The pathophysiology of human premature cervical remodeling resulting in spontaneous preterm birth: Where are we now?

Approximately one in ten (approximately 500,000) pregnancies results in preterm birth (PTB) annually in the United States. Although we have seen a slight decrease in the U.S. PTB rate between 2007 and 2014, data from 2014 to 2015 shows the preterm birth rate has slightly increased. It is even more intriguing to note that the rate of PTB has not significantly decreased since the 1980s. In order to decrease the rate of spontaneous preterm birth (sPTB), it is imperative that we improve our understanding of normal and abnormal reproductive tissue structure and function and how these tissues interact with each other at a cellular and biochemical level. Since other chapters in this issue will be focusing on the myometrium and fetal membranes, the goal of this chapter is to focus on the compartment of the cervix. We will review the current literature on normal and abnormal human cervical tissue remodeling and identify gaps in knowledge. Our goal is also to introduce a revised paradigm of normal cervical tissue structure and function which will provide novel research opportunities that may ultimately lead to developing safe and effective interventions to significantly decrease the rate and complications of prematurity.     

Surgical management of urinary stress incontinence – Where are we now?

Mid-urethral sling procedures (MUS) have been the surgical option of choice for most gynaecologists and urologists treating stress urinary incontinence (SUI) in women around the world for almost 20 years, since their introduction in the late 1990s.The evidence suggests that the long-term effectiveness of the MUS is good and similar to the Burch Colposuspension and the fascial pubovaginal slings. The bulking agents are now being put forward as another minimally invasive option for the surgical treatment of SUI.Despite the increasing evidence that the retropubic MUS are more effective in long term and in high failure risk women with recurrent SUI and ISD, the TOT continues to have a high satisfaction and usage worldwide.     

Why consider human papillomavirus vaccination in older women?

Preventive human papillomavirus (HPV) L1 vaccines are safe and efficient to prevent infection and lesions of vaccine- specific HPV types in women from 15 to 26 years, but also in older age groups. Clearly, public health funds are to be spent to organize programs for vaccination of young adolescents. Immunobridging studies and clinical trials have shown that HPV vaccines generate significantly higher plasma antibodies than following natural infections in women up to 55 years and prevent up to 90.5% (95% CI 73.7-97.5) vaccine-specific HPV infections and lesions in women aged 24-45 years who are HPV DNA-negative at the time of vaccination. However, data from clinical trials with HPV L1 vaccines in older women (older than 25 years) are still scarce compared to the amount of evidence from trials in women younger than 26 years. Information from large population-based studies indicates that older women remain at risk of infection by high-risk HPV and the risk of persistent high-risk HPV infection is significantly higher than in young women, leading to a higher risk of progressing disease and carcinoma. The natural history of HPV infection remains enigmatic as we do not know if the immune mechanisms that clear the HPV infection offer prolonged protection. On the contrary, some data indicate that seroconversion after a natural infection only partially protects against re-infection. Given the large proportions of adult men and women that change sexual partners, the protective effects of HPV L1 vaccines may offer an extra benefit against HPV-related genital diseases within a much shorter time period than after vaccination of prepubertal adolescents.     

Anti human papillomavirus vaccine: the checkmate to human papillomavirus?

Cervical cancer is the second most frequently found neoplasia in women worldwide. At least 95% of cervical cancers contain viral DNA which, in 80% of cases, belongs to one of the human papillomavirus (HPV) viral types at high oncogenic risk: 16, 18, 31 and 45. HPV is, at this point, considered the first "necessary cause" of cervical cancer, against which primary prevention with a reduction in the risk of infection can be carried out. Numerous molecular biological studies have been conducted to identify the biological markers of this infection and to refine an effective and well tolerated vaccine capable of preventing HPV infection as well as possibly treating those cases in which the infection has already caused an HPV-related disease of the genital tract. In the near future, the real primary prevention of this disease will be conducted, similar to what occurred for Hepatitis B, using immunoprophylaxis with an anti-cancer vaccine.     

Serous borderline ovarian tumors: where are we now?

