Accuracy of ICG compared with technetium-99 m for sentinel lymph node biopsy in vulvar cancer.

PURPOSE: Sentinel lymph node biopsy with radioactive tracer is the standard-of-care in lymph node status assessment in vulvar cancer. Indocyanine green fluorescence-ICG is a promising detection method, due to its advantages over technetium-99 m. In vulvar cancer, the procedure is controversial due to study heterogeneity and the small sample size in previous studies. This study evaluates ICG sentinel lymph node detection compared with the criterion-standard with technetium (dual modality method). METHODS: Preoperative technetium and intraoperative ICG for sentinel lymph node have been prospectively evaluated in early-stage vulvar cancer. The primary endpoint was to determine accuracy in the detection rate for ICG compared with technetium. Secondary objectives included tracer modality relationship with obesity, tumor size and location. RESULTS: In total, 75 patients participated at 8 centers; 38 had lateral and 37 had midline vulvar tumors. The overall sentinel lymph node detection rate was 85.3 % for technetium and 82.7 % for ICG. For lateral tumors, the detection rate was 84.2 % vs. 89.5 %, while it was 86.5 % vs. 75.7 % for middle tumors, using technetium and ICG, respectively. The median sentinel node harvest was 1.7 (range 1-4), with 24 % metastatic involvement. The sensitivity and positive predictive value for ICG based on the standard technique with technetium was 91.08 % (95 % CI, 83.76-95.84) and 94.8 % (95 % CI, 84.84-96.48), respectively. No significant differences were found comparing the two tracers in patients with midline lesions, obesity (body mass index ≥ 30) and tumor size ≥ 2-4 cm. CONCLUSION(S): ICG shows comparable performance parameters to the gold-standard of radioisotope localization.

An Easy Learning Approach to a Complex Surgical Technique: A Step-by-Step Site-Relapse Lateral Extended Endopelvic Resection (LEER).

Lateral pelvic sidewall involvement by gynecological tumors has been considered traditionally an absolute contraindication to curative resection.1 Moreover, the involvement of the pelvic sidewall at the time of relapse in cervical cancer after primary or adjuvant pelvic radiation occurs in 8.3% of patients.2,3 Laterally extended endopelvic resection (LEER), based on the ontogenetic compartment theory, provides a potential surgical option for patients for whom palliative therapy is the only alternative.4 This complex and ultraradical, surgical technique allows a high rate of complete resection in more than 70% of patients with gynecological cancers and lateral pelvic sidewall involvement. An adequate selection of patients and a deep knowledge of pelvic anatomy are crucial to obtain acceptable morbimortality rates and improved overall survival in this population.5 To deconstruct this complex procedure, we show a detailed step-by-step technique to facilitate the easy learning curve of this surgical technique. We review the Höckel original technique with different site-relapse adapted steps. We provide a pedagogical high-quality video (Video 1) and anatomical outline drawings (Fig. 1) to understand lateral pelvic wall anatomy and standardize this surgical technique. Our purpose is to bring this knowledge to gynecologists and pelvic surgeons in which pelvic lateral approach may be useful beyond gynecological oncologic surgery (Table 1).

A Combined Approach: Laparoscopic Partial Bladder Prior Transurethral Resection for Bladder Endometriosis-Case Report and Surgical Video Presentation.

OBJECTIVE: Bladder endometriosis is the presence of stroma and endometrial glands in the thickness of the detrusor muscle. The main symptoms it produces are dysuria and hematuria whose intensity is directly proportional to the size of the nodule. It is a difficult entity to diagnose for which physical examination is essential. Treatment can be medical, with hormonal therapies, or surgical by transurethral resection of the nodule and laparoscopic partial cystectomy. METHODS: To show a clinical case and review the literature about the technique used. RESULTS: A 29-year-old patient diagnosed with bladder endometriosis in which a combined approach was decided by laparoscopic partial cystectomy after transurethral resection: the patient came to our office for chronic pelvic pain, dysuria, dysmenorrhea, and a physical examination that showed a painful nodule on the anterior side of the vagina. A transvaginal ultrasound, magnetic resonance imaging, and cystoscopy confirm the diagnosis of bladder endometriosis. After a review of the literature on the management of this entity, the patient's clinic, and reproductive desires, the combined approach with excellent results was decided. Dysmenorrhea and dysuria disappeared, preserving the fertility of the patient who became pregnant 6 months after the intervention. CONCLUSION: The use of the combined approach allows to reduce the limitations of both techniques separately.

Low-grade endometrial stromal sarcoma with intravenous thrombus extension: a multidisciplinary surgical challenge.

Low-grade endometrial stromal sarcoma (LG-ESS) usually exhibits indolent behavior, often misdiagnosed and is associated with a favorable prognosis [1]. Despite the indolent nature of LG-ESS, recurrence is common, the risk is as high as 1 in 3 to 1 in 2 [2]. The behavior of such tumors can lead to invade blood vessels [3]. An intravascular tumor is associated with direct risk of sudden death from pulmonary embolism. There are very few reported cases with clinically obvious intravascular extension. Chemotherapy, radiotherapy and hormone therapy are adjuvant treatments that have not been able to demonstrate a definitive benefit in survival [4]. We want to take advantage of the opportunity, so far unpublished, to demonstrate with this case the surgical challenge described step by step, as well as to demonstrate the importance of surgery as the only curative treatment even in extended intravascular disease [5]. Here in, we present the surgical challenge of a LG-ESS in a 59-year old woman with iliac and cava vein tumoral thrombus extension. We performed a tumoral thrombectomy and vascular repair, with a pelvic exenteration and double barrel wet colostomy. After performing pelvic exenteration, the thrombus with intravascular involvement was addressed at 2 points: inferior cava vein and right common iliac vein with the extraction of the entire thrombus. These defects are corrected by angioplasty and venorrhaphy, respectively. The surgery got a complete cytoreduction. It lasted 290 minutes, with 430 mL blood loss. In patients with LG-ESS, cytoreduction is a reliable option even in extended metastatic disease.