Publications by authors named "Stefano Uccella"

200 Publications

Isolated tumour cells in a sentinel lymph node of apparent early-stage ovarian cancer: Ultrastaging of all other 27 lymph nodes.

Gynecol Oncol Rep 2022 Aug 20;42:101047. Epub 2022 Jul 20.

Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy.

Sentinel lymph node (SLN) biopsy in apparent early-stage ovarian cancer may spare the surgical staging with extensive retroperitoneal dissection and its associated morbidity. However, SLN biopsy in ovarian cancer is still experimental and under investigation. A 46-year-old post-menopausal woman with bilateral apparent stage IC1 endometrioid ovarian cancer underwent surgical staging by SLN biopsy and subsequent comprehensive laparoscopic pelvic and -aortic lymphadenectomy. Out of 4 SLNs submitted to ultrastaging, one was positive for isolated tumour cells (ITCs). We submitted to ultra-staging all the other 24 pelvic and -aortic non-SLNs, which were reported negative for disease. This is the first reported case of comprehensive lymphadenectomy after SLN biopsy with universal ultrastaging of all non-SLNs in ovarian cancer. The presence of ITCs in only one SLN, with all other 27 lymph nodes negative at ultrastaging, is consistent with the SLN concept and the assumption of a reliable lymphatic pathway in ovarian cancer.
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http://dx.doi.org/10.1016/j.gore.2022.101047DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9309418PMC
August 2022

Female Sexual Dysfunctions and Urogynecological Complaints: A Narrative Review.

Medicina (Kaunas) 2022 Jul 23;58(8). Epub 2022 Jul 23.

Obstetrics and Gynecology Unit, Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", 80128 Naples, Italy.

Female sexual dysfunctions represent a real widespread problem, usually faced from a psychological point of view; however, millions of women worldwide are impacted by pelvic floor dysfunction, personal shame and social taboos, however, continue to inhibit free conversation on the subject. Women's quality of life is considerably improved by screening, diagnosing, and controlling urogenital and sexual issues. This review aims to provide a critical perspective of urogenital conditions and common disturbances in female sexual function associated with these issues. It also includes a discussion of postpartum pelvic dysfunction.
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http://dx.doi.org/10.3390/medicina58080981DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9331312PMC
July 2022

Molecular Biology of Human Fertility: Stepping towards a Tailored Approach.

Int J Mol Sci 2022 Jul 7;23(14). Epub 2022 Jul 7.

Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, 37126 Verona, Italy.

Clinical pregnancies and live births result from a complex interaction of molecular pathways at the level of the female and male gametes during their development and interaction for fecundation, and the subsequent development of the embryo before, during, and after implantation [...].
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http://dx.doi.org/10.3390/ijms23147517DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9320404PMC
July 2022

Predictive features of borderline ovarian tumor recurrence in patients with childbearing potential undergoing conservative treatment.

Mol Clin Oncol 2022 Jul 7;17(1):121. Epub 2022 Jun 7.

Department of Medicine and Surgery, University Hospital of Parma, I-43125 Parma, Italy.

Borderline ovarian tumors (BOT) represent 10-12% of ovarian cancer cases with a higher prevalence in young patients. Although reproductive outcomes are satisfactory after conservative treatment, several authors reported a higher relapse rate in patients undergoing fertility-sparing surgery compared with radical treatment. The aim of the present study was to identify predictive factors of BOT recurrence in patients with childbearing potential undergoing conservative treatment with unilateral salpingo-oophorectomy. From January 2010 to December 2020 all patients with childbearing potential undergoing conservative treatment for early-stage BOT were included in the analysis. Expert sonographers performed the ultrasounds and classified the ovarian lesion according to International Ovarian Tumor Analysis criteria. A total of 230 patients with BOT that underwent surgical treatment during the study period were analyzed. Of these, 82 patients met the inclusion criteria. Relapse was experienced in 11 cases (13.4%), one (1.2%) peritoneal surface and 10 (12.2%) recurrences on the contralateral ovary. Ovarian tumor size >50 mm (P=0.032; OR 7.317; 95% CI 0.89-60.29), multilocular cysts >10 loculi (P=0.016; OR 7.543; 95% CI 1.64-34.78), cysts with >4 papillae (P=0.025; OR 6.190; 95% CI 1.40-27.36) were statistically correlated with recurrent BOT. Overall, the present study showed that lesions with maximum diameter >50 mm (P=0.014), multilocular cysts >10 loculi (P=0.012) and cysts with >4 papillae (P=0.003) were independent predictive factors of BOT recurrence (P<0.001; correlation coefficient R=0.481) in patients with the potential to bear children undergoing conservative treatment.
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http://dx.doi.org/10.3892/mco.2022.2554DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9214481PMC
July 2022

Transvaginal versus port-site specimen retrieval after laparoscopic myomectomy: a systematic review and meta-analysis.

Gynecol Obstet Invest 2022 Jun 21. Epub 2022 Jun 21.

Introduction: To date, there is no robust evidence suggesting whether transvaginal (TVSR) or port-site specimen retrieval (PSSR) after laparoscopic myomectomy (LM) may lead to better surgical outcomes. Considering this element, we aimed to compare surgical outcomes of TVSR versus PSSR after LM.

Methods: A search (PROSPERO ID: CRD42020176490) of international databases, from 1980 to 2020, in English language, was conducted. We selected studies that included women who underwent LM with TVSR compared with PSSR.