In the present article we report the revised microscopical features of serous borderline ovarian tumors (S-BOTs) in the context of a long personal experience, drawing parallels with the definitions and issues elaborated at the Borderline Ovarian Tumor Workshop held in August 2003 in Bethesda. In our opinion none of the histopathologic criteria of the primary tumor including micropapillary subtype of the S-BOT can be used yet as a prognostic marker. The most realistic assumption is that in the clinical course of the S-BOT dynamic transformation of different clones occurs and the process develops simultaneously with multicentric blastomogenesis in the peritoneal cavity. Hence the failure of our efforts to forecast the prognosis of the disease using the microscopical structure of the primary tumor as a point of issue. It is indispensable to control the course of the S-BOTs by performing repeated biopsies at each relapse and modify the treatment schedules according to the microscopic patterns revealed at a given stage of the disease. Relapses of the S-BOTS may occur up to 50 years later so the patient should be under surveillance especially by a urologist to detect the earliest symptoms of urinary tract obstruction. Much more attention should be paid to the local intraabdominal administration of drugs and the search for new systemic chemotherapy regimens.     

Endometrial ablation: where have we been? Where are we going?

Endometrial ablation (EA) is targeted destruction of the endothelial surface of the uterine cavity. The procedure was originally designed as a less invasive alternative to hysterectomy for the symptom of heavy menstrual bleeding unrelated to structural pathology of the uterus, that was not responsive to medical therapy. More recently it has become apparent that the procedure can be performed in the presence of submucous leiomyomas, providing they meet a number of size and location criteria. The first EA serie as published in Germany in the 1930s, but the procedure did not attract much attention until the latter part of the 20th century. Currently, EA can be performed under endoscopic direction with the neodymium:yttrium alumnum garnet laser, with a radiofrequency resectoscope, or with an expanding array of nonresectoscopic EA systems. It is apparent that most but not all of the complications associated with resectoscopic endometrial ablation are eliminated with nonresectoscopic endometrial ablation, but serious morbidity has been reported with all of the newer systems to date. Success and patient satisfaction seem to be enduring in the majority of well-selected patients treated in clinical trials, but repeat surgery, usually hysterectomy, is performed in 25% to 40% by 5 years after surgery. Increased efficiencies should be realized if the procedure could be moved to an office setting.     

Recent developments in human oocyte, embryo and blastocyst vitrification: where are we now?

The target of any cryopreservation procedure should be to ensure high survival rates of living cells after thawing. Two important parameters determine the success of any cryopreservation protocol: the manner in which cells regain equilibrium in response to cooling, and the speed of freezing (cooling rate). Slow-rate freezing protocols result in the formation of ice crystals during cooling and warming. Vitrification, in which high cooling rates in combination with a high concentration of cryoprotectant are used, does not produce any ice crystals during cooling and warming. However, there is a practical limit to the attainable cooling speed, and also a biological limit to the concentration of cryoprotectant tolerated by the cells during vitrification. Although post-warming survival depends on the species, the developmental stage and the quality of the embryos being vitrified, it seems clear that vitrification methods are increasingly successful and might be a better method than slow cooling procedures in the field of cryobiology. Many of the potential problems and benefits underlying vitrification as a method of choice for embryo cryopreservation in clinical embryology will be discussed in this review.     

The evolutionary state of electrosurgery: where are we now?

PURPOSE OF REVIEW: The purpose of this review is to discuss the evolutionary changes that have taken place in the area of electrosurgery. The distinct differences between devices along with disadvantages and ways of minimizing hazards will be analyzed. RECENT FINDINGS: Since the first surgical application of electricity in the 1880s, the use of radiofrequency current in surgery has grown. Although monopolar and bipolar energy form the backbone of electrosurgery, various modifications have been made to both the electrosurgical generators and the hand instruments. Much of the driving force behind these modifications has been the goal of minimizing possible complications while improving surgical efficiency. Recently, the ability to obtain vessel sealing has dramatically impacted clinical practice in open, laparoscopic, and vaginal surgery. SUMMARY: Current evidence demonstrates the effectiveness and safety of electrosurgical devices in gynecologic surgery. Technology has evolved to allow vessel sealing capability through various instruments. Critical to the successful use of these advanced electrosurgical devices is a thorough understanding of their individual differences and nuances in order to obtain the desired tissue effects. Further studies are needed to determine the most appropriate applications and surgical procedures for these devices.     

At what age should we be vaccinating for human papillomavirus?

Human papillomavirus (HPV) infections cause high disease burden. Primary prevention by vaccination is a major breakthrough. HPV vaccines are well tolerated and safe. Vaccines protect unexposed individuals against high-grade CIN and VIN/VaIN caused by the vaccine HPV types. Vaccines also provide protection against related oncogenic HPV types. The primary target population is young adolescents before their sexual debut. Catch-up vaccination policy up to age 26 may facilitate long-term health benefits but should not divert resources from vaccinating the primary target population or from effective cervical cancer screening programmes. Health benefits of vaccinating older age groups beyond age 26 are unknown.