Combined laparoscopic and cystoscopic approach in large deep infiltrating endometriosis of the bladder.

Resection of endometriosis nodules infiltrating the bladder is routinely performed by laparoscopy. However, laparoscopic resection may lead to inadvertent loss of healthy bladder tissue. Conversely, when bladder nodules are treated by cystoscopy alone, resection may be incomplete. A combined laparoscopic-cystoscopic approach allows safe and controlled resection. The video reports the procedure performed in a 33 year-old primipara who presented with a 40mm bladder nodule. The laparoscopic step is carried out by the gynecologist, who separates the bladder from the uterus and opens the vesico-vaginal space. Concomitantly, the urologist identifies and circumscribes the nodule's limits by cystoscopy. Then, the gynecologist identifies the circular incision previously performed, and completes the resection. The bladder defect is sutured. Early and mid-term postoperative outcomes were uneventful. In patients with large nodules of the bladder, combined laparoscopic-cystoscopic approach allows complete resection of endometriosis lesion, preserves healthy bladder tissue and avoids inadvertent injury of ureters.

Management of deep infiltrating endometriosis by laparoscopic route with robotic assistance: 3-year experience.

OBJECTIVE: To assess the feasibility of deep endometriosis surgery using robotic assistance, benefits and limits of this approach. METHOD: Case-series study enrolling patients managed for deep infiltrating endometriosis (DIE) using robotic assistance in our department between September 2011 and March 2014 (NCT02294825). Self-questionnaires including pain and digestive symptoms were filled in preoperatively and 1 year after surgery. RESULTS: Thirty-five patients were enrolled in the series. They represented 54% of patients managed for gynecological disease by laparoscopic route with robotic assistance during the study period, and 14% of patients managed for deep endometriosis in our department. Follow-up averaged 24±8 months, and no patient was lost to follow-up. Thirty-two patients had rectal involvement: rectal shaving was performed in 25 patients, disc excision in 3 and colorectal resection in 4. Three patients had bladder resection. Thirteen patients presented with deep endometriosis of the ureters: ureterolysis was performed in 11 of them, and resection of the ureter followed by reimplantation into the bladder in 2 patients. One major complication (Clavien IIIb) was recorded in a patient presenting with necrosis of the right ureter on postoperative day 5. Nine patients tried to conceive after surgery and 8 have already become pregnant (88.9%). One year after surgery, self-questionnaires revealed a significant decrease in pain symptoms and significant improvement in several item values of gastrointestinal standardized questionnaires. CONCLUSIONS: Surgical management of DIE is feasible using robotic assistance. However, data available in the literature and our own experience do not definitively support the hypothesis of the superiority of robotic assistance in the management of DIE.

In vitro fertilization outcomes after ablation of endometriomas using plasma energy: A retrospective case-control study.

OBJECTIVE: Ovarian endometrioma ablation using plasma energy appears to be a valuable alternative to cystectomy, because it could spare underlying ovarian parenchyma resulting in high spontaneous and overall pregnancy rates. After initial postoperative decrease, anti-mullerian hormone (AMH) level progressively increases several months after ablation. The aim of our study was to assess the outcomes of in vitro fertilization (IVF) in women managed for ovarian endometriomas by ablation using plasma energy, when compared to those in women free of endometriosis. METHODS: Retrospective preliminary case-control study, enrolling women undergoing IVF or IntraCytoplasmic Sperm Injection (ICSI), from July 2009 to December 2014. Cases were infertile women with previous ovarian endometrioma ablation using plasma energy and were matched by age, AMH level and assisted reproductive technique with controls presumed free of endometriosis. IVF/ICSI response (type of protocol, dose of gonadotrophin, number of oocytes, fertilization rate) and outcomes were compared between the two groups. RESULTS: In all, 37 cases were compared to 74 controls. Age (30.9±4.4 years vs. 31.7±4.2 years), AMH level (2.8±2ng/mL vs. 2.8±1.7ng/mL) and ART procedures (ICSI in 24.3% vs. 27%) were comparable between the two groups. Of the 37 cases, previous surgical procedures on right and left ovaries were performed in 27% and 21.6% of patients respectively, 81% of patients were nullipara. AFSr score was 73±41, while deep endometriosis infiltrated the rectum and the sigmoid colon in respectively 40.5% and 27% of patients. Despite a lower number of oocytes retrieved, cases presented better implantation rate, pregnancy and delivery rates per cycle, oocyte retrieval, transfer, and embryo, as well as superior cumulative birth rate per transfer. CONCLUSION: Ovarian endometrioma ablation using plasma energy is followed by good IVF/ICSI outcomes, suggesting that surgical procedure spares underlying ovarian parenchyma. These results consolidate those of previous studies reporting high spontaneous conception rate. Hence, ovarian endometrioma ablation using plasma energy appears to be a valuable alternative to cystectomy in patients presenting with endometriosis and pregnancy intention.