Results: We did not find significant differences for operative time (MD=-8.90 [95% CI -30.00, 12.20]; I2=87%), myoma retrieval time (MD=-1.85 [95% CI -13.55, 9.85]; I2=98%), blood loss (MD=-27.62 [95% CI -178.68, 124.43]; I2=91%), intra-operative complication rate (OR 0.51, 95% CI 0.01-23.09; I2=69%) and hospital stay (MD=-0.14 [95% CI -0.43; 0.15]; I2=64%); we found a significant lower post-operative rescue analgesics utilization in the TVSR group compared with the PSSR group (OR 0.31, 95% CI 0.16-0.61, I2=0).

Conclusion: TVSR and PSSR after LM showed comparable results for operative time and surgery-related complications. However, the need of post-operative rescue analgesics was lower in women who underwent TVSR.
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http://dx.doi.org/10.1159/000525624DOI Listing
June 2022

Effects of transdermal versus oral hormone replacement therapy in postmenopause: a systematic review.

Arch Gynecol Obstet 2022 Jun 17. Epub 2022 Jun 17.

Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.

Purpose: To summarize available evidence comparing the transdermal and the oral administration routes of hormone replacement therapy (HRT) in postmenopausal women.

Methods: We performed a systematic review of the literature on multiple databases between January 1990 and December 2021. We included randomized controlled trials and observational studies comparing the transdermal and oral administration routes of estrogens for HRT in postmenopausal women regarding at least one of the outcomes of interest: cardiovascular risk, venous thromboembolism (VTE), lipid metabolism, carbohydrate metabolism, bone mineral density (BMD), and risk of pre-malignant and malignant endometrial lesions, or breast cancer.

Results: The systematic literature search identified a total of 1369 manuscripts, of which 51 were included. Most studies were observational and of good quality, whereas the majority of randomized controlled trials presented a high or medium risk of bias. Oral and transdermal administration routes are similar regarding BMD, glucose metabolism, and lipid profile improvements, as well as do not appear different regarding breast cancer, endometrial disease, and cardiovascular risk. Identified literature provides clear evidence only for the VTE risk, which is higher with the oral administration route.

Conclusions: Available evidence comparing the transdermal and oral administration routes for HRT is limited and of low quality, recommending further investigations. VTE risk can be considered the clearest and strongest clinical difference between the two administration routes, supporting the transdermal HRT as safer than the oral administration route.
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http://dx.doi.org/10.1007/s00404-022-06647-5DOI Listing
June 2022

See-and-treat in-office hysteroscopy versus operative hysteroscopy for the treatment of retained products of conception: A retrospective study.

J Obstet Gynaecol Res 2022 Jun 13. Epub 2022 Jun 13.

Department of Obstetrics and Gynecology, Hillel Yaffe Medical Center, Hadera, Israel.

Aim: To compare the efficacy and safety of in-office hysteroscopy with a see-and-treat approach with that of operative hysteroscopy for the treatment of retained products of conception (RPOC).

Methods: We retrospectively identified all consecutive patients who underwent hysteroscopic treatment of RPOC between 2015 and 2019. We excluded patients with RPOC larger than 2 cm at preoperative transvaginal ultrasounds. Between 2015 and 2017, all hysteroscopic removals of RPOC were performed by operative hysteroscopy. Between 2018 and 2019, all cases of RPOC less than 2 cm in size were hysteroscopically removed by the see-and-treat approach in the office setting. Sociodemographic, clinical, and procedure characteristics along with complications were retrieved from medical records.

Results: Between 2015 and 2019, 119 women underwent hysteroscopic removal of RPOC equal to or smaller than 2 cm: 53 patients by in-office hysteroscopy, and 66 by operative hysteroscopy. The two groups were similar in preoperative characteristics. Although the time required to complete the RPOC removal was similar, the total procedure and assistant time were significantly higher in the operative hysteroscopy group (p < 0.001). Moreover, operative hysteroscopy was associated with a higher proportion of cases complicated by excessive bleeding, cervical tear, or uterine perforation (p = 0.016). Failure to complete the procedure was similarly reported in the two groups (p = 0.58).

Conclusions: In-office hysteroscopy with the see-and-treat approach for RPOC equal to or smaller than 2 cm appears as effective as operative hysteroscopy, but safer. In-office hysteroscopy may be considered the first choice for treating RPOC equal to or smaller than 2 cm.
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http://dx.doi.org/10.1111/jog.15327DOI Listing
June 2022

Laparoscopic Ultra-radical Lymph Node Debulking Using Yasargil Clamps for Gynecological Malignancies: Results from a Large, Multicenter, Retrospective Analysis.

J Minim Invasive Gynecol 2022 May 29. Epub 2022 May 29.

Unit of Gynecologic Oncology, ARNAS "Civico - Di Cristina - Benfratelli", Palermo, Italy (Drs. Di Donna, Sozzi, Cucinella, Giallombardo, Laganà, and Chiantera); Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Palermo, Italy (Drs. Laganà and Chiantera).

Study Objective: Resection of bulky lymph nodes in gynecologic oncology is a challenging procedure. Considering the risk of intraoperative vascular injury, a technique to avoid severe complications is mandatory. In this study, we aimed to analyze the feasibility of laparoscopic ultraradical lymph node debulking using Yasargil clamps in patients with gynecologic cancer with bulky lymph node metastases.

Design: Multicenter retrospective case series (ClinicalTrialg.gov ID: NCT05318170), between September 2010 and April 2020.

Setting: Units of Gynecologic Oncology.

Patients: Patients with gynecologic cancer with bulky lymph node metastases.

Interventions: Laparoscopic ultraradical lymph node debulking using Yasargil clamps.

Measurements And Main Results: Forty-three patients with gynecologic cancer with bulky pelvic and/or aortic lymph nodes metastases undergoing laparoscopic lymph node debulking surgery using Yasargil clamps were included. Median surgical time was 300 minutes (range, 120-550 minutes); median estimated blood loss was 170 mL (range, 0-700 mL). Median size of lymph nodes was 50 mm (range, 25-100). R0 resection was achieved in all cases. Four intraoperative complications (9.3%) occurred. No conversion to open surgery was required. There were 8 postoperative complications, classified grade 2 or worse. There were no cases with intra- or postoperative mortality.

