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De Carvalho L.F.P.,Obstetrics and Gynecology and Womens Health Institute | De Carvalho L.F.P.,University of Sao Paulo | Abrao M.S.,University of Sao Paulo | Biscotti C.,Cleveland Clinic | And 5 more authors.
Journal of Molecular Histology | Year: 2013

Oxidative stress is associated with many disease states including gynecologic disease. This process can damage lipids, proteins and DNA. The present study highlights the role of oxidative stress induced DNA damage as measured by 8-hydroxy-2-deoxyguanosine in development of benign gynecological conditions (BGC). Our aim was to map the oxidative DNA damage on female reproductive organs and highlight the high amount found in a variety of benign gynecologic disorders. Seventeen biopsy specimens from female pelvic organs were divided in two groups: healthy organs tissue and BGC tissue. Healthy organs biopsy tissue included the cervix, tubes, uterus, peritoneum, and topic endometrium in secretory phase. Benign gynecological biopsy tissue included hydrosalpinges, leiomyoma, adenomyosis and tubal cysts. Immunohistochemical staining showed significantly higher levels of DNA damage between BGC and healthy organs [19.36 % (6.20; 32.51) vs. 4.61 % (0.63; 8.53); P < 0.0344]. Our results highlight the involvement of oxidative stress DNA damage in female benign pelvic disease. Hydrosalpinges, leiomyoma, and adenomyosis exhibit the highest amounts of oxidative DNA damage in the pelvic cavity. © 2012 Springer Science+Business Media Dordrecht.


Jelovsek J.E.,Gynecology and Womens Health Institute | Piccorelli A.,Cleveland Clinic | Barber M.D.,Gynecology and Womens Health Institute | Tunitsky-Bitton E.,Gynecology and Womens Health Institute | Kattan M.W.,Cleveland Clinic
Female Pelvic Medicine and Reconstructive Surgery | Year: 2013

Objectives: This study aimed to develop and internally validate a nomogram that facilitates decision making between patient and physician by predicting a woman's individual probability of developing urinary (UI) or fecal incontinence (FI) after her first delivery. Methods: This study used Childbirth and Pelvic Symptoms Study data, which estimated the prevalence of postpartum UI and FI in primiparous women after vaginal or cesarean delivery. Two models were developed using antepartum variables, and 2 models were developed using antepartum plus labor and delivery variables. Urinary incontinence was defined by a response of leaking urine "sometimes" or "often" using the Medical, Epidemiological, and Social Aspects of Aging Questionnaire. Fecal incontinence was defined as any involuntary leakage of mucus, liquid, or solid stool using the Fecal Incontinence Severity Index. Logistic regression models allowing nonlinear effects were used and displayed as nomograms. Overall performance was assessed using the Brier score (zero equals perfect model) and concordance index (c-statistic). Results: A total of 921 women enrolled in the Childbirth and Pelvic Symptoms Study, and 759 (82%) were interviewed by telephone 6 months postpartum. Two antepartum models were generated, which discriminated between women who will and will not develop UI (Brier score = 0.19, c-statistic = 0.69) and FI (Brier score = 0.10, c-statistic = 0.67) at 6 months and 2 models were generated (Brier score = 0.18, c-statistic= 0.68 and Brier score = 0.09, c-statistic = 0.68) for predicting UI and FI, respectively, for use after labor and delivery. Conclusions: These models yielded 4 nomograms that are accurate for generating individualized prognostic estimates of postpartum UI and FI and may facilitate decision making in the prevention of incontinence. Copyright © 2013 by Lippincott Williams & Wilkins.


Tunitsky E.,Gynecology and Womens Health Institute | Tunitsky E.,Cleveland Clinic | Murphy A.,Cleveland Clinic | Barber M.D.,Gynecology and Womens Health Institute | And 2 more authors.
Female Pelvic Medicine and Reconstructive Surgery | Year: 2013

Objective: To develop and validate a new ureteral anastomosis simulation model. Methods: We designed a training model to simulate the task of ureteral anastomosis required for ureteroneocystostomy that is suitable for robotic and laparoscopic approaches. Face validity was measured using questions related to surgical authenticity and educational value of the model. Construct validity was measured by comparing scores using Global Operative Assessment of Laparoscopic Skills Scale (GOALS) scale between ''procedure experts,'' ''robotic experts,'' and ''trainees'' groups. One-way analysis of variance was used to compare differences in the scores and operating times between the 3 groups. Associations between previous surgical experience and performance scores were measured using the Spearman rho correlation coefficient. Results: Four urologists experienced with robotically assisted ureteroneocystostomies were included in the procedure experts group. The robotic experts group consisted of 5 gynecologists experienced in robotic surgery. The trainees group consisted of 12 urology and gynecology upper-level residents and fellows. All experts agreed or strongly agreed that the model was authentic to the live procedure and a useful training tool. Mean (SD) total GOALS scores were significantly better for the procedure experts group compared to the robotic experts group and to the trainees group (P=0.02 vs P=0.004, respectively). The robotic experts group's GOALS scores were also significantly higher than that of the trainees group (P=0.05). There were no differences in mean times required to complete the procedure. Surgical experience moderately correlated with scores on all 3 assessment scales. Conclusions: Superior performance on the model by more experienced surgeons demonstrates evidence of construct validity. This authenticand useful model allows surgeons to learn and practice the ureteral anastomosis portion of the ureteral reimplantation surgeries before operating on a live patient. Copyright © 2013 by Lippincott Williams & Wilkins.