Multiple nodule removal in multifocal colorectal endometriosis instead of "en bloc" large colorectal resection.

Surgical management of colorectal endometriosis follows the principles of two main philosophies or approaches: radical and conservative. The radical approach has recently been recommended in multifocal colorectal endometriosis, which frequently concerns patients with rectal nodules. However, an alternative conservative management could employ selective retrieval of macroscopic colorectal deep endometriosis nodules by bowel shaving and disc excision, with preservation of the mesorectum. The conservative approach is justified by the evidence that low colorectal resection may lead to postoperative functional digestive symptoms for which management is most challenging. However, there is a lack of data in the literature specifically focusing on patients with multiple excision of deep colorectal endometriosis. No data exist about the minimal length of healthy bowel that should be conserved between two successive transversal bowel sutures, and on consecutive improvement of functional outcomes. Conversely, no evidence exists on presumed reduction of recurrence rate when young patients undergo low large colorectal resection, instead of multiple selective excisions. Further comparative studies would be welcome, among which the ENDORE randomized trial which may play a central role by comparing functional outcomes related to radical and conservative approach in deep endometriosis infiltrating the rectum.

Neurosyphilitic gumma on F18-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography: an old disease investigated with a new technology.

Neurosyphilitic gumma is a slowly progressive inflammatory manifestation of tertiary syphilis. It is characterised by chronic granulomata that ranges from microscopic lesions to large tumour-like masses. While cutaneous, mucosal and skeletal gummatous lesions are not uncommon, neurosyphilitic gumma is rare. F18-2-fluoro-2-deoxy-D-glucose (FDG) positron emission tomography (PET) has been used effectively to assess the metabolic nature of brain masses, in particular in guiding biopsy and grading gliomas. However, the inflammatory nature of lesions such as neurosyphilitic gumma poses challenges to diagnostic imaging modalities including CT scans, MRI and PET. Since FDG is not a specific tracer for malignancy, neurosyphilitic gumma can mimic a high-grade glioma by demonstrating intense FDG uptake and is therefore a potential diagnostic pitfall. We report a case of neurosyphilitic gumma identified on FDG PET.

Stoma obstruction after laparoscopic adjustable gastric banding for morbid obesity: report of two cases and treatment options.

Laparoscopic adjustable gastric band is one of the surgical options available for morbid obesity in the current century. Its popularity is gained by its proven efficacy with a reported low incidence of the intraoperative as well as the postoperative complications. Stomal obstruction post-laparoscopic adjustable gastric band (LAGB) has been under reported in the English literature. We report this complication in two patients and discuss two different simple modalities of treatment. Post-LAGB complications are numerous, dealing with their complications have a steeping curve. Educating the patients postoperatively in regard to food ingestion manner is a must and should prevent such complication.

Intracranial syphilitic gumma resembling malignant brain tumour.

We report a patient with a temporal lobe syphilitic gumma mimicking a malignant brain tumour in a 43-year-old immunocompetent man. The diagnosis was confirmed histologically and using polymerase chain reaction. Syphilitic gummatous involvement of the central nervous system is rare, with only a few cases having been reported. The unique feature of this case was the extensive oedema surrounding the lesion, suggestive of an active process.

Desmoplastic infantile ganglioglioma/astrocytoma with cerebrospinal metastasis.

Desmoplastic infantile ganglioglioma and astrocytoma (DIG/DIA) are rare intracranial tumours of early childhood that involve superficial cerebral cortex and leptomeninges. Despite the large size of the tumour and the presence of poorly differentiated cells, it is believed that the prognosis of DIG/DIA is excellent. We report two patients with DIG/DIA who developed multiple cerebrospinal metastases. To our knowledge only two similar cases have been reported in the literature. It appears that not all tumours with histological features of DIG/DIA behave in a benign way. It is possible that what is called DIG/DIA may be a heterogenous group of tumours with variable biological behaviour.

Long term outcome in children with Moyamoya disease: experience with 16 patients.

We present our experience with 16 children with Moyamoya disease/variant diagnosed at the Royal Alexandra Hospital for Children, Westmead, Sydney, Australia in the period between January 1982 and March 2004. Thirteen of these patients had one of the different revascularisation procedures. We reviewed the modes of presentation and the long-term outcome in these children. In our series the functional outcome was related to the functional status at presentation and was not related to the type of surgical procedure or age at presentation. We believe this is the largest reported series of Moyamoya disease/variant in Australia.

Third ventricular cavernous haemangioma.