Conclusion: In our experience, in carefully selected patients with gynecologic cancer with bulky lymph nodes, laparoscopic lymph node debulking using Yasargil clamps could be considered a valid option to avoid potential severe vascular intraoperative complications.
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http://dx.doi.org/10.1016/j.jmig.2022.05.016DOI Listing
May 2022

Effects of neuraxial analgesia technique on labor and maternal-fetal outcomes: a retrospective study.

Arch Gynecol Obstet 2022 May 22. Epub 2022 May 22.

Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.

Purpose: To compare the effects of epidural analgesia (EA) and combined spinal epidural analgesia (SEA) on labor and maternal-fetal outcomes.

Methods: We retrospectively identified and included 1499 patients with a single cephalic fetus who delivered at the study center from January 2015 to December 2018 and received neuraxial analgesia at the beginning of the active phase of labor (presence of regular painful contractions and cervical dilatation between 4 and 6 cm). Data including analgesia, labor characteristics, and maternal-fetal outcomes were retrieved from the prospectively collected delivery room database and medical records.

Results: SEA was associated with a shorter first stage of labor than EA, with a median difference of 60 min. On multivariable ordinal logistic regression analysis, neuraxial analgesia, gestational age, fetal weight, labor induction, and parity were independently associated with the first stage length: patients in the EA group were 1.32 times more likely to have a longer first stage of labor (95% CI 1.06-1.64, p = 0.012) than those in the SEA group. Additionally, a significantly lower incidence of fundal pressure was performed among patients who underwent SEA (OR 0.55, 95% CI 0.34-0.9, p = 0.017). No associations were observed between the used neuraxial analgesia technique and other outcomes.

Conclusions: SEA was associated with a shorter length of the first stage of labor and a lower rate of fundal pressure use than EA. Further studies confirming the effects of SEA on labor management and clarifying differences in maternal-fetal outcomes will allow concluding about the superiority of one technique upon the other.
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http://dx.doi.org/10.1007/s00404-022-06600-6DOI Listing
May 2022

Cervical versus utero-ovarian ligament injection of the tracer for the pelvic sentinel lymph node mapping in gynecologic oncology: a prospective observational study.

Gynecol Obstet Invest 2022 May 18. Epub 2022 May 18.

Objective: In gynecologic oncology, the consolidated injection site for the pelvic sentinel lymph node mapping is the cervix. However, in apparent early-stage ovarian cancer, current trials map the pelvic area injecting the tracers in the utero-ovarian ligament. A different injection site is proposed based on a possible different lymphatic ovarian drainage through the utero-ovarian ligament and uterus and consequently a different pelvic sentinel lymph node mapping than the cervix; however, this was never proven. On that basis, this study aimed to investigate whether injecting the tracer in the utero-ovarian ligament map the same or a different pelvic sentinel lymph node than the cervix.

Design: Prospective observational study.

Methods: All consecutive women undergoing primary surgery for gynecologic malignancy with planned pelvic sentinel lymph node mapping were enrolled. The cervical injection was performed at 3 and 9 o'clock injecting indocyanine green. Bilateral utero-ovarian ligament injection was performed injecting methylene blue. The probability of detecting the same sentinel lymph node (concordance rate) and the probability of detecting a different sentinel lymph node (discordance rate) in each hemipelvis were compared using the McNemar's exact test.

Results: Out of 36 hemipelvis (18 patients), the overall detection rate with cervical indocyanine green injection was 86.1% (31/36) versus 52.8% (19/36) with utero-ovarian ligament methylene blue injection (p=0.0004). Indocyanine green and methylene blue identified the same sentinel lymph node in all hemipelvis when sentinel lymph node mapping was obtained by both dyes (19/19; concordance rate 100%). No different or additional sentinel lymph nodes were identified by one of the two dyes (0/19; discordance rate 0%). The probability of detecting the same pelvic sentinel lymph node by the two injections sites was significantly higher than the probability of detecting a different pelvic sentinel lymph node (p<0.0001).

Limitations: The use of two different dyes with known different sentinel lymph node mapping performance impedes to evaluate differences in detection rate attributable to the two injection sites, limiting the comparison only in hemipelvis in which both dyes identified a sentinel lymph node.

Conclusions: Cervix and utero-ovarian ligament are two sites for the tracer injection that have a higher probability of detecting the same than a different pelvic sentinel lymph node. Given the higher technical challenge in performing the utero-ovarian ligament injection, these results suggest that the injection of the tracer into the cervix could be a more reliable alternative for the pelvic sentinel lymph node mapping in ovarian cancer.
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http://dx.doi.org/10.1159/000525126DOI Listing
May 2022

Letter: Pay Attention to the False Myths.

J Obstet Gynaecol Can 2022 05;44(5):472-474

Arbor Vitae Endoscopic Centre, Rome, Italy.

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http://dx.doi.org/10.1016/j.jogc.2022.03.005DOI Listing
May 2022

Different Surgical Approaches for Early-Stage Ovarian Cancer Staging. A Large Monocentric Experience.

Front Med (Lausanne) 2022 25;9:880681. Epub 2022 Apr 25.

Department of Medicine and Health Science, "V.Tiberio" Università Degli Studi del Molise, Campobasso, Italy.

Introduction: Ovarian cancer is the third most frequent gynecological cancer. In early stage ovarian cancer (ESOC) comprehensive surgical staging is recommended. Surgical staging is traditionally approached by laparotomy, although minimally invasive surgery can be a valid alternative in selected patients. This study aims to analyze the surgical and oncological outcomes of three different surgical approaches in a large series of patients.

