Port-site metastases following robot-assisted laparoscopic surgery for gynecological malignancies.

OBJECTIVE: To evaluate the incidence and possible predictors associated with port-site metastases following robotic surgery. DESIGN: Prospective study. SETTING: University Hospital. POPULATION: Women with gynecological cancer. METHODS: The occurrence of port-site metastases in the first 475 women undergoing robotic surgery for gynecological cancer was reviewed. MAIN OUTCOME MEASURES: Rate of port-site metastases. RESULTS: A port-site metastasis was detected in nine of 475 women (1.9%). Eight women had either an unexpected locally advanced disease or lymph-node metastases at the time of surgery. All nine women received postoperative adjuvant therapy. Women with ≥ stage III endometrial cancer and women with node positive cervical cancer had a significantly higher risk of developing a port-site metastasis, as did women with high-risk histology endometrial cancer. Port-site metastases were four times more likely to occur in a specimen-retrieval port. One (0.2%) isolated port-site metastasis was detected. The median time to occurrence of a port-site metastasis was 6 months (range 2-19 months). Six of the nine women (67%) have died and their median time of survival from recurrence was 4 months (range 2-16 months). CONCLUSION: In women with gynecological cancer, the incidence of port-site metastases following robotic surgery was 1.9%. High-risk histology and/or advanced stage of disease at surgery seem to be contributing factors.

Reproducibility and accuracy of robot-assisted laparoscopic fertility sparing radical trachelectomy.

OBJECTIVE: To assess the accuracy and reproducibility of robot-assisted laparoscopic abdominal fertility sparing radical trachelectomy in women with early stage cervical cancer. METHODS: Relevant prospective clinical data from 13 consecutive women planned for robotic radical trachelectomy between 2007 and 2012 were compared with retrospective data from 12 consecutive women planned for vaginal radical trachelectomy between 2000 and 2007. The first follow up on all women included a similar vaginal ultrasonographic measurement of the remaining cervical length and the position of the cerclage, enabling a direct comparison. Peri- and postoperative clinical data were evaluated. RESULTS: The remaining cervical length was equal between the robotic and vaginal procedures (mean 11 mm, range 8-13 mm; mean 11 mm, range 5-19 mm respectively, p=0.92). The distance from the cerclage to the inner cervical os was significantly shorter and less variable in the robot group (robot mean 2mm, range of 1-4mm, vaginal mean 4mm, range 2-7 mm, p=0.003). Rejection of the cerclage (n=3) and/or cervical stenosis (n=3) was diagnosed in four women, all of whom in the vaginal group, between one and 13 months after surgery. CONCLUSIONS: Robotic trachelectomy is equally reproducible and accurate as the vaginal trachelectomy in terms of the remaining cervical length and results in a significantly more precise placement of the cerclage.

Cesarean scar pregnancy: Reproductive outcome after robotic laparoscopic removal with simultaneous repair of the uterine defect.

OBJECTIVE: To describe perioperative adverse events, fertility and obstetric outcome, following a robot assisted laparoscopic approach for treating Cesarean scar pregnancies (CSP). STUDY DESIGN: A retrospective case series of 14 consecutive women with a CSP and a wish for and attempts towards subsequent pregnancies, having undergone minimal invasive surgical treatment at two tertiary referral Swedish centers (Dep's of Obstetrics and Gynecology Skåne University Hospital, Lund, and Södersjukhuset, Stockholm) between 2008 and 2019. The surgery was performed by temporary intraoperative occlusion of the uterine blood supply, removal of the CSP and repair of the niche, by the use of robot assisted laparoscopy (Da Vinci surgical robot, Intuitive Surgical, Sunnyvale, CA). RESULTS: All surgeries were uneventful with a median bleeding of 75 mL. One woman had a postoperative Clavien-Dindo complication grade IIIa (hysteroscopic resection of an isthmic synechiae). During follow up nine women (64 %) conceived naturally; eight of these had an uneventful pregnancy and a full-term Cesarean delivery and one had recurrent CSP and Cesarean with simultaneous hysterectomy in gestational week 33. CONCLUSION: A robotic removal of a CSP with simultaneous repair of the defect is a feasible option with acceptable reproductive outcome and should be considered when counseling women with a wish for future childbirth in cases of a live CSP and a thin, or absent, myometrium in the niche. A temporary intraoperative occlusion of the uterine blood supply may be useful in cases of live pregnancies and/or high serum ß-hCG levels.

