The clinical importance of polyp size measurement through two-dimensional saline infusion sonohysterography prior to hysteroscopic resection in predicting premalignant and malignant endometrial lesions.

OBJECTIVE: To evaluate the clinical importance of endometrial polyp size measured using saline infusion sonohysterography (SIS) before performing a hysteroscopic resection in predicting premalignant/malignant lesions. METHODS: A retrospective observational study analysis was conducted of 365 patients, who underwent SIS, in a reference hospital. The longest plane of the polyp size was taken as base. Polyps were classified as benign, premalignant, or malignant. RESULTS: The rates of premalignant and malignant lesions were 7.4% and 0.9%, respectively. The mean polyp size was 17.7 ± 0.5 mm in benign patients and 23.7 ± 1.8 mm in premalignant/malignant individuals (P < 0.001). In the group of polyps that were 0-10, 10-20, 20-30, and >30 mm, premalignancy/malignancy rates were 0.0%, 4.8%, 13.3%, and 18.8%, respectively. The cut-off value for polyp size to be able to predict lesions was calculated as 22.5 mm (sensitivity: 63%, specificity: 80%) on receiver operating characteristics curve analysis (P = 0.001, area under the curve 0.732). The power of the study was calculated as 90.86%. CONCLUSION: During the female reproductive years, endometrial polyps smaller than 10 mm, as measured in SIS, can be followed. However, when the polyp size is 22.5 mm or more, especially in postmenopausal women, treatment should be planned.

Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low-Risk Endometrial Cancer also Be Valid for the High-Intermediate- and High-Risk Patients? A Multi-Center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001).

This study was conducted to compare the long-term oncological outcomes of laparotomy and laparoscopic surgeries in endometrial cancer under the light of the 2016 ESMO-ESGO-ESTRO risk classification system, with particular focus on the high-intermediate- and high-risk categories. Using multicentric databases between January 2005 and January 2016, disease-free and overall survivals of 2745 endometrial cancer cases were compared according to the surgery route (laparotomy vs. laparoscopy). The high-intermediate- and high-risk patients were defined with respect to the 2016 ESMO-ESGO-ESTRO risk classification system, and they were analyzed with respect to differences in survival rates. Of the 2745 patients, 1743 (63.5%) were operated by laparotomy, and the remaining were operated with laparoscopy. The total numbers of high-intermediate- and high-risk endometrial cancer cases were 734 (45%) patients in the laparotomy group and 307 (30.7%) patients in the laparoscopy group. Disease-free and overall survivals were not statistically different when compared between laparoscopy and laparotomy groups in terms of low-, intermediate-, high-intermediate- and high-risk endometrial cancer. In conclusion, regardless of the endometrial cancer risk category, long-term oncological outcomes of the laparoscopic approach were found to be comparable to those treated with laparotomy. Our results are encouraging to consider laparoscopic surgery for high-intermediate- and high-risk endometrial cancer cases.

Management of intra-abdominally translocated contraceptive devices, is surgery the only way to treat this problem?

This study was a multi-centre retrospective review of patients with uterine perforation caused by intrauterine contraceptive devices (IUDs). A total of 15 patients were registered, in a seven year period. Among them, five were asymptomatic and the rest were symptomatic. Asymptomatic patients were managed conservatively, except in one case in which the patient requested surgery because she also wanted a tubal ligation. Symptomatic patients all underwent surgery. All the surgeries were elective and all the surgical procedures were initiated laparoscopically. There were seven complications in the surgically managed group: conversion to laparotomy (n = 3), bowel injury (n = 2), bladder injury (n = 1), and wound infection (n = 1). Mild and severe adhesions (81.8%), and abscess (18.1%) formation related to translocated IUD (TIUD) were observed during surgery. All the patients were uneventful at 1 to 5 years of follow-up. A TIUD, by causing adhesions, complicates future laparoscopic surgery and increases the likelihood of conversion to laparotomy. While surgery is indicated to prevent TIUD-induced adhesive complications, it may also be the cause of both adhesions and complications, resulting in a vicious cycle. Some asymptomatic women, especially elderly patients with comorbidities, may not need or may be better managed without treatment. Impact statement In this study we try to find an answer for the question of "Should removal of a translocated intrauterine contraceptive device (TIUD) routinely be performed even if patients are asymptomatic?" From only the theoretical point of view there were some reports supporting conservative management in asymptomatic patients. The other studies addressing this issue were case reports including few patients with a short-term follow-up. The novelties of the present study include multi-centre design, detailed clinical and surgical information about the patients and the long period of follow-up. Most clinicians have limited experiences in managing TIUD because perforation is a rare event. So it can be difficult to know exactly what the surgeon will encounter intraoperatively. We undertook this study with the aim of providing a perspective about patients with TIUD for those faced with this situation. This is a descriptive study reporting 15 cases of TIUDs and management. Asymptomatic patients were managed conservatively, and symptomatic patients were operated. There are important implications resulting from this study that in asymptomatic patients leaving the IUD in place may be a reasonable option, mostly as the risk of surgical intervention is quite high with a high rate of complications with surgical management.