Shaw J.,Cleveland Clinic | Tunitsky-Bitton E.,Cleveland Clinic | Barber M.D.,Cleveland Clinic | Jelovsek J.E.,Cleveland Clinic | Jelovsek J.E.,Gynecology and Womens Health Institute
International Urogynecology Journal and Pelvic Floor Dysfunction | Year: 2014

Introduction and hypothesis: We describe the presentation, diagnosis, and management of ureterovaginal fistula over a 7-year period at a tertiary care center. Methods: A retrospective review of ureterovaginal fistula cases between 2003 and 2011 was performed. Demographic information, antecedent event, symptoms, diagnostic modalities, and management strategies were reviewed. Results: Nineteen ureterovaginal fistulas were identified during the 7-year study period. One fistula followed a repeat cesarean section and 18 fistulas followed a hysterectomy (9 total abdominal, 6 total laparoscopic, 3 vaginal hysterectomies). Ureteral injuries were not recognized in any of the patients at the time of index surgery. Computed tomography (CT) urography was the most commonly utilized diagnostic modality (58%). Primary non-surgical management with ureteral stents was attempted and successful in 5 out of 7 cases (71%). There were 14 total surgical repairs, including 2 cases in which stents were successfully placed, but the fistula persisted, and 6 additional cases where attempted stent placement failed. Surgical repair consisted of 10 ureteroneocystostomies performed via laparotomy and 4 performed laparoscopically, 3 of which were robotically assisted. Conclusions: Despite being uncommon, ureterovaginal fistula should remain in the differential diagnosis of new postoperative urinary incontinence after gynecological surgery. Conservative management with ureteral stent appears to be the best initial approach in selected patients, with a success rate of 71%. Minimally invasive approaches to performing ureteroneocystostomy have high success rates, comparable to those of open surgical repair. © The International Urogynecological Association 2013.


PubMed | Cleveland Clinic and Gynecology and Womens Health Institute
Type: Journal Article | Journal: American journal of obstetrics and gynecology | Year: 2016

Many women who experience endometriosis and endometriomas also encounter problems with fertility.The purpose of this study was to determine the impact of surgical excision of endometriosis and endometriomas compared with control subjects on ovarian reserve.This was a prospective cohort study of 116 women aged 18-43 years with pelvic pain and/or infertility who underwent surgical treatment of suspected endometriosis (n=58) or endometriomas (n=58). Based on surgical findings, the suspected endometriosis group was further separated into those with evidence of peritoneal disease (n=29) and those with no evidence of endometriosis (n=29). Ovarian reserve was measured by anti-Mllerian hormone and compared before surgery and at 1 month and 6 months after surgery.Baseline anti-Mllerian hormone values were significantly lower in the endometrioma vs negative laparoscopy group (1.8 ng/mL [95% confidence interval, 1.2-2.4 ng/mL] vs 3.2 ng/mL [95% confidence interval, 2.0-4.4 ng/mL]; P<.02), but the peritoneal endometriosis group was not significantly different than either of these groups. Only patients with endometriomas had a significant decline in ovarian reserve at 1 month (-48%; 95% confidence interval, -54 to -18%; P<.01; mean anti-Mllerian hormone baseline value, 1.77-1.12 ng/mL at 1 month). Six months after surgery, anti-Mllerian hormone values continued to be depressed from baseline but were no longer significantly different. The rate of anti-Mllerian hormone decline was correlated positively with baseline preoperative anti-Mllerian hormone values and the size of endometrioma that was removed. Those with bilateral endometriomas (n=19) had a significantly greater rate of decline (53.0% [95% confidence interval, 35.4-70.5%] vs 17.5% [95% confidence interval, 3.2-31.8%]; P=.002).At baseline, patients with endometriomas had significantly lower anti-Mllerian hormone values compared with women without endometriosis. Surgical excision of endometriomas appears to have temporary detrimental effects on ovarian reserve.


