Lymphadenectomy in endometrial cancer - achieving more with less?

The lymph node status of patients with endometrial cancer is known to be a crucial determinant for the prognosis of the disease. It also provides the indication for further adjuvant treatment. The staging of endometrial cancer by surgery has been a controversial issue for more than 30 years. The significant complication rate after lymphadenectomy and the development of minimally invasive surgery have led to the use of sentinel lymph node (SLN) mapping. In the present review, we present the development of surgical staging procedures in patients with endometrial cancer and summarize the recently expanding body of published literature on the subject. SLN mapping is a safe and accurate technique, especially when indocyanine green is used as a tracer. SLN mapping appears to reduce complication rates as well as costs without affecting the oncologic outcome. Large prospective studies are needed to establish the effects of SLN mapping on the outcome of disease, especially in high-risk patients with endometrial cancer. Furthermore, the need for additional systematic lymphadenectomy prior to adjuvant radio-chemotherapy in patients diagnosed with isolated lymph node metastasis during SLN biopsy must be investigated further. This might pave the way for a new surgical approach in patients with endometrial cancer.

Uterine Fibroids and Infertility.

Infertility is a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Uterine fibroids are the most common tumor in women, and their prevalence is high in patients with infertility. Fibroids may be the sole cause of infertility in 2-3% of women. Depending on their location in the uterus, fibroids have been implicated in recurrent pregnancy loss as well as infertility. Pregnancy and live birth rates appear to be low in women with submucosal fibroids; their resection has been shown to improve pregnancy rates. In contrast, subserosal fibroids do not affect fertility outcomes and their removal does not confer any benefit. Intramural fibroids appear to reduce fertility, but recommendations concerning their treatment remain unclear. Myomectomy should be discussed individually with the patient; other potential symptoms such as dysmenorrhea or bleeding disorders should be included in the indication for surgery.

Perioperative considerations in the treatment of endometriosis

Endometriosis is one of the most common benign diseases in women of reproductive age. Nearly all gynecological offices and clinics will contain patients with endometriosis; the frequency and severity of the disease will vary from one setting to another. Adjoining specialties, such as internal medicine, general medicine, surgery, urology, orthopedics, neurology and psychosomatic medicine, will be challenged directly or indirectly by various forms of endometriosis and its sequelae. The disease is characterized by pelvic pain, dysmenorrhea, dyspareunia and sterility. Even now, several years may elapse between the onset of the disease and its diagnosis. The diagnosis of endometriosis is complicated by the diversity of the symptoms. A precise documentation of the patient's medical history and thorough diagnostic procedures are essential to establish a robust diagnosis. This article will discuss the perioperative considerations, diagnosis and treatment of endometriosis.

Ectopic pregnancy in noncommunicating horn of unicornuate uterus: 3D-ultrasound and primary laparoscopic management.

Unicornuate uterus with pregnancy in the noncommunicating rudimentary horn is extremely rare. Diagnosis requires awareness, high suspicion index, 3D ultrasound, and MRI. If missed, it can be catastrophic. Treatment varies across literature. We present a case where detection was done by 3D ultrasound and primary laparoscopic surgery done for treatment.

Recurrent implantation failure - an overview of current research.

BACKGROUND: Recurrent implantation failure (RIF) can be defined as a failure to achieve a clinical pregnancy after transfer of at least four embryos of good quality in a minimum of three fresh or frozen cycles in women under the age of 40. RIF is often a complex problem with a wide variety of etiologies and mechanisms as well as treatment options. SUMMARY: Anatomical conditions of the uterus, thrombophilia, genetic abnormalities, or immunological factors are only a few examples which could be responsible for RIF. The recommendations for women with RIF vary depending on the source of their problem. There is not just one treatment option, but many depending on the etiology and the severity of the problem. KEY MESSAGE: However, it would help to establish a set of standardized examinations and tests to use, in order to do a preliminary evaluation on each patient, which would then hopefully direct the approach of treatment for each individual couple.