We report a case of a third ventricular cavernous haemangioma (cavernoma). Cavernomas rarely occur within the ventricular system. Only 47 well-documented cases have been reported in the literature, 21 of which were located in the third ventricle. Cavernomas should be considered in the differential diagnosis of third ventricular lesions. Ventriculoscopy is very useful in establishing the diagnosis.

Intraventricular meningioma with drop metastases and subgaleal metastatic nodule.

We report a case of malignant intraventricular meningioma with CSF drop metastases and an implantation metastatic subgaleal nodule in a 53-year-old woman. Malignant intraventricular meningiomas are rare with only seven cases being reported in the literature. These tumours can be very aggressive and one should consider immediate postoperative radiotherapy.

Juvenile pilocytic astrocytoma 'pilomyxoid variant' with spinal metastases.

We report a case of juvenile pilocytic astrocytoma of the hypothalamic/chiasmatic region with cerebrospinal fluid dissemination in a 16-month old girl. The tumour in this case had unusual histological features including the abundance of myxoid background, the absence of Rosenthal fibres and the presence of an angiocentric pattern. These features are consistent with the recently described "variant" named pilomyxoid astrocytoma. It remains unclear whether pilomyxoid astrocytoma represents an aggressive variant of classical juvenile pilocytic astrocytoma, or an entirely distinct clinico-pathological entity. Larger series and new molecular techniques may answer this question in the future.

Intramedullary ancient schwannoma of the cervical spinal cord: case report and review of literature.

We report a rare case of intramedullary ancient schwannoma of cervical spinal cord in a 68 year old patient. About 49 cases of intramedullary schwannomas and neurofibromas have been reported in the literature but to our knowledge there is no report of the 'ancient' variety of intramedullary schwannoma. The cell of origin of these tumours is the schwann cell, which normally does not exist in the parenchyma of the central nervous system. Many theories have been advanced to explain this paradox. According to one theory, these tumours arise from the perivascular nerve plexus of the pial vessels. This plexus was found mostly to exist along the branches of the anterior spinal artery. In our case, the tumour was supplied by two branches of the anterior spinal artery, which may add further support to the above theory.

Intracranial and spinal tuberculosis requiring neurosurgical intervention. The Wellington Hospital experience 1998-2001.

AIMS: To describe the Wellington Neurosurgical Unit's recent experience of managing tuberculosis between January 1998 and January 2001. METHODS: Patients with microbiologically confirmed tuberculosis of the central nervous system and whose management included surgery are described. Personal recall and review of the hospital records were used to extract relevant data. RESULTS: Five patients were identified. As well as involvement of the brain parenchyma, meninges, spinal cord or spinal column, all had evidence of tuberculosis elsewhere. All but one patient deteriorated neurologically after being started on antituberculous chemotherapy. CONCLUSIONS: The number of patients presenting with neurotuberculosis appears to have increased recently in the Wellington region. The high proportion of paradoxical progression in our series is unusual. Neurosurgical intervention may be required for diagnosis, to treat hydrocephalus, or to relieve mass effect. Management is prolonged and often complex, and close co-operation is required between the neurosurgical team and a physician experienced in the management of tuberculosis.

Tumor lysis syndrome in small cell carcinoma and other solid tumors.

OBJECTIVE: To review the risk factors and clinical findings associated with tumor lysis syndrome (TLS) in patients with small cell carcinomas and other solid tumors. METHODS: Reports of TLS in the English-language literature were identified by searching MEDLINE and the bibliographies of relevant case reports, journal articles, and book chapters. All reports identified through these searches, including abstracts from national meetings, were reviewed and included in this analysis. Data regarding clinical and biochemical parameters relevant to the occurrence of TLS were extracted from each report. RESULTS: Of the 25 reported solid tumor patients who developed TLS, 7 had small cell carcinoma, 5 breast cancer, and 4 neuroblastoma. TLS was associated with a variety of treatment regimens, including chemotherapy, immunotherapy, hormonal therapy, radiation therapy, and surgery. Common risk factors for TLS in this population included pretreatment renal insufficiency, elevated serum lactate dehydrogenase (LDH), and hyperuricemia. Among the typical biochemical findings of TLS, acute renal insufficiency and hyperuricemia were identified in nearly all patients and hyperkalemia, hyperphosphatemia, hypocalcemia, and increased serum LDH were reported in over 75% of patients. In addition, seven patients, including the current case, presented with profound metabolic acidosis. Nine of 25 patients died during the acute episode of TLS. CONCLUSIONS: Although TLS occurs infrequently in patients with solid tumors, the risk factors and biochemical abnormalities associated with this potentially fatal complication of therapy must be recognized to allow for adequate monitoring and early initiation of appropriate therapeutic measures.