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Infertility is a highly relevant global issue affecting the reproductive health of at least 15% of reproductive-aged couples worldwide. The scope and severity of the infertility problem is even more prevalent in developing countries, mostly due to untreated reproductive tract infections (RTIs). Infertility, however, goes beyond the mere inability to procreate, but brings about profound psychological, social, and ethical implications of enormous magnitude. In vitro fertilization (IVF) and other assisted reproduction technologies (ARTs) have gradually become widespread therapeutic options. After all, the implementation of medically assisted reproductive procedures in order to overcome infertility is in keeping with the tenets of the reproductive rights agenda laid out at the International Conference on Population and Development (ICPD) in Cairo in 1994. Nonetheless, concerns still linger about how to implement and regulate such interventions in an ethically tenable fashion. The unremitting pace at which such techniques develop have upset the very notion of sexuality relating to reproduction as well as the concept of family itself. That rift risks causing a crisis in terms of bioethics sustainability and enforcement, which is bound to happen when science and innovation outpace the bioethical precepts on which we rely for essential guidance in medical practice. The authors argue in favor of an approach to regulation and policy-making that puts on the forefront a thorough assessment as to potential risks that such interventions might entail for foundational bioethics principles and inalienable human rights.

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INTRODUCTION: When cervical cancer is detected at an early stage (International Federation of Gynecology and Obstetrics [FIGO] IA2-IB1), it can be successfully treated by radical surgery alone. Considering that most patients are young and sexually active at the moment of diagnosis and the long life expectancy of survivors after the treatment, quality of life (QoL) and sexual function are important issues for cancer survivors and caregivers. However, only a few studies have examined the QoL and sexual function in disease-free cervical cancer survivors, and there are no studies in the literature comparing prospectively sexual function after different types of radical hysterectomy. AIM: To compare sexual function in two groups of early stage cervical cancer survivors treated by radical surgery alone, undergoing two different types of radical hysterectomy. METHODS: Patients treated by radical hysterectomy with systematic lymphadenectomy for early stage cervical cancer (FIGO IA2-IB1) have been enrolled and divided in two groups with regard to type of radical hysterectomy performed; S1: modified radical hysterectomy (Piver II/Type B), S2: classic radical hysterectomy (Piver III/ Type C2). MAIN OUTCOME MEASURE: Twenty-four months after surgery we assessed the sexual function using the European Organization for Research and Treatment of Cancer Cervix Cancer Module Questionnaire, which is a validated system for the assessment of disease- and treatment-specific issues that affect the QoL and sexual functioning of women who are treated for cervical cancer. RESULTS: Of the 31 patients enrolled in the S1 group and 46 in the S2 group, 23 and 33 patients have been included, respectively. We observed significant differences between the two groups in terms of symptom experience, sexual/vaginal functioning, sexual activity, and sexual enjoyment. There was not any significant difference regarding lymphedema, peripheral neuropathy, and sexual worry. CONCLUSION: Survivors of early stage cervical cancer treated by modified radical hysterectomy (Piver II/ Type B) have a better sexual function than those operated by classic radical hysterectomy (Piver III/ Type C2).

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INTRODUCTION: Radical hysterectomy represents the gold standard treatment in patients with early-stage cervical cancer and a valid choice of treatment, after neoadjuvant chemotherapy (NACT), in locally advanced tumors. Laparotomy is still considered the standard approach for radical hysterectomy; however, the extraperitoneal route has been described as a valid alternative for pelvic lymphadenectomy, with shorter operative time, shorter ileus and reduced postoperative pain and hospitalization. We designed the first prospective study to evaluate the technique of total extraperitoneal radical hysterectomy for surgical treatment of locally advanced cervical cancer after platinum-based NACT, in terms of feasibility and safety. METHODS: Consecutive patients affected by locally advanced cervical carcinoma were considered for eligibility in this observational study. After a primary complete evaluation, all patients were submitted to platinum-based NACT. Inclusion criteria were: stage IB2-IIIB cervical carcinoma already submitted to neoadjuvant chemotherapy with a complete or partial response after three cycles of chemotherapy, WHO performance status≤1, adequate renal, hepatic and cardiac function, BMI<40, age≤75 years, no concurrent or previous malignant disease, no previous radiation therapy, and signed informed consent. Patients included in the study were submitted to type C2 extraperitoneal radical hysterectomy. RESULTS: From January 2006 to October 2008, 46 patients were enrolled and compared with a control group selected from the historical database. The mean operative time in the extraperitoneal radical hysterectomy group was 195 min (range: 120-240) versus 235 min (range: 215-310) in the intraperitoneal radical hysterectomy group (P<0.05). Median postoperative ileus was 32 h (range: 24-36) versus 67 h (range: 42-78) (P<0.05). VAS (Visual Analogue Scale) score at 24 and 48 h was 8 (range: 6-8) versus 8 (range: 6-9) (P=NS) and 3.5 (range: 2-7) versus six (range: 5-9) (P<0.05) respectively. No differences in terms of intraoperative and postoperative complications were recorded. CONCLUSIONS: Total extraperitoneal radical hysterectomy in locally advanced cervical cancer is feasible and safe. If compared with intraperitoneal abdominal radical hysterectomy, no significant differences in terms of surgical data or complications were found. Extraperitoneal radical hysterectomy seems to compare favorably to the intraperitoneal approach in terms of operative time, postoperative ileus, and VAS score at 48 h.