The sentinel node concept in early cervical cancer performs well in tumors smaller than 2 cm.

OBJECTIVE: The aim of the study was to evaluate the sentinel node (SLN) concept for lymphatic mapping in early stage cervical cancer. METHODS: 105 women with early stage (1a1-2a) cervical cancer were scheduled for the sentinel node procedure in conjunction with a complete pelvic lymphadenectomy. The day before surgery, 1-1.5 mL 120MBq Tc(99) albumin nanocolloid was injected submucosally at four points around the tumor followed by a lymphoscintigram (LSG) to achieve an overview of the radiotracer uptake. RESULTS: During surgery, the overall detection rate (gamma probe) of at least one SLN was 90% (94/105 women) whereas at least one SLN was identified in 94% (61/65 women) with a tumor 2 cm) node without radiotracer uptake. The negative predictive value for patients with cervical cancers

Robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy with short and long term morbidity data.

OBJECTIVE: To evaluate feasibility and morbidity of robot assisted laparoscopic radical hysterectomy. METHODS: From December 2005 to September 2008 robot assisted laparoscopic radical hysterectomy and pelvic lymphadenectomy was performed on 80 women. Using a prospective protocol, and an active investigation policy for defined adverse events, perioperative, short and long term data were obtained. RESULTS: Time for surgery (skin to skin) reached 176 and 132 min after 9 and 34 procedures respectively. All tumours were radically removed. Median number of retrieved lymph nodes was 26 (range 15-55). All women had an early follow up (1-3 months) and 43 of eligible 46 women (93%) had a long term follow up (> or =12 months). In 33 of 80 women (41%) the peri/postoperative period was uneventful. The remainder had one or more mainly mild adverse events, most commonly from the vaginal cuff (n=17, 21%) or the lymphatic system (n=16, 20%). The proportion of uneventful cases increased significantly over time. Five women were resutured for dehiscence of the vaginal cuff, two women were reoperated for trocar site hernias and one woman had a ureter stricture that resolved following stent treatment. Eight women (14%) needed 60 days or more to resume spontaneous voiding. One 72-year old woman with disseminated endometrial cancer on autopsy died of pulmonary embolism 31 days after surgery. CONCLUSIONS: Robot assisted laparoscopic radical hysterectomy is a feasible alternative to conventional laparoscopy and open surgery. Effort should be made to ensure proper closure of the vaginal cuff, trocar sites and to develop nerve sparing techniques.

Robot-assisted laparoscopic surgery for a rudimentary uterine horn with two non-communicating cavities.

Due to severe dysmenorrhoea a 29-year-old woman, gravida 2 para 2, was diagnosed with a unicornuate uterus and a rare variety of a rudimentary uterine horn associated with two separate non-communicating cavities. Increasingly intense dysmenorrhoea, refractory to medical treatment, motivated fertility-sparing surgical treatment. A da Vinci S-HD robot was side-docked to facilitate simultaneous vaginal access during surgery. After sacrificing the left uterine artery for hemostatic reasons, the rudimentary horn with one cavity was resected. Guided by vaginal ultrasonography we then completely resected the second cavity located deep in the myometrium without entering the cavity of the functioning hemiuterus. Finally the uterine defect was sutured in two layers. Surgery and postoperative course were uneventful. At 4-month follow-up, dysmenorrhoea was alleviated, and 3 months later the patient had an early intrauterine pregnancy. We believe the precise dissection capabilities of the robot facilitated in particular resection of the second, deeply located cavity and its multilayer reapproximation by sutures. A video of the procedure is provided.

The effect of relcovaptan (SR 49059), an orally active vasopressin V1a receptor antagonist, on uterine contractions in preterm labor.

Relcovaptan (SR 49059) is a non-peptide, orally active vasopressin V1a receptor inhibitor. The effect on uterine contractions in 18 women with preterm labor in pregnancy weeks 32-36 was assessed in a double-blind investigation. The inclusion criterion was at least four regular uterine contractions over 30 min as measured by external tocodynamometry. Twelve patients received at random a single oral dose of 400 mg relcovaptan and six received placebo, and contractions were monitored up to 6 h thereafter. Rescue medication (beta-adrenoceptor-stimulating drug) was allowed after 2 h. Before drug administration a mean (+/- SE) of 8.2 +/- 1.4 and 9.7 +/- 1.6 contractions/30 min were recorded in the relcovaptan- and placebo-treated groups, respectively. In the former group, the frequency of uterine contractions started to decrease within the first half hour, and 1.5-2 h after dosing it was steady at 3.2 +/- 0.9 contractions/30 min. Correspondingly, after placebo, 7.8 +/- 2.2 contractions/30 min were recorded, a statistically significant difference (p = 0.017). The activity in the relcovaptan-treated women remained low, whereas in the placebo group inhibited uterine contractions were observed only in women receiving 'rescue' tocolytic treatment. It is concluded that relcovaptan inhibits preterm labor.