Methods: We retrospectively included all histologically proven ESOC cases treated between January 2014 and December 2017. ESOC was defined as stage IA to IIB according to the 2018 FIGO staging system. Subjects were divided into groups 1, 2, and 3, based on the surgical approach (open abdominal, laparoscopic, or robotic, respectively).

Results: Within patients enrolled during the study period, 455 met the inclusion criteria. No difference in intraoperative complications was recorded in the three groups ( = 0.709). Conversely, a significant difference occurred in postoperative complications (16.2 vs. 3.8 vs. 11.1%, in groups 1, 2, and 3 respectively, = 0.004). No difference was found in overall survival (OS) (32 vs. 31 vs. 25 months, = 0.481) and disease-free survival (DFS) (26 vs. 29 vs. 24 months, = 0.178) in groups 1, 2, and 3, respectively. At univariate analysis FIGO stage I ( = 0.004) showed a lower recurrence rate compared to FIGO stage II.

Conclusion: No significant difference was found in OS and DFS among the three groups (open, laparoscopic, and robotic). The minimally invasive approach showed lower rate of complications than the laparotomic approach.
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http://dx.doi.org/10.3389/fmed.2022.880681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9081786PMC
April 2022

Psychological Impact of the Very Early Beginning of the COVID-19 Outbreak in Healthcare Workers: A Bayesian Study on the Italian and Swiss Perspectives.

Front Public Health 2022 24;10:768036. Epub 2022 Mar 24.

Surgery and Emergency Department, Ospedale Regionale di Lugano, Lugano, Switzerland.

Background: We investigated the COVID19-related psychological impact on healthcare workers in Italy and in Italian-speaking regions of Switzerland, three weeks after its outbreak. All professional groups of public hospitals in Italy and Switzerland were asked to complete a 38 questions online survey investigating demographic, marital and working status, presence of stress symptoms and need for psychological support.

Results: Within 38 h a total of 3,038 responses were collected. The subgroup analysis identified specific categories at risk according to age, type of work and region of origin. Critical care workers, in particular females, reported an increased number of working hours, decline in confidence in the future, presence of stress symptoms and need for psychological support. Respondents reporting stress symptoms and those with children declared a higher need for psychological support.

Conclusions: The large number of participants in such a short time indicates for a high interest on topic among health-care workers. The COVID19 outbreak has been experienced as a repeated trauma for many health-care professionals, especially among female nurses' categories. Early evidence of the need of implementating short and long-term measures to mitigate impact of the emotional burden of COVID-19 pandemic are still relevant.
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http://dx.doi.org/10.3389/fpubh.2022.768036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8987285PMC
March 2022

Left External Iliac Vein Injury During Laparoscopic Pelvic Lymphadenectomy for Early-Stage Ovarian Cancer: Our Experience and Review of Literature.

Front Surg 2022 9;9:843641. Epub 2022 Mar 9.

Department of Gynecology Oncology, "Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Giovanni Paolo II", Bari, Italy.

Laparoscopic surgical staging is the standard treatment of early-stage ovarian tumors with similar survival outcomes if compared with laparotomic procedures. In this article, we report a case regarding an incidental external iliac vein injury during a pelvic lymphadenectomy for fertility sparing treatment of early-stage ovarian cancer with a video showing the laparoscopic repair without any consequence or side effect. A 36 year-old obese woman with Body Mass Index 30 kg/m referred at our hospital with an histological diagnosis of high grade ovarian serous carcinoma after a left laparoscopic salpingo-oophorectomy performed in another hospital. After an hysteroscopy with endometrial biopsy, a laparoscopic surgical staging with a pelvic and aortic lymphadenectomy with lymph-node dissection until the left renal vein, omentectomy, and appendectomy were performed. A thermal injury to the left external iliac vein occurred using the bipolar forceps during lymphadenectomy and was repaired after an immediate clamping of the site using endoclinch and the suction irrigator probe. The laceration on the iliac vein was successfully repaired using 10 mm laparoscopic titanium clips; after a follow-up of 42 months no recurrence was detected. In conclusion, laparoscopy is a safe and effective therapeutic option for fertility sparing treatment patients with early stage ovarian carcinoma with a significantly low morbidity and postoperative hospitalization, but it should be reserved for oncologic surgeons trained in advanced laparoscopic procedures and repair of vascular injuries potentially associated with high mortality rate.
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http://dx.doi.org/10.3389/fsurg.2022.843641DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8959709PMC
March 2022

First and second waves of SARS-COV-2 infection in the obstetric population.

J Obstet Gynaecol 2022 Mar 11:1-4. Epub 2022 Mar 11.

Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy.

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http://dx.doi.org/10.1080/01443615.2022.2038107DOI Listing
March 2022

Prevalence of Intrauterine Adhesions after Myomectomy: A Prospective Multicenter Observational Study.

Gynecol Obstet Invest 2022 15;87(1):62-69. Epub 2022 Feb 15.

Department of Obstetrics and Gynecology and CERICSAL (CEntro di RIcerca Clinico SALentino), "Veris delli Ponti Hospital", Scorrano, Italy.

Objectives: The aim of this study was to evaluate intrauterine adhesion formation after laparoscopic and laparotomic myomectomy.

Design: This is a prospective, multicenter, observational study (ClinicalTrials.gov ID: NCT04030273).

Methods: We included patients after laparotomic and laparoscopic myomectomy. All patients underwent postsurgical diagnostic hysteroscopy, after 3 months. The intrauterine adhesion rate and associated factors were investigated.