The diagnostic value of frozen section for borderline ovarian tumours.

Borderline ovarian tumours (BOTs) are characterised histologically by a low degree of cellular proliferation and nuclear atypia in the absence of infiltrative growth or stromal invasion. Surgical treatment has been a crucial component of BOT therapy. Surgical decisions are established intraoperatively via the frozen section. We evaluated the accuracy of frozen section diagnosis. The rate of correct diagnosis, underdiagnosis and overdiagnosis of BOTs with frozen sections was 78%, 17% and 5%, respectively. The sensitivity and positive predictive values for the diagnosis of BOTs with frozen sections were 82.3% and 93.3%, respectively. The positive likelihood ratio was 0.82 (95% CI: 0.85-0.96). The histological classification of BOTs had a significant effect on the accuracy of diagnosis (p = 0.001). Frozen section diagnosis is not suitable to be considered as the gold standard for a definitive diagnosis. Clinicians should be aware that using frozen sections is insufficient for the accurate staging of BOTs.

Does metoclopramide exposure alter endometrial receptivity and decrease pregnancy rates?

OBJECTIVE: The aim of this study was to investigate the effect of metoclopramide on endometrial receptivity with an immunohistochemical investigation of integrin ß3 expression in pregnant rats. MATERIALS AND METHODS: In the present study, the pregnant mice administrated by different doses of metoclopramide were used to explore the effect of metoclopramide on embryo implantation, especially on the endometrial receptivity. RESULTS: The statistical results showed that the number of implanted embryos was gradually declining along the increasing dose of metoclopramide. When the administrated dose of metoclopramide was 3 mg/kg per day, great changes were observed in the exposed uterine morphology and down-regulated integrin ß3 were also found in high dose metoclopramide-exposed mice. CONCLUSION: Metoclopramide exposure, especially in high doses may alter endometrial receptivity by effecting integrin expression on decidual tissue which can decrease pregnancy rates. This drug should only be recommended for use during pregnancy when benefit outweighs the risk.

Comparison of maternal and fetal outcomes of IVF and spontaneously conceived twin pregnancies: three year experience of a tertiary hospital.

OBJECTIVES: The aim of this study was to compare maternal and fetal outcomes of spontaneously conceived and in-vitro fertilization (IVF) twin pregnancies that were admitted to our obstetric clinic and delivered between January 1, 2011 to November 1, 2014. MATERIAL METHOD: A total of 84 twin pregnancies were enrolled for the study and divided into two groups: group 1 as IVF (n = 19) and group 2 as spontaneously conceived (n = 65) twin pregnancies. Data of neonatal various morbidities needs neonatal intensive care unit (NICU) such as necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), sepsis, retinopathy of prematurity (ROP), and intraventricular hemorrhage (IVH) and maternal morbidities such as preeclampsia, eclampsia, postpartum bleeding, gestational diabetes mellitus(GDM) were collected by hospital records. RESULTS: There were no statistical difference between two groups regarding hypertension related to pregnancy, intrauterine growth retardation, Apgar scores, NICU needs, birth weight and height (P > 0.05). The rate of premature rupture of membranes, maternal age, antenatal anemia and premature birth were detected higher in IVF group when compared with the other group (P < 0.05). CONCLUSION: Although twin pregnancies, regardless of conception method are high risk pregnancies in terms of obstetric and perinatal outcomes, premature rupture of membranes, maternal age, antenatal anemia and premature birth risks are higher in IVF twin pregnancies.