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INTRODUCTION: Bladder dysfunctions are a common sequela after radical hysterectomy (RH, former type III sec Piver) ranging from 8 to 80%. This discrepancy, probably, reflects the different bladder function evaluation methods utilized in literature. MATERIAL AND METHODS: We searched English-language medical reports published from 1952 to 2010, on MEDLINE. Inclusion criteria were: (1) studies of urological dysfunctions in patients with cervical cancer, treated with type III sec Piver (C2 sec Querleu) radical hysterectomy; (2) use of urodynamic measurement. RESULTS: The overall incidence of urodynamic bladder dysfunctions is 72%. Follow-up >12 months studies report a high incidence of overactive detrusor low compliance (34%). Eight out of 19 studies show a decrease of the maximal urethral closure pressure (MUCP). DISCUSSION AND CONCLUSIONS: Follow-up timing seems to be the major factor influencing the wide range of incidence of bladder dysfunction. Urodynamic data could help physicians to formulate appropriate evaluation and treatment for patients having urge incontinence (UI) after RH.

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INTRODUCTION: The introduction of screening programs have made cervical cancer detectable at earlier stages and in younger patients. Nevertheless, only a few studies have examined the QoL and sexual function in disease-free cervical cancer survivors. AIM: The objective of this study is to evaluate the sexual function in a cervical cancer patient's group treated with neoadjuvant chemotherapy (NACT) plus type C2/type III radical hysterectomy (RH). METHODS: We have enrolled in the oncologic group (OG) sexually active patients affected by cervical cancer (stage IB2 to IIIB) treated with NACT followed by RH. MAIN OUTCOME MEASURES: Included subjects were interviewed with the European Organization for Research and Treatment of Cancer (EORTC) QLQ-CX24 Questionnaire. Two consecutive assessments were recorded: at the first evaluation postoperatively (T1) and at the 12-month follow-up visit (T2). Results were compared with a benign gynecological disease group (BG) and with a healthy control group (HG). RESULTS: A total of 33 patients for OG, 37 for BG, and 35 women for HG were recruited. After surgery, sexual activity has been resumed by 76% of the OG patients and 83.7% of the BG patients (P = not significant). Cancer survivors had clinically worse problems with symptom experience, body image, and sexual/vaginal functioning than controls (P < 0.05). OG patients also reported more severe lymphedema, peripheral neuropathy, menopausal symptoms, and sexual worry. For sexual activity, the score difference between cancer survivors and women with benign gynecological disease is not statically significant. Concerning sexual enjoyment assessment, our study shows comparable results for OG and BG. CONCLUSION: Nevertheless, the worsening of symptom experience, body image, and sexual/vaginal functioning, OG patients have same sexual activity and sexual enjoyment data compared with those of BG patients. Thus, NACT followed by RH could be a valid therapeutic strategy to treat and improve well-being especially in young cervical cancer patients.

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OBJECTIVE: To evaluate the clinical benefit of a 3-day topotecan schedule in heavily pretreated recurrent ovarian cancer patients scheduled for palliative treatment. METHODS: Eligibility criteria were 2 or more prior chemotherapy regimens, Eastern Cooperative Oncology Group performance status of 2 or less; adequate organ function, assessable disease by serum CA-125 measurement before each cycle; and 1 or more cycle of topotecan (1.5 mg/m per day) on 3 consecutive days of a 28-day treatment cycle. Toxicity was graded according to the National Cancer Institute Common Toxicity Criteria version 3. Tumor response, stable disease, and progression were evaluated on the basis of CA-125 levels. RESULTS: A total of 68 patients were considered eligible for the study. Median age was 58 years (range, 40-77 years), and the median number of prior chemotherapy regimens was 2 (range, 2-6). A total of 272 cycles of topotecan were administered, with a median of 4 cycles per patient (range, 1-8). No treatment delays or dose reduction was recorded. Major toxicities were grade 3/4 (18%) neutropenia, neutropenic fever (6%), grade 4 thrombocytopenia (3%), requirements for blood (5%), and platelet transfusions (3%). Thirty-five (54%) of the 64 evaluable patients showed a clinical benefit. Of these, 11 patients (17%) had a partial response, and 24 (37%) had stable disease with a median time to progression of 7.5 months (range, 6-10 months) and 4 months (range, 2-6 months), respectively. CONCLUSION: More than half of heavily pretreated ovarian cancer patients may benefit from 3-day topotecan.