Results: Between January 2020 and December 2020, 38 and 24 consecutive patients underwent laparoscopic and laparotomic myomectomy, respectively. All diagnostic hysteroscopies were performed in the office setting without complications. Intrauterine adhesions were identified in 19.4% of women (95% CI: of 9-29%). Factors univariately associated (p < 0.2) with the presence of intrauterine adhesions after myomectomy were previous uterine surgery, the surgical approach (laparoscopic or laparotomic), the number of removed fibroids, the type and diameter of the largest myoma, and the opening of the uterine cavity. In the multivariable analysis, only the opening of the uterine cavity (odds ratio [OR] 51.99; 95% confidence interval [CI]: 4.53-596.28) and the laparotomic approach (OR, 16.19; 95% CI: 1.66-158.35) were independently associated with the identification of intrauterine adhesions after myomectomy.

Limitations: One of the main limitations of our study is that we used uterine manipulator only in the laparoscopic group; in addition, we did not perform a preoperative hysteroscopy to evaluate the rate of intrauterine adhesions potentially present even before the myomectomy.

Conclusions: The prevalence of intrauterine adhesions after 3 months from surgery was significantly associated with the opening of the uterine cavity and the laparotomic approach.
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http://dx.doi.org/10.1159/000522583DOI Listing
May 2022

CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis.

J Sex Med 2022 03 29;19(3):452-470. Epub 2022 Jan 29.

Department of Obstetrics and Gynecology, IRCCS San Raffaele Scientific Institute, University Vita and Salute, Milan, Italy.

Background: Genitourinary syndrome of menopause (GSM) is a widespread condition with a great impact on quality of life and self-image.

Aim: We aimed to systematically review the current literature on CO2-Laser therapy efficacy for the treatment of GSM.

Methods: MEDLINE and Embase databases were systematically queried in December 2020 Studies included women with a diagnosis of Vulvo-Vaginal Atrophy (VVA) or GSM without an history of gynaecological and/or breast cancer, pelvic organ prolapse staged higher than 2, pelvic radiotherapy or Sjogren's Syndrome. The quality of the evidence was assessed with the Cochrane risk of bias tool. This study is registered on PROSPERO, number CRD42021238121.

Outcomes: Effects of CO2-Laser therapy on GSM symptoms assessed through subjective or objective efficacy measurement methods.

Results: A total of 803 articles were identified. Of these, 25 studies were included in this review for a total of 1,152 patients. All studies showed a significant reduction in VVA and/or GSM symptoms (dryness, dyspareunia, itching, burning, dysuria). The pooled mean differences for the symptoms were: dryness -5.15 (95% CI:-5.72,-4.58; P < .001; I:62%; n = 296), dyspareunia -5.27 (95% CI:-5.93,-4.62; P < .001; I:68%; n = 296), itching -2.75 (95% CI:-4.0,-1.51; P < .001; I:93%; n = 281), burning -2.66 (95% CI:-3.75, -1.57; P < .001; I:86%; n = 296) and dysuria -2.14 (95% CI:-3.41,-0.87; P < .001; I:95%; n = 281). FSFI, WHIS and VMV scores also improved significantly. The pooled mean differences for these scores were: FSFI 10.8 (95% CI:8.41,13.37; P < .001; I:84%; n = 273), WHIS 8.29 (95% CI:6.16,10.42; P < .001; I:95%; n = 262) and VMV 30.4 (95% CI:22.38,38.55; P < .001; I:24%; n = 68). CO2-Laser application showed a beneficial safety profile and no major adverse events were reported.

Clinical Implications: Vaginal laser treatment resulted in both a statistically and clinically significant improvement in GSM symptoms. FSFI improved significantly in all 8 included studies but it reached a clinically relevant level only in 2 of them.

Strengths & Limitations: The strength of the current meta-analysis is the comprehensive literature search. We reported data from a high number of patients (1,152) and high number of laser applications (more than 3,800). The main limitations are related to the high heterogeneity of the included studies investigating laser effects. Moreover, most of them are single center and nonrandomized studies.

Conclusion: The data suggest that CO2-Laser is a safe energy-based therapeutic option for the management of VVA and/or GSM symptoms in postmenopausal women; however, the quality of the body of evidence is "very low" or "low". Filippini M, Porcari I, Ruffolo AF, et al., CO2-Laser therapy and Genitourinary Syndrome of Menopause: A Systematic Review and Meta-Analysis. J Sex Med 2022;19:452-470.
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http://dx.doi.org/10.1016/j.jsxm.2021.12.010DOI Listing
March 2022

Tranexamic acid for the prevention and the treatment of primary postpartum haemorrhage: a systematic review.

J Obstet Gynaecol 2022 Jan 7:1-13. Epub 2022 Jan 7.

Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy.

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.
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http://dx.doi.org/10.1080/01443615.2021.2013784DOI Listing
January 2022

Is the Deep Endometriosis or the Surgery the Cause of Postoperative Bladder Dysfunction?

J Minim Invasive Gynecol 2022 04 2;29(4):567-575. Epub 2022 Jan 2.

Department of Obstetrics and Gynecology, Insubria University, Varese, Italy.

Study Objective: To assess whether deep endometriosis surgery affects the bladder function.

Design: Prospective multicenter observational study (Canadian Task Force classification II-2).

Setting: Academic research centers.

Patients: Thirty-two patients with diagnosis of deep endometriosis requiring surgery.

Interventions: Women were evaluated with urodynamic studies, International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form, and International Consultation on Incontinence Questionnaire Overactive Bladder Module questionnaires before and 3 months after surgery.