Laparoscopic removal of an intrauterine device from the sigmoid colon.

Uterine wall perforation which is commonly seen through the posterior wall of the uterus is the most serious complication of an intrauterine device (IUD). We present a case of laparoscopic removal of an IUD from the sigmoid colon in a 31-years-old female who was admitted to hospital with a history of pelvic pain and abnormal vaginal bleeding for one month. The dislocated IUD was removed from the sigmoid colon of laparoscopic intervention without any complications. In conclusion, the treatment modality for the removal of a dislocated IUD is possible by laparoscopic surgery in selected patients where the dislocated IUD is accessible.

Surgical Treatment of Scar Endometriosis Following Cesarean Section, a Series of 12 Cases.

It is difficult to conduct studies with larger series in rarely observed diseases. We report our experience in managing cesarean scar endometriosis (CSE) and emphasize the diagnosis and treatment options. The objective of our study is to review the clinical characteristics of CSE and to evaluate our surgical outcomes. We have collected and documented a case series of 12 patients who underwent surgical wide en bloc excision with surrounding clear margins for CSE. Patients' demographic features, symptoms, and clinical and operative findings were evaluated. The mean age was 34.6 years. Cyclical pain was documented in seven patients, while three patients presented with noncyclical pain. Menstrually-related enlargement of the nodule was observed in four patients, and only one patient had a complaint of dark brown leakage. The mean operation time was 26 min. The endometriotic lesions ranged from a diameter of 2 to 8 cm in size. Patients recovered completely, and no recurrence was observed. To prevent iatrogenic transplantation, additional attention is needed during surgery that exposes endometrial tissue. Complete wide excision of CSE is both diagnostic and therapeutic. To avoid unnecessary referrals, awareness of its typical clinical manifestations remains the mainstay for intervention. The most important issues to be considered during surgery is nonspreading endometriosis while manipulation.

Immediate repair of an incompletely transected obturator nerve during robotic-assisted pelvic lymphadenectomy.

Intraoperative injury of the obturator nerve may occur in gynecologic oncologic procedures when extensive pelvic side wall dissection is performed. In this case, we report an immediate repair of an incompletely transected obturator nerve during robotic-assisted pelvic lymphadenectomy. A 62-year-old gravida 3, para 3 woman was admitted to our clinic for postmenopausal bleeding. The result of an endometrial biopsy was complex endometrial hyperplasia with atypia, and a robotic-assisted laparoscopic hysterectomy was performed. A frozen section of the specimen revealed grade 1 endometrioid adenocarcinoma with >1/2 myometrial invasion. During the pelvic lymphadenectomy, the left obturator nerve was incompletely transected. The obturator nerve edges were oriented and reapproximated end-to-end with two 6/0 polypropylene sutures. The operation and console times were 244 and 223 minutes, respectively. The final pathologic finding was a stage IB endometrial adenocarcinoma. The number of the obtained lymph nodes was 38. Postoperatively, the patient did not exhibit any clinically apparent loss of adductor function or any other neurologic deficiency. Over 6 months of follow-up, the patient experienced no residual neuropathy or deficit in the left thigh. Robotic-assisted repair of a transected obturator nerve during surgery is feasible, and immediate repair of the damaged nerve may result in no neurologic deficit postoperatively.

Robotic-assisted dissection of bulky lymph nodes in cervical cancer.

The resection of bulky lymph node metastases, which may provide a therapeutic benefit, has been proposed in several studies based on laparotomy and laparoscopy. There is no published study in the literature examining the resection of bulky lymph node metastases using a robotic technique. In this report, we presented a patient with cervical cancer who underwent robotic-assisted dissection of bulky lymph nodes. The robotic-assisted operation time was 255 minutes, and the mean console time was 215 minutes. The estimated blood loss was 70 mL. The number of lymph nodes retrieved was 28, and the number of the dissected paraaortic lymph nodes was 13. The number of the lymph node metastases was eight. The bulky lymph nodes which are difficult to be eradicated with standard radiation therapy can be resected with robotic-assisted surgery and successful resection of the lymph nodes can improve the treatment strategy. This minimal invasive technique is safe and feasible for bulky lymph node dissection.