Surgical outcomes of conventional laparoscopic and robotic-assisted hysterectomy.

INTRODUCTION: The aim of the present study was to compare surgical outcomes of total laparoscopic hysterectomy with those of the robotic approach using the da Vinci Xi system. METHODS: Patients who underwent hysterectomy with da Vinci Xi for early endometrial cancer or benign indications from 2018 to 2019 were selected. The control group consisted of patients who underwent conventional laparoscopy. RESULTS: A total of 300 patients were included in the study. The mean duration of surgery differed significantly (p = 0.025) between those who underwent laparoscopy (125.01 ± 76.168) and robotic-assisted surgery (142.96 ± 82.657 min). Blood loss, median hospital stay, intraoperative and postoperative complications were similar in both groups. No statistical difference was observed in the subgroups with a body mass index of more than 30 kg/m2 or more than 40 kg/m2 concerning the duration of surgery or the surgical outcome. CONCLUSION: The da Vinci Xi did not improve surgical outcomes in patients who underwent hysterectomy by trained laparoscopists and takes more time than conventional laparoscopy when performed in patients of normal weight.

Video Feedback and Video Modeling in Teaching Laparoscopic Surgery: A Visionary Concept from Kiel.

Learning curves for endoscopic surgery are long and flat. Various techniques and methods are now available for surgical endoscopic training, such as pelvitrainers, virtual trainers, and body donor surgery. Video modeling and video feedback are commonly used in professional training. We report, for the first time, the application of video modeling and video feedback for endoscopic training in gynecology. The purpose is to present an innovative method of training. Attendees (residents and specialists) of minimally invasive surgery courses were asked to perform specific tasks, which were video recorded in a multimodular concept. Feedback was given later by an expert at a joint meeting. The attendees were asked to fill a questionnaire in order to assess video feedback given by the expert. The advantages of video feedback and video modeling for the development of surgical skills were given a high rating (median 84%, interquartile ranges (IQR) 72.5-97.5%, n = 37). The question as to whether the attendees would recommend such training was also answered very positively (median 100%, IQR 89.5-100%, n = 37). We noted a clear difference between subjective perception and objective feedback (58%, IQR 40.5-76%, n = 37). Video feedback and video modeling are easy to implement in surgical training setups, and help trainees at all levels of education.

The Development of Laparoscopy-A Historical Overview.

The advent of laparoscopy marked a fundamental change in the evolution of medicine. The procedure progressed consistently after the first time it was performed in a human being nearly a hundred years ago. The 1960's and 1980's witnessed groundbreaking changes. During this time, laparoscopy evolved from a purely diagnostic procedure into an independent surgical approach. Outstanding pioneers of the times were Palmer, Frangenheim and Semm. Laparoscopy advanced rapidly and influenced gynecology as well. The procedure was initially attacked most vociferously by the surgical fraternity. However, within a short period of time the pendulum shifted: laparoscopy became the preferred surgical approach for a variety of diseases-whether benign or malignant-in several medical disciplines. Laparoscopy has become a routine approach in the twenty-first century. Technical advancements have led to robot-assisted surgery. Future developments will include artificial intelligence and augmented reality. In the present article we address past milestones, current practices, and future challenges in laparoscopy.

Ovariopexy-Before and after Endometriosis Surgery.

Endometriosis surgery is often very challenging. Key to complete resection of endometriosis is access to the retroperitoneum. Endometriosis can involve the ureter and uterine vessels, and ovary on the lateral pelvic wall makes retroperitoneal access difficult. Primary and post-surgical adhesions prevalence in endometriosis is very high. Ovariopexy, transposition of ovaries temporarily, is done for better surgical access and to reduce postoperative adhesions. We concluded that although limited evidence, ovariopexy is an excellent tool to aid endometriosis surgery and prevent postoperative adhesions. It is cost effective, simple and complication rate almost nil. More robust trials are required to substantiate evidence for its impact on preventing postoperative adhesions and its effect on fertility. In this review, we describe our technique of ovariopexy supplemented with a video, with the aim to put light on this useful and important technique, which is beneficial both for surgeons and patients.

