Cystic Walthard Nests of the Peritoneal Diaphragm: A Report of 3 Cases of a Common Process at an Unusual Site and Occurring in Patients With Endometriosis.

Nests of cells resembling urothelium, eponymously named "Walthard nests," are well-known incidental findings over the fallopian tube and occasionally undergo cystification resulting in clinical detection and surgical removal. Only rarely is this process noted outside the pelvic peritoneum. Herein we describe cystic Walthard nests occurring in the diaphragmatic peritoneum of three patients (aged 25, 36, and 39 yr) undergoing surgical evaluation for presumed endometriosis. In each case, small pearly white nodules on the diaphragmatic peritoneum were noted and biopsied. Microscopic examination revealed cystic spaces filled with pale eosinophilic secretion. The cysts were lined mostly by stratified transitional cells with pale eosinophilic to focally clear cytoplasm. Umbrella cells were focally present in all cases, and 1 showed focal glandular differentiation resembling cystitis glandularis. In areas, the epithelial cells became flattened and attenuated and nuclei were bland. By immunohistochemistry, all were positive for GATA3, cytokeratin 7, and BEREP4 and negative for cytokeratin 20, estrogen receptor, and WT-1. Walthard nests can rarely occur outside the pelvic peritoneum where they may be noted incidentally during surgery for other indications. This should be readily distinguished pathologically from other peritoneal lesions but lack of significant prior comment of them occurring on the diaphragm may result in diagnostic difficulty.

Robotic surgery in gynaecology: Scientific Impact Paper No. 71 (July 2022).

The use of robotic-assisted keyhole surgery in gynaecology has expanded in recent years owing to technical advances. These include 3D viewing leading to improved depth perception, limitation of tremor, potential for greater precision and discrimination of tissues, a shorter learning curve and improved comfort for surgeons compared with conventional keyhole and open abdominal surgery. Robotic-assisted keyhole surgery, compared with conventional keyhole surgery, improves surgical performance without increasing operating time, minimises blood loss and intra- or postoperative complications, while reducing the need to revert to abdominal surgery. Moreover, surgeons using a robot experience fewer skeletomuscular problems of their own in the short and long term than those operating without a robot as an additional tool. This Scientific Impact Paper looks at the use of a robot in different fields of gynaecological surgery. A robot could be considered safe and a more effective surgical tool than conventional keyhole surgery for women who have to undergo complex gynaecology surgery or have associated medical issues such as body-mass index (BMI) at 30 kg/m2 or above or lung problems. The introduction of the use of robots in keyhole surgery has resulted in a decrease in the number of traditional open surgeries and the risk of conversion to open surgery after traditional keyhole surgery; both of which should be considered when examining the cost-benefit of using a robot. Limitations of robotic-assisted surgery remain the associated higher costs. In womb cancer surgery there is good evidence that introducing robotics into the service improves outcomes for women and may reduce costs.

Peritoneal Fluid Cytokines Reveal New Insights of Endometriosis Subphenotypes.

Endometriosis is a common inflammatory gynecological disorder which causes pelvic scarring, pain, and infertility, characterized by the implantation of endometrial-like lesions outside the uterus. The peritoneum, ovaries, and deep soft tissues are the commonly involved sites, and endometriotic lesions can be classified into three subphenotypes: superficial peritoneal endometriosis (PE), ovarian endometrioma (OE), and deep infiltrating endometriosis (DIE). In 132 women diagnosed laparoscopically with and without endometriosis (n = 73, 59 respectively), and stratified into PE, OE, and DIE, peritoneal fluids (PF) were characterized for 48 cytokines by using multiplex immunoassays. Partial-least-squares-regression analysis revealed distinct subphenotype cytokine signatures-a six-cytokine signature distinguishing PE from OE, a seven-cytokine signature distinguishing OE from DIE, and a six-cytokine-signature distinguishing PE from DIE-each associated with different patterns of biological processes, signaling events, and immunology. These signatures describe endometriosis better than disease stages (p < 0.0001). Pathway analysis revealed the association of ERK1 and 2, AKT, MAPK, and STAT4 linked to angiogenesis, cell proliferation, migration, and inflammation in the subphenotypes. These data shed new insights on the pathophysiology of endometriosis subphenotypes, with the potential to exploit the cytokine signatures to stratify endometriosis patients for targeted therapies and biomarker discovery.

Laparoscopic Excision Versus Ablation for Endometriosis-associated Pain: An Updated Systematic Review and Meta-analysis.