Four Cases of Chylous Ascites following Robotic Gynecologic Oncological Surgery.

Chylous ascites is an uncommon form of ascites characterized by milky-appearing fluid caused by blocked or disrupted lymph flow through chyle-transporting vessels. The most common causes of chylous ascites are therapeutic interventions and trauma. In this report, we present four cases of chylous ascites following robot-assisted surgery for endometrial staging and the treatment strategies that we used. After retroperitoneal lymph node dissection, leaving a drain is very useful in diagnosing chylous ascites and observing its resolution; furthermore, the use of octreotide in conjunction with TPN appears to be an efficient treatment modality for chylous ascites and should be considered before any invasive intervention.

Significance of foamy histiocytes in cervical smears from postmenopausal women.

OBJECTIVE: To determine the significance of the presence of foamy histiocytes (FH) in postmenopausal cervicovaginal smears for the detection of endometrial carcinomas (EC). STUDY DESIGN: Endometrial sampling was performed over 6 months in 53 of 102 cases that presented with postmenopausal FH, benign endometrial cells (BEC), FH with BEC (FH + BEC), and atypical endometrial cells (AEC), resulting in a total of 41,150 cervicovaginal smears. The control group consisted of 58 cases with a cytologic diagnosis of a normal smear (NS). RESULTS: There were 0 (0%), 1 (4.54%), 2 (13.33%), 2 (33.33%), and 5 (50.00%) cases of EC diagnosed on histopathologic evaluation in patients with NS (n = 58), BEC (n = 22), FH (n = 15), FH + BEC (n = 6), and AEC (n = 10), respectively. The sensitivities and specificities of the cytologic diagnoses of FH, FH + BEC, and AEC for the detection of EC were 81.7 and 100%, 93.6 and 100%, and 92.1 and 100%, respectively. CONCLUSION: The cytologic diagnoses of FH and FH + BEC had reasonably high sensitivities and specificities for the diagnosis of EC by cervicovaginal smear. Additional studies are needed.

Two Live Births following Robotic-Assisted Abdominal Cerclage in Nonpregnant Women.

Introduction. To report the robotic-assisted abdominal cerclage performed in two nonpregnant women and the success of live birth outcomes. Presentation of Cases. A 36-year-old woman with a complaint of recurrent second trimester pregnancy losses and a 35-year-old patient with a complaint of preterm deliveries and cervical insufficiency underwent robotic assisted abdominal cervicoisthmic cerclage placement in nonpregnant period. The two patients had spontaneous pregnancy after the robotic-assisted abdominal cerclage and delivered healthy infants. Discussion. The limitations of traditional laparoscopic abdominal cerclage have been accomplished with robotic surgery advantages especially intuitive movements and increased range of motion. There are only a few studies in the literature including robotic assisted abdominal cerclage in nonpregnant women, and only five successful live birth outcomes were reported. In this paper, we reported the sixth and seventh cases of achieved live pregnancy after robotic assisted abdominal cerclage in the literature. Conclusion. Robotic assisted abdominal cerclage is a good alternative surgical method with successful pregnancy outcomes.

Clinical significance of benign endometrial cells found in papanicolaou tests of Turkish women aged 40 years and older.

BACKGROUND: Spontaneously exfoliated benign-appearing endometrial cells (BEC) on a Papanicolaou smear might indicate endometrial pathology in postmenopausal women, necessitating further investigation. A cut-off age of 40 years was included in the Bethesda System 2001 based on studies of clinical significance of endometrial cells in Pap smears in Western countries. AIMS: The purpose of this study was to determine the significance of age subgroup for women with a cytological diagnosis of BEC, regardless of menopausal status, in a retrospective cohort of Turkish women. MATERIALS AND METHODS: Between October 2006 and November 2011, 41 patients with a BEC diagnosis and 64 patients with a cytological diagnosis of normal smear (NS) were enrolled; regardless of menopausal status, these women were 40 years and older and for whom follow-up endometrial biopsies had been performed. RESULTS: On subsequent histopathologic evaluation, no malignant lesion was detected in women aged 40-50 years compared to three endometrioid-type adenocarcinomas in women older than 50 years with cytological diagnosis of BEC. There was a significant difference between women older than 50 years with cytologic diagnosis of BEC and NS in relation to premalignant lesions on histopathologic evaluation; however, this was not the case for women aged 40-50 years. CONCLUSIONS: According to our study, reporting BEC for women aged between 40 and 50 years has minor clinical significance but is significant for women older than 50 years, regardless of menopausal status. Larger sample size would be appropriate to confirm the results of the current study.