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OBJECTIVE: To assess feasibility and safety of fertility-sparing laparoscopic staging in women affected by unexpected ovarian cancer desiring to preserve their fertility. DESIGN: Prospective study. SETTING: University clinic. PATIENT(S): Twenty-seven patients already operated on elsewhere for a presumably benign ovarian cyst. INTERVENTION(S): Laparoscopic fertility-sparing staging operations. MAIN OUTCOME MEASURE(S): Perioperative and survival data, reproductive outcome. RESULT(S): Histologic findings after first surgery: 12 low malignant potential neoplasms, 11 invasive epithelial ovarian carcinomas,1 sex-cord stromal, and 3 germ cell neoplasms. Fertility-sparing staging consisted of exploration of the peritoneal cavity, peritoneal washing cytology, multiple peritoneal biopsies, omolateral adnexectomy (except in borderline tumors), omentectomy, omolateral or bilateral pelvic and aortic lymph node sampling (except in borderline tumors, well differentiated, mucinous, and granulosa cell (GC) neoplasms), endometrial biopsy, appendectomy in mucinous type. Overall, seven patients (26%) were upstaged. Six patients received adjuvant platinum-based chemotherapy. Two term pregnancies occurred. After a median follow-up of 20 months all patients are alive; one patient has FIGO stage Ic clear cell carcinoma, which recurred 8 months after surgery. CONCLUSION(S): Laparoscopic fertility-sparing staging in early ovarian malignancies is feasible and safe in selected and counseled patients and should be performed in experienced gynecological oncology centers trained in endoscopic procedures.

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OBJECTIVE(S): The aim of the present study is to prospectively investigate the efficacy and complications of macroplastique transurethral implantation in cervical cancer patients affected by stress urinary incontinence (SUI) after radical hysterectomy (RH). METHODS: Patients affected by de novo SUI post type 3 RH were considered for eligibility in this study. Preoperative and postoperative assessment included a standardized urogynecological history, urogynecological and neurological physical examination, evaluation of severity of SUI symptoms, a 3-day voiding diary, urine culture and urodynamic assessment. All patients underwent transurethral implantation using Macroplastique Implantation System (MIS). Patient follow-up was performed 6 and 12 months after surgery. RESULTS: A total of 24 consecutive patients were enrolled. At the 12 month follow up SUI cure rate was 42% (10 of 24 patients), the improvement rate was 42% (10 of 24) and the failure rate was 16% (4 of 24). The overall success rate was 84% (10 patients cured and 10 improved). No intraoperative or postoperative early complications were found. The 4 patients in whom treatment was not a success had preoperative urethral hypermobility. Subjective patient perception of SUI symptom severity showed significant improvement (mean severity of urinary loss perception 6.6+/-1.8 vs 2.3+/-3.3, p<0.05). The frequency of incontinence on the 3-day voiding diary was significantly reduced at the follow up (14.5+/-5.8 vs 4.3+/-7.9 episodes per 3 days, p<0.05). CONCLUSION(S): Bulking agents urethral injection could be a valid option having no surgical complications. This therapeutic strategy is able to treat SUI and improve well being of cervical cancer patients after radical surgery.

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Several authors have proposed the use of a less aggressive surgery (i.e. conization, trachelectomy plus laparoscopic lymphadenectomy, modified or type 2 radical hysterectomy) for patients affected by early stages invasive cervical carcinoma. Tumor size and pelvic nodal status are parameters that must be evaluated to better select a patient's population suitable of a less aggressive surgery, with the aim of sparing morbidity without jeopardizing cancer cure.

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OBJECTIVE: To report on posttrachelectomy refractory cervical stenosis in two women with early cervical cancer that was resolved by using a Petit-Le Four tube, an older type of cervical pessary. DESIGN: Case report. SETTING: Tertiary care, university hospital. PATIENT(S): Two young women with FIGO stage IB1 cervical cancer and posttrachelectomy cervical stenosis. INTERVENTION(S): Cervical dilatations and Petit-Le Four cervical pessary insertion. MAIN OUTCOME MEASURE(S): Treatment of hematometra, pelvic pain, and infertility. RESULT(S): The Petit-Le Four cervical pessary is a good therapeutic option for the treatment of cervical stenosis after trachelectomy performed for early cervical cancer. CONCLUSION(S): Persistent hematometra from cervical stenosis could compromise both fertility and quality of life, and often requires dilatation of the cervical ostium, which must be performed several times in the same patient to obtain optimal results. Cervical dilators left in place could help physicians in the treatment of recurrent cervical stenosis after trachelectomy.

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