregnancy and delivery rates remain comparable to other causes of infertility.What are the implications of these findings for clinical practice and/or further research? These pieces of information can help to make adequate counselling about reproductive outcomes for infertile women with ovarian endometriomas and allow a proper decision-making approach shared with the patient.

Background Endometrial carcinoma represents a sentinel cancer for Lynch syndrome (LS) identification. It is crucial to highlight how other types of tumors can arise in the gynecological tract acting as sentinel tumors in LS patients.Up to now, no established LS patient management strategy has incorporated the presence of these additional candidate sentinel tumors to improve the prevention and management of LS tumors. Methods In order to investigate the involvement of the most frequent gynecological cancers in gynecological cancers, we studied different subsets of gynecological cancers using both somatic approaches, including mismatch repair (MMR) gene immunohistochemical expression, microsatellite instability, and germline analyses ofMSH2, MSH6, MLH1, PMS2 and EPCAM genes.A total of 261 patients referring to the Cancer Genetic Counselling Service of our institution were included in the study. In detail, our series was composed of 131 patients affected by uterus cancers including endometrial, isthmus and non-HPV endocervical carcinomas, 113 patients affected by ovarian cancers and 17 patients affected by synchronous endometrial/ovarian carcinomas (SEOC).In addition, we studied 115 cases of endometrial cancers identified by 2 years of universal testing (endometrial cancers/UTs) using IHC analysis of four MMR proteins. Results and conclusions The incidence of MMR defective gynecological cancers ranged from 7.1 to 47.1% depending on cancer site and selection. LS patients carriers of pathogenetic MMR variants were identified in 19.8% of uterus cancers, 35.3% of SEOC, 4.4% of ovarian cancers. In addition, pathogenetic MMR variants were identified in 4.3% of endometrial cancers/universal testing investigated with universal screening.In conclusion, gynecological cancers are heavily involved in LS and our study shows that MMR screening using immunohistochemical pattern and MSI analysis of endometrial and ovarian cancers as well as of rare entities such as non-HPV related endocervical cancers and synchronous endometrial and ovarian cancers are sentinels for LS.Tumor testing approach improves early identification of MMR defective gynecological cancers and this is an effective strategy to detect high-risk patients and to offer them and their relatives personalized cancer prevention.

Transvaginal extraction is a feasible method to remove surgical specimen. In this study, we aim to report our experience with in-bag transvaginal specimen retrieval after laparoscopic myomectomy over the past 15 years.Single-center retrospective analysis.Academic hospital.Women who underwent laparoscopic myomectomy from January 2005 to April 2021.Posterior colpotomy and in-bag transvaginal extraction of the surgical specimen.We collected and analyzed data about patients' characteristics, main indication for surgery, and intra- and postoperative (within 30 days) complications.A total of 692 women underwent transvaginal specimen retrieval after laparoscopic myomectomy (mean largest myoma diameter: 6.64 ± 2.21 cm; mean specimen weight: 177 ± 140 g; mean operative time: 84.1 ± 37.1 minutes; mean blood loss: 195 ± 191 mL). Within 30-days, we reported the following colpotomy-related complications: a total of 4 cases (0.6%) of vaginal bleeding, 3 of which resolved spontaneously (1 case required readmission with new colporrhaphy under general anesthesia), and 2 cases (0.3%) of vaginal pain, with no underlying cause identified on physical examination and pelvic ultrasound. Specimen weight was positively correlated with longer operative time, intraoperative blood loss, and length of hospital stay.Posterior colpotomy and in-bag transvaginal extraction can be considered a feasible option for retrieval of surgical specimens after laparoscopic myomectomy.