Robot-assisted tubal reanastomosis: initial experience in a single institution.

OBJECTIVE: To assess surgical outcomes for robot-assisted tubal reanastomosis in a single institution. MATERIALS AND METHODS: Between March 2009 and January 2010, 10 patients underwent robot-assisted tubal ligation reversal (TLR) with a da Vinci S surgical system. Patient demographic data, including operative times, operative and postoperative complications, hospital stay, conversion to laparotomy and pregnancy rates were recorded. RESULTS: Mean age and body mass index for the patients were 37.7 (35-42) years and 28.9 (23.9-36.3) kg/m(2), respectively. The mean console time was 102.5 min and the mean total operation time was 130.6 (102-164) min. The mean hospital stay was 1.2 (1-2) days. There were no significant intra-operative or early-postoperative complications. All surgeries were completed robotically with no conversion to laparotomy. There were seven subsequent pregnancies in the study participants, representing a pregnancy rate of 70%, of which five were intrauterine pregnancies, one was an ectopic pregnancy, and one was an abortus. CONCLUSION: Robot-assisted TLR is safe and feasible. This procedure may facilitate minimally invasive treatment for patients who want to regain their fertility without the aid of artificial reproductive techniques.

Comparison of robotic-assisted laparoscopic myomectomy outcomes with laparoscopic myomectomy.

PURPOSE: This study aimed at comparing short-term outcomes of patients who underwent robotic-assisted laparoscopic myomectomy and laparoscopic myomectomy. METHODS: From January 2008 to August 2010, prospective data including 15 consecutive patients who underwent robotic-assisted myomectomy (RALM) with the da Vinci surgical system were recorded. These cases were compared with a retrospective cohort of 23 patients who underwent laparoscopic myomectomy (LM). Patient demographics, fibroid characteristics and peri-operative data (operative time, anesthesia time, set-up time, console time for robotic cohort, Estimated blood loss (EBL), length of hospital stay, conversion to laparotomy and operative complications were collected in both groups. RESULTS: Mean operative time for the robotic group was 138.73 ± 39.51 min compared with 140.57 ± 38.17 min for the laparoscopy group (p = 0.887). No significant differences were noted between RALM versus LM for hospital stay (1.67 ± 0.58 vs. 1.87 ± 0.67 days, p = 0.369) and EBL (101.33 ± 39.84 vs. 119.78 ± 43.70 ml, p = 0.549). The numbers, size and location of myomas removed for two groups were similar. None of the cases in both groups required conversion to laparotomy. There were no significant intra-operative and post-operative complications in either group. CONCLUSION: RALM appears to provide the same surgical outcomes when compared with traditional laparoscopic myomectomy.

Robot-assisted hysterectomy vs total laparoscopic hysterectomy: a comparison of short-term surgical outcomes.

BACKGROUND: The objective of the study was to compare the short-term outcomes of robot-assisted hysterectomy with laparoscopic hysterectomy. METHODS: This study compared 60 patients who underwent robot-assisted hysterectomy (RAH) with 60 patients who underwent laparoscopic hysterectomy (LH). RESULTS: The mean ages of the patients in the RAH and LH groups were 51.52 ± 6.97 and 50.68 ± 8.92 years, respectively. The mean operative times for the RAH and LH groups were 108.12 ± 34.65 and 90.67 ± 25.20 min, respectively (p = 0.002). None of the cases in the RAH group required conversion to laparotomy; the rate of conversion to open laparotomy in the LH group was 1.6%. The complication rate among patients who underwent RAH was 8.3% compared with 6.6% in the laparoscopic cohort. CONCLUSIONS: Robot-assisted hysterectomy is feasible and safe, resulting in similar surgical results when compared with traditional laparoscopic hysterectomy. It appears that, in the hands of a skilled laparoscopic surgeon, robot-assisted hysterectomy is not superior to the laparoscopic approach.