Measurements And Main Results: The main outcome measure was the impact of deep endometriosis surgery on urodynamic parameters. All cystomanometric parameters showed an improvement postoperatively: in particular, the first desire to void (120 vs 204 mL; p <.001) and the bladder capacity (358 vs 409 mL; p = .011) increased significantly after surgery. Of the uroflow parameters, the maximal voiding flow improved significantly postoperatively (19 vs 25 mL/s; p = .026). The International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form (2.5 vs 0; p = .0005) and International Consultation on Incontinence Questionnaire Overactive Bladder Module (4.3 vs 1.2; p <.001) questionnaires showed a significant postoperative improvement too.

Conclusion: Our data show that in a selected population of patients with deep infiltrating endometriosis (not requiring bowel or ureteral resection), the bladder function improves after surgery, both during filling and on voiding urodynamic phases. Postoperatively, patients with deep infiltrating endometriosis become aware of bladder filling later, have a higher bladder capacity, and have a higher maximal flow. The postoperative urodynamic results are corroborated by the improved scores on the bladder questionnaires.
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http://dx.doi.org/10.1016/j.jmig.2021.12.017DOI Listing
April 2022

Predictive Score of Nodal Involvement in Endometrial Cancer Patients: A Large Multicentre Series.

Ann Surg Oncol 2022 Apr 26;29(4):2594-2599. Epub 2021 Nov 26.

Department of Medicine and Surgery, University of Parma, Parma, Italy.

Background: Sentinel lymph node (SLN) biopsy is considered the standard of care in early-stage endometrial cancer (EC). For SLN failure, a side-specific lymphadenectomy is recommended. Nevertheless, most hemipelvises show no nodal involvement. The authors previously published a predictive score of lymphovascular involvement in EC. In case of a negative score (value 3-4), the risk of nodal metastases was extremely low. This multicenter study aimed to analyze a predictive score of nodal involvement in EC patients.

Methods: The study enrolled patients with EC who had received comprehensive surgical staging with nodal assessment. A preoperative predictive score of nodal involvement was calculated for all the patients before surgery. The score included myometrial infiltration, tumor grading (G), tumor diameter, and Ca125 assessment. The STARD (standards for Reporting Diagnostic accuracy studies) guidelines were followed for score accuracy.

Results: The study analyzed 1038 patients and detected 155 (14.9%) nodal metastases. The score was negative (3 or 4) for 475 patients and positive (5-7) for 563 of these patients. The score had a sensitivity of 83.2%, a specificity of 50.8%, a negative predictive value of 94.5%, and a diagnostic value of 55.7%. The area under the curve was 0.75. The logistic regression showed a significant correlation between a negative score and absence of nodal metastasis (odds ration [OR], 5.133, 95% confidence interval [CI], 3.30-7.98; p < 0.001).

Conclusion: The proposed predictive score is a useful test to identify patients at low risk of nodal involvement. In case of SLN failure, the application of the current score in the SLN algorithm could allow avoidance of unnecessary lymphadenectomies.
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http://dx.doi.org/10.1245/s10434-021-11083-xDOI Listing
April 2022

Overall survival after surgical staging by lymph node dissection versus sentinel lymph node biopsy in endometrial cancer: a national cancer database study.

Int J Gynecol Cancer 2022 01 8;32(1):28-40. Epub 2021 Nov 8.

Department Obstetrics and Gynecology, Mayo Clinic Rochester, Rochester, Minnesota, USA

Objective: Substituting lymphadenectomy with sentinel lymph node biopsy for staging purposes in endometrial cancer has raised concerns about incomplete nodal resection and detrimental oncological outcomes. Therefore, this study aimed to investigate the association between the type of lymph node assessment and overall survival in endometrial cancer accounting for node status and histology.

Methods: Women with stage I-III endometrial cancer who underwent hysterectomy and lymph node assessment from January 2012 to December 2015 were identified in the National Cancer Database. Patients who underwent neoadjuvant therapy, had previous cancer, and whose follow-up was less than 90 days were excluded. Multivariable Cox proportional hazards regression analyses were performed to assess factors associated with overall survival.

Results: Of 68 614 patients, 64 796 (94.4%) underwent lymphadenectomy, 1777 (2.6%) underwent sentinel node biopsy only, and 2041 (3.0%) underwent both procedures. On multivariable analysis, neither sentinel lymph node biopsy alone nor sentinel node biopsy followed by lymphadenectomy was associated with significantly different overall survival compared with lymphadenectomy alone (HR 0.92, 95% CI 0.73 to 1.17, and HR 0.91, 95% CI 0.77 to 1.08, respectively). When stratified by lymph node status, sentinel node biopsy alone or followed by lymphadenectomy was not associated with different overall survival, both in patients with negative (HR 0.95, 95% CI 0.73 to 1.24, and HR 1.04, 95% CI 0.85 to 1.27, respectively) or positive (HR 0.91, 95% CI 0.54 to 1.52, and HR 0.77, 95% CI 0.57 to 1.04, respectively) lymph nodes. These findings held true when sentinel node biopsy alone and sentinel node biopsy plus lymphadenectomy groups were merged, and on stratification by histotype (type one vs type 2) or inclusion of only complete lymphadenectomy (at least 10 pelvic nodes and at least one para-aortic node removed). In all analyses, age, Charlson-Deyo score, black race, AJCC pathological T stage, grade, lymphovascular invasion, brachytherapy, and adjuvant chemotherapy were independently associated with overall survival.

Discussion: No difference in overall survival was found in patients with endometrial cancer who underwent sentinel node biopsy alone, sentinel node biopsy followed by lymphadenectomy, or lymphadenectomy alone. This observation remained regardless of node status, histotype, and lymphadenectomy extent.
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http://dx.doi.org/10.1136/ijgc-2021-002927DOI Listing
January 2022

Endobag use in laparoscopic gynecological surgeries: a systematic review.

Minim Invasive Ther Allied Technol 2022 Jun 3;31(5):698-703. Epub 2021 Nov 3.