Falcone T.,Gynecology and Womens Health Institute
Gynecological Surgery | Year: 2010

Endometriosis has been one of the most confusing gynecological diseases since it was first described. Whereas there is a reasonable body of evidence in literature to demonstrate an association between endometriosis and infertility, a definite cause and effect relationship has not been established. The mechanism by which endometriosis causes infertility remains an enigma. Virtually every aspect of reproduction in women with endometriosis has been investigated and purported to be impaired. Impairment of implantation and pregnancy rates seems to affect women with endometriosis. Whether this is due to poor quality embryos derived from impaired oocytes or endometrial defects or both has been argued. Structural abnormalities of the uterine wall and tube in women with endometriosis have also been described by other researchers. Adding more confusion to this topic is the altered immune function and the peritoneal environment and their detrimental effects on the sperm motility and morphology. This uncertain pathophysiology has resulted in the lack of consensus on the treatment of endometriosis-associated infertility. The aim of this review is to describe the current pathophysiology of endometriosis-related infertility, how laparoscopic surgery may influence fertility rates. © 2010 Springer-Verlag.


Falcone T.,Gynecology and Womens Health Institute
Fertility and Sterility | Year: 2014

In this Views and Reviews contribution there are four articles that provide insight into the present and future applications of robot assisted surgery. The potential application of this technology in reproductive surgery, oncology, general gynecology and urology is an ongoing controversy. © 2014 American Society for Reproductive Medicine.


Svets M.,Gynecology and Womens Health Institute | Falcone T.,Gynecology and Womens Health Institute
Women's Health | Year: 2011

Christ Hospital of Cincinnati (OH, USA) sponsored the 13th annual Pelvic Anatomy and Gynecologic Surgery Symposium held on 9-â€"11 December 2010 in Las Vegas (NV, USA). Course directors were Mickey M Karram and Michael S Baggish. Invited faculty included Tommaso Falcone and Mark Walters, both from the Cleveland Clinic Foundation in Cleveland (OH, USA). In addition, John Gebhart from the Mayo Clinic in Rochester (MN, USA) and Javier F Magrina from the Mayo Clinic Scottsdale (AZ, USA) rounded out the speakers' list. The symposium gathered renowned experts in open, vaginal, laparoscopic and robotic pelvic surgeries to discuss issues and controversies surrounding minimally invasive gynecologic surgery. © 2011 Future Medicine Ltd.


Catenacci M.,Gynecology and Womens Health Institute | Flyckt R.L.,Gynecology and Womens Health Institute | Falcone T.,Gynecology and Womens Health Institute
Placenta | Year: 2011

Minimally invasive surgical techniques are becoming increasingly common in gynecologic surgery. However, traditional laparoscopy can be challenging. A robotic surgical system gives several advantages over traditional laparoscopy and has been incorporated into reproductive gynecological surgeries. The objective of this article is to review recent publications on robotically-assisted laparoscopy for reproductive surgery. Recent clinical research supports robotic surgery as resulting in less post-operative pain, shorter hospital stays, faster return to normal activities, and decreased blood loss. Reproductive outcomes appear similar to alternative approaches. Drawbacks of robotic surgery include longer operating room times, the need for specialized training, and increased cost. Larger prospective studies comparing robotic approaches with laparoscopy and conventional open surgery have been initiated and information regarding long-term outcomes after robotic surgery will be important in determining the ultimate utility of these procedures. © 2011 Elsevier Ltd. All rights reserved.


Frick A.C.,Gynecology and Womens Health Institute | Walters M.D.,Gynecology and Womens Health Institute | Larkin K.S.,Gynecology and Womens Health Institute | Barber M.D.,Gynecology and Womens Health Institute
American Journal of Obstetrics and Gynecology | Year: 2010

Objective: The aim of this study was to assess the risk of unanticipated abnormal gynecologic pathology at the time of reconstructive pelvic surgery to better understand risks of uterine conservation in the surgical treatment of uterovaginal prolapse. Study Design: This was a retrospective analysis of pathology findings at hysterectomy with reconstructive pelvic surgery over a 3.5-year period. Results: Seventeen of 644 patients had unanticipated premalignant or malignant uterine pathology (2.6%; 95% confidence interval, 1.7-4.2). Two (0.3%; 95% confidence interval, 0.09-1.1) had endometrial carcinoma. All cases of unanticipated disease were identified in postmenopausal women. Conclusion: Premenopausal women with uterovaginal prolapse and normal bleeding patterns or with negative evaluation for abnormal uterine bleeding have a minimal risk of abnormal gynecologic pathology. In postmenopausal women without bleeding, the risk of unanticipated uterine pathology is 2.6% but may be reduced by preoperative endometrial evaluation. However, in women with a history of postmenopausal bleeding, even with a negative endometrial evaluation, we do not recommend uterine preservation at the time of prolapse surgery. © 2010 Mosby, Inc. All rights reserved.

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