Robotic-assisted infrarenal aortic lymphadenectomy and pelvic lymphadenectomy for endometrial staging using a single docking procedure.

► We describe a new technique for robotic infrarenal para-aortic lymphadenectomy. ► This technique includes the new robotic trocar insertion sites. ► We perform the complete lymphadenectomy with a single docking procedure. ► This technique is feasible for complete lymphadenectomy in endometrial staging.

Robotic-assisted sacrocolpopexy/sacrocervicopexy repair of pelvic organ prolapse: initial experience.

PURPOSE: To present the short-term surgical outcomes of robotic-assisted sacrocolpopexy and sacrocervicopexy. METHODS: Between January 2009 and September 2010, 12 patients underwent robotic-assisted pelvic organ prolapse repair including six sacrocolpopexy and six sacrocervicopexy. Patients' demographics, surgical procedures, operative and postoperative complications, hospital stay, conversion to laparotomy, time data including all operative times and estimated blood loss (EBL) were recorded. RESULTS: All surgeries were completed robotically with no conversion to laparotomy. The average operative time for the robotic-assisted sacrocolpopexy (RASCP) was 150.5 ± 29.6 min (range 114-189) and the mean console time was calculated as 123.6 ± 34.2 min (range 84-166). The averages of the dissection and the suturation time were 34.8 ± 24.3 min (range 13-72) and 63.3 ± 21.8 min (range 28-95), respectively. The mean length of hospitalization was 2.8 ± 0.7 days (range 2-4) and the mean EBL was calculated as 12.5 ± 4.1 ml (range 10-20). There was one intraoperative complication. The mean age and body mass index of the patients underwent robotic-assisted sacrocervicopexy were 38.1 ± 6.5 years (29-47) and 28.4 ± 5.8 kg/m(2) (18.6-34.4), respectively. The mean operating times were calculated as follows: set-up time was 25.6 ± 4.0 min, docking time was 3 ± 0.8 min, dissection time was 28.6 ± 7.7 min, suturation time was 70.8 ± 10.9 min and console time was 123.1 ± 23.6 min. There were no recurrences during the follow-up period (12 months) in both groups of the patients. CONCLUSION: The use of the robotic system during pelvic organ prolapse repair is feasible, safe and may support the surgeon during dissection and suturing at the level of sacral promontory.

Comparison of robotic-assisted surgery outcomes with laparotomy for endometrial cancer staging in Turkey.

PURPOSE: To compare the results of patients on whom staging was applied by robotic-assisted laparoscopic surgery and laparotomy for endometrial cancer. METHOD: The study included 10 patients who had undergone robotic-assisted endometrial staging (group 1) and 12 patients staged by open surgery (group 2). Demographical characteristics and operative outcomes of all patients were compared. Body mass index, age, previous abdominal surgeries, histopathologic characteristics, performed operative procedure, operation time, complications, hospitalization duration, estimated blood loss and number of resected lymph nodes were recorded for all patients. RESULTS: Mean age of the patients in the robotic surgery group was 55.7 years (37-66) and in the laparotomy group 56.4 years (47-75). Body mass index was calculated as 32.7 kg/m² (24.5-40.3) in group 1 and 30.3 kg/m² (25.9-35.8) in group 2. Total duration of operation was 234.6 min (137-300) and 168.5 min (102-232) in group 1 and 2, respectively. Mean duration of hospitalization in group 1 was 2.8 days (2-5) and in group 2 was 8.8 days (6-13). Estimates of blood loss were 95 ml (20-210 ml) in the robotic surgery group and 255 ml (80-420) in the other group. The mean number of resected lymph nodes was 42 (13-86) and 46.5 (26-107) in the robotic-assisted surgery group and laparotomy group, respectively. None of the cases in the robotic-assisted endometrial staging group required transition to laparotomy. CONCLUSION: Robotic surgery may be preferred over laparotomy with respect to the advantages observed in the duration of hospitalization, estimated amount of blood loss and complications. There was no significant difference between the two methods in terms of number of resected lymph nodes. Despite the limited number of patients in this study, these results are important as they represent the first data on robotic surgery in Turkey.