Challenges Posed by Embryonic and Anatomical Factors in Systematic Lymphadenectomy for Endometrial Cancer.

Lymph node involvement has been shown to be one of the most relevant prognostic factors in a variety of malignancies; this is also true of endometrial cancer. The determination of the lymph node status is crucial in order to establish the tumor stage, and to consider adjuvant treatment. A wide range of surgical staging practices are currently used for the treatment of endometrial cancer. The necessity and extent of lymph node dissection is an ongoing controversial issue in gynecological oncology. Lymph node surgery in endometrial cancer is technically challenging, and can be time consuming because of the topographic complexity of lymphatic drainage as such, and the fact that the lymph nodes are directly adjacent to both blood vessels and nerves. Therefore, profound and exact knowledge of the anatomy is essential. Sentinel lymph node mapping was recently introduced in surgical staging with the aim of reducing morbidity, whilst also obtaining useful prognostic information from a patient's lymph node status. The present review summarizes the current evidence on the role of lymph node surgery in endometrial cancer, focusing on the embryological, anatomical, and technical aspects.

Uterine anomalies and endometriosis.

INTRODUCTION: Endometriosis is a common disease in women of reproductive age. In addition to causing pain, it may also reduce fertility. The coexistence of endometriosis and congenital uterine anomalies (CUA) has been frequently reported in the published literature. The present report is a review of existing studies on the subject and our own hitherto unpublished data. EVIDENCE ACQUISITION: The electronic search was conducted using the Pubmed database with specific keyword combinations including endometriosis, adenomyosis, infertility, Müllerian malformations/anomalies, and septate uterus. The principal aspects addressed in the present study were: diagnosis, management, and classification of CUA, their impact on fertility and coexistence with endometriosis. EVIDENCE SYNTHESIS: Endometriosis and CUA are frequently detected in the exploration of infertility, because both of these are liable to impair fertility. Endometriosis is associated with obstructive anomalies and nonobstructive malformations, especially those concerning the septate uterus. The diagnosis and management of CUA have been discussed for several years. Various classification systems have been proposed. CONCLUSIONS: The analysis of the existing literature has revealed the absence of any consensus about the management, diagnosis, and classification of CUA, especially with regard to the septate uterus. We need to find and speak a common language in order to avoid inappropriate or unnecessary surgery and optimize the individual patient's treatment. The combined presence of endometriosis or adenomyosis and CUA is a reason to perform precise diagnostic imaging investigations and early surgery for the purpose of enhancing the chances of pregnancy in infertile patients. Further research is needed on the subject.

Sleep restores daytime deficits in procedural memory in children with attention-deficit/hyperactivity disorder.

Sleep supports the consolidation of declarative and procedural memory. While prefrontal cortex (PFC) activity supports the consolidation of declarative memory during sleep, opposite effects of PFC activity are reported with respect to the consolidation of procedural memory during sleep. Patients with attention-deficit/hyperactivity disorder (ADHD) are characterised by a prefrontal hypoactivity. Therefore, we hypothesised that children with ADHD benefit from sleep with respect to procedural memory more than healthy children. Sixteen children with ADHD and 16 healthy controls (aged 9-12) participated in this study. A modification of the serial-reaction-time task was conducted. In the sleep condition, learning took place in the evening and retrieval after a night of sleep, whereas in the wake condition learning took place in the morning and retrieval in the evening without sleep. Children with ADHD showed an improvement in motor skills after sleep compared to the wake condition. Sleep-associated gain in reaction times was positively correlated with the amount of sleep stage 4 and REM-density in ADHD. As expected, sleep did not benefit motor performance in the group of healthy children. These data suggest that sleep in ADHD normalizes deficits in procedural memory observed during daytime. It is discussed whether in patients with ADHD attenuated prefrontal control enables sleep-dependent gains in motor skills by reducing the competitive interference between explicit and implicit components within a motor task.