Inhibitory effects of SR 49059 on oxytocin-and vasopressin-induced uterine contractions in non-pregnant women.

BACKGROUND: Compounds that block uterine oxytocin and vasopressin V1a receptors have a therapeutic potential in preterm labor and primary dysmenorrhoea. The orally active vasopressin V1a receptor antagonist, SR49059, inhibits the effect of vasopressin on human uterine activity in vivo, but the influence on the response to oxytocin is unknown. METHODS: In a placebo-controlled, double-blind, parallel-group, four-dose comparison, the inhibitory effect of SR 49059 on oxytocin- and vasopressin-induced uterine contractions in humans was investigated. Sixteen healthy female subjects, who had previously undergone sterilization with tubal ligation, participated in intrauterine pressure recordings at one of the first 3 days of bleeding of two menstrual cycles. Intravenous bolus injections of 10 pmol/kg body weight of vasopressin (Period 1) and of 50 pmol/kg body weight of oxytocin (Period 2) were given 1 h before and 1, 2 and 4 h after oral administration of 0 (placebo), 25, 75 or 200 mg of SR 49059. The area between the recording curve and zero level of intrauterine pressure (AUC) was calculated. Vital signs as well as urine and plasma safety parameters were measured. The plasma concentrations of oxytocin, vasopressin and the study drug were also estimated. RESULTS: The plasma concentrations of SR 49059 appeared to be dose related, with mean maximal values of 62.0, 163.7 and 468.0 ng/ml in the 25, 75 and 200 mg dose groups, respectively, in Period 1 with vasopressin and 34.4, 116.7 and 418.0 ng/mL, respectively, in Period 2 with oxytocin. Tmax was observed at about 1 h. The cumulative AUC over 50 min after vasopressin injection per se was significantly higher than that after oxytocin in spite of a five times lower dose and lower plasma concentrations. Pretreatment by SR 49059 caused a dose-related reduction in AUCs for vasopressin, whereas no such effect was seen for oxytocin. With vasopressin as an agonist, a lower diastolic blood pressure was observed in all SR 49059 treatment groups, but not with oxytocin. CONCLUSIONS: The much higher potency of vasopressin compared with oxytocin on uterine activity in non-pregnant women at menstruation was confirmed. SR 49059 dose-dependently inhibits vasopressin-induced contractions, whereas such an effect was not seen with the present doses of SR 49059 and oxytocin. A marked reduction by SR 49059 of diastolic blood pressure after vasopressin injection was observed, indicating an inhibition by this compound of vascular vasopressin receptors.

Oxytocin mRNA content in the endometrium of non-pregnant women.

OBJECTIVE: To study oxytocin mRNA in the human endometrium at different phases of the menstrual cycle. DESIGN: An exploratory study in non-pregnant women. SETTING: The Department of Obstetrics and Gynecology, Lund University Hospital, Sweden. PARTICIPANTS: Thirty-three women of fertile age undergoing hysterectomy or endometrial curettage on routine benign gynaecologic indications. METHODS: Endometrial tissue was obtained throughout the menstrual cycle. The presence of oxytocin mRNA was investigated by in situ hybridisation and by real time PCR. MAIN OUTCOME MEASURES: Oxytocin mRNA signalling intensity found by in situ hybridisation of tissue obtained at different times of the menstrual cycle. Relative amounts of oxytocin mRNA measured by real time PCR. RESULTS: The signal for oxytocin mRNA obtained by in situ hybridisation was more pronounced in glandular epithelial cells than in stromal cells. Furthermore, it was most marked around mid-cycle. The expression of oxytocin mRNA was confirmed by real time PCR. CONCLUSIONS: The results indicate that oxytocin may be synthesised in the endometrium of non-pregnant women, particularly in the glandular epithelial cells. Hormone released from these sources may have a paracrine action on the uterus. Oxytocin mRNA expression seems to be ovarian hormone dependent with the highest concentration around mid-cycle.