Lebanese American University Medical Center - Rizk Hospital, Beirut, Lebanon.

Purpose: The purpose of this systematic review was to assess the characteristics of endobags present in the market, the weight of specimen removed, complications of the operations and time required for in-bag morcellation in women undergoing laparoscopic gynecologic surgeries.

Material And Methods: We performed a systematic review, including prospective and retrospective studies, with or without randomized allocation of the patients, using endobags in laparoscopic gynecologic surgeries. We extracted data about study design, type and price of bag used, type of surgical procedure, specimen weight, mean time for morcellation and for total surgical procedure, complications.

Results: We included 11 studies, including a total of 1160 patients, in which the investigators used MorSafe, Endocatch II autosuture, More-Cell-Safe, Endocatch, EcoSac and LapBag. A wide range of specimens were morcellated with the largest successfully morcellated specimen weighing 2314 gr. Only half of the studies comparing uncontained and contained morcellation found a significant increase of total operative time. Finally, the number of complications was not increased when endobag was used.

Conclusion: According to our systematic review, in-bag (contained) morcellation can be considered as a safe and unexpensive option, associated with a very low number of complications, even with large specimens.
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http://dx.doi.org/10.1080/13645706.2021.1982727DOI Listing
June 2022

Practice changes in Italian Gynaecologic Units during the COVID-19 pandemic: a survey study.

J Obstet Gynaecol 2021 Sep 28:1-8. Epub 2021 Sep 28.

Department of Obstetrics and Gynaecology, AOUI Verona, University of Verona, Verona, Italy.

The impact of Coronavirus disease 2019 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Therefore, a survey was conducted among all Italian Gynaecological Units Directors in April 2020. The response rate was 90% (135/150). 77.8% of centres performed surgery only for oncologic or not deferrable pathologies, and 9.6% was closed. 68.7% of directors were at least moderately satisfied by published guidelines/recommendations, but 94.8% of respondents identified limitations, mainly (83%) the absent definition of benign non-deferrable pathology. Responders considered as non-deferrable severe endometriosis (69.6%), endometriosis with organ failure/dysfunction (74.1%), and unresponsive symptomatic fibroids (89.6%). Despite guidelines/recommendations, respondents treated ovarian (77%) and endometrial (71.6%) cancer as usual. Only a minority of respondents reduced the laparoscopic approach (11.2%) and adopted all recommended surgical precautions (9.6%). Compliance with available guidelines/recommendations appears incomplete. Reconsidering guidelines/recommendations regarding oncological cases and specify non-deferrable benign pathologies would improve guidelines/recommendations compliance.Impact statement The SARS-CoV-2 pandemic has profoundly influenced medical routine practice worldwide. Surgery units have been forced to reduce or even completely restrict their activity to re-allocate human resources. Many major international gynaecological societies have released statements and guidelines, providing various recommendations to guide practice changes. However, the impact of the SARS-CoV-2 pandemic on Italian Gynaecological Units practice and the compliance and satisfaction with available guidelines/recommendations is unknown. Study results provide evidence showing how the SARS-CoV-2 pandemic has changed surgical activity in the Italian Gynaecological Units. Most centres reduced surgical activity, limiting surgery only for oncologic or not deferrable pathologies. Moreover, our research shows the level of compliance and satisfaction with available guidelines/recommendations and where they need to be improved. Most directors were at least moderately satisfied but identified different limitations. Guidelines/recommendations do not provide enough details, such as the absent definition of benign non-deferrable pathologies. The limited compliance with available guidelines/recommendations and identified limitations suggest reconsidering guidelines/recommendations focussing on identified gaps. Provide more details, such as specifying non-deferrable benign pathologies, would improve guidelines/recommendations compliance.
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http://dx.doi.org/10.1080/01443615.2021.1954149DOI Listing
September 2021

A Multicentric Randomized Trial to Evaluate the ROle of Uterine MANipulator on Laparoscopic/Robotic HYsterectomy for the Treatment of Early-Stage Endometrial Cancer: The ROMANHY Trial.

Front Oncol 2021 10;11:720894. Epub 2021 Sep 10.

Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.

Objective: This prospective randomized trial aimed to assess the impact of the uterine manipulator in terms of lymph vascular space invasion (LVSI) in patients undergoing minimally invasive staging for early-stage endometrial cancer.

Methods: In this multicentric randomized trial, enrolled patients were randomly allocated in two groups according to the no use (arm A) or the use (arm B) of the uterine manipulator. Inclusion criteria were G1-G2 early-stage endometrial cancer at preoperative evaluation. The variables collected included baseline demographic characteristics, perioperative data, final pathology report, adjuvant treatment, and follow-up.

Results: In the study, 154 patients (76 in arm A and 78 in arm B) were finally included. No significant differences were recorded regarding the baseline characteristics. A statistically significant difference was found in operative time for the laparoscopic staging (p=0.005), while no differences were reported for the robotic procedures (p=0.419). The estimated blood loss was significantly lower in arm A (p=0.030). No statistically significant differences were recorded between the two study groups in terms of peritoneal cytology, LVSI (p=0.501), and pattern of LVSI (p=0.790). No differences were detected in terms of overall survival and disease-free survival (p=0.996 and p=0.480, respectively). Similarly, no differences were recorded in the number of recurrences, 6 (7.9%) in arm A and 4 (5.2%) in arm B (p=0.486). The use of the uterine manipulator had no impact on DFS both at univariable and multivariable analyses.

Conclusions: The intrauterine manipulator does not affect the LVSI in early-stage endometrial cancer patients undergoing laparoscopic/robotic staging.

Clinical Trial Registration: https://clinicaltrials.gov, identifier (NCT: 02762214).
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http://dx.doi.org/10.3389/fonc.2021.720894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461311PMC
September 2021

Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial.