Objective Based on the SUCCOR study database, our primary objective was to identify the independent clinical pathological variables associated with the risk of relapse in patients with stage IB1 cervical cancer who underwent a radical hysterectomy. Our secondary goal was to design and validate a risk predictive index (RPI) for classifying patients depending on the risk of recurrence. Methods Overall, 1116 women were included from January 2013 to December 2014. We randomly divided our sample into two cohorts: discovery and validation cohorts. The test group was used to identify the independent variables associated with relapse, and with these variables, we designed our RPI. The index was applied to calculate a relapse risk score for each participant in the validation group. Results A previous cone biopsy was the most significant independent variable that lowered the rate of relapse (odds ratio [OR] 0.31, 95% confidence interval [CI] 0.17–0.60). Additionally, patients with a tumor diameter >2 cm on preoperative imaging assessment (OR 2.15, 95% CI 1.33–3.5) and operated by the minimally invasive approach (OR 1.61, 95% CI 1.00–2.57) were more likely to have a recurrence. Based on these findings, patients in the validation cohort were classified according to the RPI of low, medium, or high risk of relapse, with rates of 3.4%, 9.8%, and 21.3% observed in each group, respectively. With a median follow-up of 58 months, the 5-year disease-free survival rates were 97.2% for the low-risk group, 88.0% for the medium-risk group, and 80.5% for the high-risk group (p < 0.001). Conclusion Previous conization to radical hysterectomy was the most powerful protective variable of relapse. Our risk predictor index was validated to identify patients at risk of recurrence.

Benign gynaecological diseases are usually treated with minimally invasive approaches. Robotic surgery seems an alternative to laparoscopic surgery. No definitive conclusions have yet been made regarding comparison of robotic versus laparoscopic surgery for benign diseases. In this scenario, we performed a systematic review in order to assess the advantages and disadvantages of laparoscopy versus robotic surgery and conclude whether laparoscopy should be replaced by robotic surgery for the treatment of benign gynaecological conditions, following the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) Statement. We included 64 studies: no significant difference was observed regarding overall complication rate; no significant benefit of robotic approach was demonstrated regarding length of hospital stay and conversion to laparotomy; furthermore, robotic surgery is more easily used by non-experienced surgeons, while it is more expensive and characterised by longer operative time. In conclusion, current evidence indicates neither statistically significant nor clinically meaningful differences in surgical outcomes between robotic and laparoscopic surgeries for benign gynaecological diseases. Impact statement

OBJECTIVE To compare three types of biopsy forceps for hysteroscopic endometrial biopsy in postmenopausal women. METHODS Postmenopausal women undergoing operative hysteroscopy with endometrial biopsy for abnormal uterine bleeding or endometrial thickness (≥5 mm) were included. Operative hysteroscopy with endometrial biopsy was performed by hysteroscopic forceps. Women were randomized (1:1:1 ratio) in three groups and allocated to undergo endometrial biopsy by hysteroscopy using spoon, alligator, or snake forceps. RESULTS Seventy-five women were included in the study, 25 in each group. The duration of the biopsy was comparable between the three groups (P = 0.334) with a median of 180 seconds (range 20-480 seconds). No differences were observed about the number of attempts (P = 0.602), the use of another instrument (P = 0.276), and the biopsy appropriateness (P = 0.592). The spoon forceps group reported higher levels of pain compared to the alligator and snake forceps groups (P

Objective To assess characteristics, incidence, risk factors, and reporting rate of needlestick injuries (NSIs) among Obstetrics and Gynecology trainees. Study design We performed a nationwide cross-sectional survey study. The 40-items survey Obstetrics Needlestick Injury Questionnaire (ONSI-Q) was used to investigate the prevalence of NSIs, participant attitudes, associated factors, and the NSI reporting rate among trainees in Obstetrics and Gynecology. The target responders were all trainees of Obstetrics and Gynecology training programs in Italy. The trainees were invited between September 2018 and December 2018 via a web-based platform. Results Among 1049 trainees, 1041 (99.2%) completed the survey. Out of 1041 trainees, 639 (61.4%) had at least one NSI, and 90.9% (581/639) experienced at least one during obstetric surgery. The number of NSIs increased with the year of training, with 2.48 NSIs per trainee in the fifth year. 90.6% (579/639) reported details about the most recent NSI, which was during obstetric surgery in 95.3% (552/579) of cases. 57.1% (315/552) experienced the most recent NSI during cesarean section, which was mainly inflicted by someone else (72.4%; 228/315). 42.9% (237/552) of NSIs were during perineal suture, and 84% (199/237) of them were self-inflicted. 77.9% (417/535) of trainees did not report the NSI. Associated factors were non-high-risk patients, self-inflicted NSI, and the first NSI. Conclusions NSIs are frequent among Obstetrics and Gynecology trainees but not reported, and obstetric surgery is the primary source. These data support the European efforts to improve working practices' safety. The education about protective strategies and reporting should be a priority.