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ObjectiveTo estimate the effectiveness and safety of laparoscopic surgical excision of rectovaginal endometriosis.DesignA multicentre, prospective cohort study.Setting51 hospitals accredited as specialist endometriosis centres.Participants5162 women of reproductive age with rectovaginal endometriosis of which 4721 women had planned laparoscopic excision.InterventionsLaparoscopic surgical excision of rectovaginal endometriosis requiring dissection of the pararectal space.Main outcome measuresStandardised symptom questionnaires enquiring about chronic pelvic pain, bladder and bowel symptoms, analgesia use and quality of life (EuroQol) completed prior to surgery and at 6, 12 and 24 months postoperatively. Serious perioperative and postoperative complications including major haemorrhage, infection and visceral injury were recorded.ResultsAt 6 months postsurgery, there were significant reductions in premenstrual, menstrual and non-cyclical pelvic pain, deep dyspareunia, dyschezia, low back pain and bladder pain. In addition, there were significant reductions in voiding difficulty, bowel frequency, urgency, incomplete emptying, constipation and passing blood. These reductions were maintained at 2 years, with the exception of voiding difficulty. Global quality of life significantly improved from a median pretreatment score of 55/100 to 80/100 at 6 months. There was a significant improvement in quality of life in all measured domains and in quality-adjusted life years. These improvements were sustained at 2 years. All analgesia use was reduced and, in particular, opiate use fell from 28.1% prior to surgery to 16.1% at 6 months. The overall incidence of complications was 6.8% (321/4721). Gastrointestinal complications (enterotomy, anastomotic leak or fistula) occurred in 52 (1.1%) operations and of the urinary tract (ureteric/bladder injury or leak) in 49 (1.0%) procedures.ConclusionLaparoscopic surgical excision of rectovaginal endometriosis appears to be effective in treating pelvic pain and bowel symptoms and improving health-related quality of life and has a low rate of major complications when performed in specialist centres.

Laparoscopic supracervical hysterectomy is an efficient alternative to laparoscopic-assisted vaginal hysterectomy or total laparoscopic hysterectomy. This report describes a laparoscopic supracervical hysterectomy using the McCartney transvaginal tube. This technique allows safe extraction of the uterine body, closure of the vault, and inspection of the operating field while maintaining the pneumoperitoneum.[PUBLICATION ABSTRACT]

The E3 ligase Cbl-b acts on TAM tyrosine kinase receptors and has a critical role in the regulation of natural killer (NK) cell rejection of metastatic tumours; a small molecule TAM kinase inhibitor is shown to enhance the anti-metastatic NK cell activity. Controlling NK cell anti-metastatic activity This study describes a previously unknown role for the E3 ubiquitin ligase Cbl-b as part of a regulatory pathway in innate natural killer (NK) cells that licenses them to spontaneously reject cancer metastases. Genetic loss of Cbl-b or inactivation of its E3 ligase activity in mice allows NK cells to suppress growth of both multiple primary tumours and distant tumour metastases. The effect is mediated via members of the TAM family tyrosine kinase receptors, and treatment of wild-type NK cells with a small-molecule TAM inhibitor conferred therapeutic NK cell activity against metastatic melanomas. This suggests a possible approach for NK-cell-based anti-metastatic therapy in humans and at the same time explains the anti-metastatic properties of the widely used anticoagulant warfarin. Tumour metastasis is the primary cause of mortality in cancer patients and remains the key challenge for cancer therapy 1 . New therapeutic approaches to block inhibitory pathways of the immune system have renewed hopes for the utility of such therapies 2 . Here we show that genetic deletion of the E3 ubiquitin ligase Cbl-b (casitas B-lineage lymphoma-b) or targeted inactivation of its E3 ligase activity licenses natural killer (NK) cells to spontaneously reject metastatic tumours. The TAM tyrosine kinase receptors Tyro3, Axl and Mer (also known as Mertk) were identified as ubiquitylation substrates for Cbl-b. Treatment of wild-type NK cells with a newly developed small molecule TAM kinase inhibitor conferred therapeutic potential, efficiently enhancing anti-metastatic NK cell activity in vivo . Oral or intraperitoneal administration using this TAM inhibitor markedly reduced murine mammary cancer and melanoma metastases dependent on NK cells. We further report that the anticoagulant warfarin exerts anti-metastatic activity in mice via Cbl-b/TAM receptors in NK cells, providing a molecular explanation for a 50-year-old puzzle in cancer biology 3 . This novel TAM/Cbl-b inhibitory pathway shows that it might be possible to develop a ‘pill’ that awakens the innate immune system to kill cancer metastases.