Acta Obstet Gynecol Scand 2021 Oct 15;100(10):1840-1848. Epub 2021 Aug 15.

Division of Obstetrics and Gynecology, Department of Maternal, Neonatal and Infant Health, ASL Biella, Biella, Italy.

Introduction: The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other.

Material And Methods: We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, vs closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up.

Results: Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] vs 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ.

Conclusions: Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.
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http://dx.doi.org/10.1111/aogs.14238DOI Listing
October 2021

Linzagolix: a new GnRH-antagonist under investigation for the treatment of endometriosis and uterine myomas.

Expert Opin Investig Drugs 2021 Sep 4;30(9):903-911. Epub 2021 Aug 4.

Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genova, Italy.

Introduction: Uterine myomas and endometriosis are benign hormone-dependent diseases affecting women of reproductive age. Substantial efforts have been made to develop innovative medical options for treating these gynecologic diseases. Elagolix and relugolix have been approved in some countries for treating endometriosis and myomas, respectively; however, linzagolix (OBE 2109, KLH 2109) is a new oral gonadotropin-releasing hormone (GnRH) antagonist in phase II-III trials. Treatment options for women with contraindications for hormonal therapies or who refuse particular options, are the driving force behind the development of new drugs in this area.

Area Covered: This drug evaluation highlights definitive and preliminary results from previous and ongoing studies of linzagolix for the treatment of endometriosis and myomas.

Expert Opinion: Linzagolix showed a dose-dependent and rapidly reversible action on the pituitary-gonadal axis. In a recent phase II trial (EDELWEISS), linzagolix significantly reduced pain related to endometriosis and improved quality of life at single daily doses of 75-200 mg. The preliminary results of international, double-blind phase III trials (PRIMROSE 1 and 2) reported its efficacy in treating heavy menstrual bleeding related to myomas with a good safety profile. Further studies will determine the necessity of add-back therapy during long-term use of linzagolix.
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http://dx.doi.org/10.1080/13543784.2021.1957830DOI Listing
September 2021

An Italian National Survey on Ovarian Cancer Treatment at first diagnosis. There's None so Deaf as those who will not Hear.

J Cancer 2021 27;12(15):4443-4454. Epub 2021 May 27.

Unit of Surgical Gynecol Oncology, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy.

Epithelial ovarian cancer (EOC) is the most lethal gynecological malignancy, crucial prognostic factors are no gross residual disease and centralization of cases. To evaluate the centralization of EOC patients, we report the results of a survey that shows the daily management of EOC patients in Italy. A 49-items electronic unblinded survey assessing demographics, practice characteristics, current opinions and approach to managing advanced EOC at first diagnosis was sent both to general gynecologists (GG) and gynecologic oncologists (GO). Differences in frequency distribution of answers between gynecologists with different expertise were evaluated using Fisher exact test. Multivariable analyses were performed applying generalized linear models. 84/192 (44%) GG and 108/192 (56%) GO from all Italian regions answered to our survey. GOs declared to perform fertility sparing surgery in early EOC more frequently than GG (p=0.002). GOs can perform a frozen section and have both a gynecopathologist and a dedicated general surgeon. 89% of GOs consider as "optimal debulking" no gross residual disease and 81% achieve this at upfront cytoreduction in more than 40% of patients. Use of neoadjuvant chemotherapy decreases in higher volume centers (p<0.001) while it is lower in the group of GOs than in the GGs group (p<0.001). EOC patients are still treated by GGs. GOs perform more upfront surgery and achieve optimal debulking in a greater percentage of patients than GGs. In Italy an adequate centralization of cases has not yet been achieved, and this may have detrimental effects on the quality of treatment.
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http://dx.doi.org/10.7150/jca.57894DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8210549PMC
May 2021

The Psychological Impact of COVID-19 on Healthcare Providers in Obstetrics: A Cross-Sectional Survey Study.

Front Psychol 2021 9;12:632999. Epub 2021 Apr 9.

Department of Obstetrics and Gynecology, AOUI Verona, University of Verona, Verona, Italy.

To assess the psychological distress of healthcare providers (HCPs) working in the field of obstetrics during the coronavirus disease 2019 (COVID-19) pandemic and to identify factors associated with psychological distress at the individual, interpersonal, and organizational level. Cross-sectional survey study. Four University hospitals in Italy. HCPs working in obstetrics, including gynecologists, residents in gynecology and obstetrics, and midwives. The 104-item survey Impatto PSIcologico COVID-19 in Ostetricia (IPSICO) was created by a multidisciplinary expert panel and administered to HCPs in obstetrics in May 2020 a web-based platform. Psychological distress assessed by the General Health Questionnaire-12 (GHQ-12) included in the IPSICO survey. The response rate to the IPSICO survey was 88.2% (503/570), and that for GHQ-12 was 84.4% (481/570). Just over half (51.1%; 246/481) of the GHQ-12 respondents reported a clinically significant level of psychological distress (GHQ-12 ≥3). Psychological distress was associated with either individual (i.e., female gender, stressful experience related to COVID-19, exhaustion, and the use of dysfunctional coping strategies), interpersonal (i.e., lower family support, limitations in interactions with colleagues), and organizational (i.e., reduced perception of protection by personal protective equipment, perceived delays on updates and gaps in information on the pandemic) factors in dealing with the pandemic. Results confirm the need for monitoring and assessing the psychological distress for HCPs in obstetrics. Interventions at the individual, interpersonal, and organizational level may relieve the psychological distress during the COVID-19 pandemic and foster resilience skills in facing emotional distress.
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http://dx.doi.org/10.3389/fpsyg.2021.632999DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8062879PMC
April 2021
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