The aim of this study was to update the evidence on the surgical management of endometriosis-associated pain. Does laparoscopic excision offer any benefits over laparoscopic ablation? This is a systematic review and meta-analysis in which we searched MEDLINE, Embase, Institute for Scientific Information conference proceedings, the International Standard Randomised Controlled Trial Number registry, the Register and Meta-register for randomized controlled trials, the World Health Organization trials search portal, the Cochrane Library, and the British Library of electronic theses. Three randomized controlled trials were included, which enrolled 335 participants with a sample size per study ranging from 24 to 178 participants. Of these 3 studies, data from 2 could be pooled for meta-analysis. The primary outcome measure was the reduction in the visual analog scale score for dysmenorrhea. The secondary outcome measures included the reduction in the visual analog scale score for dyspareunia, dyschezia, and chronic pelvic pain and the reduction in Endometriosis Health Profile-30 core pain scores. The meta-analysis showed that the excision group had a significantly greater reduction in symptoms of dysmenorrhea (mean difference [MD] = 0.99; 95% confidence interval [CI], -0.02 to 2.00; p = .05) and dyschezia (MD = 1.31; 95% CI, 0.33-2.29; p = .009) compared with ablation. The symptoms of dyspareunia showed a nonsignificant benefit with excision (MD = 0.96; 95% CI, -0.07 to 1.99; p = .07). Data from 1 study showed a significant reduction in chronic pelvic pain (MD = 2.57; 95% CI, 1.27-3.87; p = .0001) and Endometriosis Health Profile-30 core pain scores (MD = 13.20; 95% CI, 3.70-22.70; p = .006) with the excision group compared with the ablation group. The limited available evidence shows that at 12 months postsurgery, symptoms of dysmenorrhea, dyschezia, and chronic pelvic pain secondary to endometriosis showed a significantly greater improvement with laparoscopic excision compared with ablation.

A 16-week secondary abdominal ectopic pregnancy with a simultaneous intratubal placenta and abdominal fetus.

An unusual case of a simultaneous tubal and abdominal ectopic pregnancy with the placenta in the intact tube and fetus in the abdominal cavity demonstrating the pathogenesis of secondary abdominal pregnancy subsequently managed by laparoscopic salpingectomy and removal of the abdominal fetus.

Robot-assisted laparoscopy for deep infiltrating endometriosis: international multicentric retrospective study.

BACKGROUND: This study aimed to assess the interest in robot-assisted laparoscopy for deep infiltrating endometriosis and to investigate the perioperative results. METHODS: From November 2008 to April 2012, 164 women with stage 4 endometriosis who underwent robot-assisted laparoscopy (da Vinci Intuitive Surgical System) were included by to eight international participating clinical centers. This study evaluated the procedures performed, the duration of the intervention, the complications, the recurrence, and the impact on fertility. RESULTS: The average operative time was 180 min. The main complications were laparotomy (n = 1, 0.6%), sutured bowel injury (n = 2, 1.2%), transfusion for a 2,300-ml bleed (n = 1), prolonged urinary catheterization (n = 1, 0.6%), ureter-bladder anastomotic leak (n = 1, 0.6%), and ureteral fistula after ureterolysis (n = 2, 1.2%). The reoperation rate was 1.8% (n = 3). The mean follow-up period was 10.2 months. A full recovery was experienced by 86.7% (98/113) of the patients. After surgery, 41.2% (42/102) of the patients had a desire for pregnancy, and 28.2% (11/39) of them became pregnant. CONCLUSION: This study analyzed the largest series of robot-assisted laparoscopies for deep infiltrating endometriosis published in the literature. No increase in surgical time, blood loss, or intra- or postoperative complications was observed. The interest in robot-assisted laparoscopy for deep infiltrating endometriosis seems to be promising.

A pilot study of robotic uterine and vaginal vault manipulation: the ViKY Uterine Positioner™.

A pilot study of uterine and vaginal vault manipulation using a new surgical robot-The ViKY Uterine Positioner™--enrolled 36 cases comprising 31 hysterectomies, two myomectomies, two sacrocolpopexies and one excision of severe endometriosis performed between July 2010 and February 2012 in a tertiary referral District General Hospital in the UK. Mean age was 48 years, body mass index 25.7 kg/m(2) and uterine weight 231 g. Nine cases were foot-controlled and 27 by Bluetooth voice control. ViKY UP™ docking time once V-Care™ was inserted was 4.3 min. The device caused no peri-operative complications. Adequate mobilization, visualization and range of movement was possible in 81, 78 and 61 % of cases, respectively, with most of the problems arising in cases with uterine weight >350 g. ViKY UP™ was detached and an assistant was required in three cases, whilst V-Care™ came out of the uterus in one case. The learning curve led to various adjustments including optimizing patient position, increasing the device range of movement and adjusting device sensitivity. As a result, problems were minimized in our last nine cases. Adding robotic uterine manipulation is the obvious next step to give the gynecologist the ultimate control and stability of the uterus during robotic-assisted surgery without having to lift their head from the viewfinder or rely on a remotely situated perineal assistant. ViKY UP™ is the first device to deliver this. Pilot study results did not demonstrate compromised safety, and the device appears to be effective and easy to learn.