Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial.

INTRODUCTION: The transfusion rate in hysterectomies for benign pathology is almost 3%. However, despite the strong interest in reducing intraoperative bleeding, limited evidence is available regarding the technical aspects concerning uterine vessel management during a total laparoscopic hysterectomy (TLH). Uterine artery (UA) closure in TLH can be performed at the origin from the internal iliac artery or at the uterus level (UL). However, low-quality evidence is available regarding the superiority of one method over the other. MATERIAL AND METHODS: We performed a single-blind randomized (1:1) controlled trial (NCT04156932) between December 2019 and August 2020. One hundred and eighty women undergoing TLH for benign gynecological diseases were randomized to TLH with UA closure at the origin from the internal iliac artery (n = 90), performed at the beginning of the procedure by putting two clips per side at the origin, vs closure at the UL (n = 90). Intraoperative blood loss estimated from suction devices was the primary outcome. Secondary end points were perioperative outcomes, the conversion rate from one technique to the other, and complication rates with 4 months of follow up. RESULTS: Uterine artery closure at the origin was completed in all 90 patients (0%), whereas closure at the UL was converted to closure at the origin in 11 cases (12.2%; p < 0.001); failures were mainly associated with the presence of endometriosis (81.8% [9/11] vs 10.1% [8/79]; p < 0.001). In the intention-to-treat analysis, the intraoperative blood loss was higher in the group assigned to the closure at the UL (108.5 mL) than in the group with closure at the origin (69.3 mL); the mean difference was 39.2 mL (95% CI 13.47-64.93 mL; p = 0.003). Other perioperative outcomes and complications rates did not differ. CONCLUSIONS: Uterine artery closure at the origin reduces intraoperative blood loss during a TLH and appears to be more reproducible than closure at the UL without higher complication rates. However, the absent translation in clinical benefits impedes the support of a clinical superiority in all women. Closure at the origin may provide clinical advantages in the presence of severe preoperative anemia or pelvic anatomic distortion.

Laparoscopic Excision of a 5-cm Retroaortic Relapse of Ovarian Cancer.

OBJECTIVE: To demonstrate the feasibility of laparoscopic secondary cytoreduction of isolated lymph node relapse of ovarian carcinoma. DESIGN: A video explanation of a safe excision of ovarian cancer relapse using pictures to show the anatomic landmark of the retroperitoneum guiding the procedure. SETTING: Department of Obstetrics and Gynecology, Ospedale degli Infermi Hospital, Biella, Italy. The video was approved by the local institutional review board. INTERVENTIONS: A 61-year-old woman was referred to our center after the diagnosis of a 5-cm bilobate lumbo-aortic relapse of ovarian cancer, 15 months after comprehensive primary surgery, performed in another center by laparotomy and chemotherapy for a stage IIIA2 disease [1-4]. By laparoscopy, extensive adhesiolysis between the small bowel and abdominal wall was performed, showing a peritoneal cavity without any signs of carcinomatosis or disease spread. The laparoscopic operation continued with opening of the preaortic retroperitoneum and exposure of the major vessels, the psoas muscles, and the ureters. The disease relapses were identified as 2 confluent bulky nodal tissues on the left and posterior aspect of the aorta. Complete laparoscopic excision of the 2 masses was achieved. Postoperative course was uneventful, and the patient was discharged from the hospital 2 days after the surgery. Final pathological examination revealed that the 2 masses removed consisted of a total of 10 and 7 metastatic nodes, respectively. The patient initiated postoperative platinum-based chemotherapy 3 weeks after the surgery, and at present, 13 months after the operation, computed tomography scan is negative, and she is free of the disease. CONCLUSION: Laparoscopic approach to isolated relapse of ovarian cancer is feasible and safe, with fast recovery.

The Case of a Serous Borderline Ovarian Tumor in a 15-Year Old Pregnant Adolescent: Sonographic Characteristics and Surgical Management.

OBJECTIVE: This study aimed to describe a rare case of a serous borderline ovarian tumor (BOT) diagnosed during pregnancy in a 15-year old adolescent. RESULTS: The suspect of BOT was raised at a transvaginal ultrasound scan in early first trimester (at 5 weeks of amenorrhea), due to the presence of a moderately vascularized irregular papilla in the context of a unilocular low-level right ovarian cyst. The patient and her parents required termination of pregnancy, irrespective of the diagnosis of an ovarian lesion. After termination of pregnancy, the patient underwent laparoscopic enucleation of the ovarian mass, omentectomy, and peritoneal biopsies. No intra-abdominal spillage of the ovarian mass occurred, and the surgical specimens were put in an endobag and extracted transvaginally. Final pathological examination confirmed the diagnosis of a serous borderline ovarian tumor. The patient of free of disease after 8 months of follow-up. CONCLUSION: Although rare, borderline ovarian tumors can be diagnosed in an adolescent during pregnancy. The combination of specific sonographic assessment and minimally invasive conservative surgery appears as a very effective approach in this type of patient. KEY POINTS: · BOTs can occur in pregnant adolescents.. · Transvaginal ultrasound is crucial to suspect BOT.. · Laparoscopic conservative treatment is feasible..

Impact of Sport Activity and Physical Exercise on Obstetrical and Perineal Outcomes at Delivery: A Prospective Study.

OBJECTIVE: This study was aimed to investigate the effects of physical activity on perineal outcomes at delivery according to the different levels and types of maternal physical activity before and during pregnancy. STUDY DESIGN: We prospectively evaluated the obstetrical and perineal outcomes of all consecutive women who delivered at the Del Ponte Hospital, in the period between July 2014 and September 2014. Women were divided into three groups according to the features of physical activity performed before pregnancy: group 1: "very sporty women," group 2: "moderately sporty women," and group 3: "inactive women." A subanalysis of our data was performed based on the specific type of sport activity, on the degree of involvement of perineal muscles during physical activity, and on the continuation/discontinuation of this activity during pregnancy. RESULTS: A total of 135, 84, and 85 women were included in group 1, group 2, and group 3, respectively. The demographic characteristics were comparable among all the groups. Sport activity during pregnancy was more frequent in groups 1 and 2 (59.3 and 53.6%, respectively, vs. 29.4% in group 3; p = 0.003). No differences among groups were detected in terms of perineal outcomes. A lower rate of episiotomy/lacerations ≥ 2nd degree was found among women who practiced sports that specifically involved the perineal muscles and who continued this practice during pregnancy. CONCLUSION: Perineal outcomes are not influenced by the intensity of sport activity performed before/during pregnancy. Continuous sports during pregnancy that specifically train the perineal muscles are associated with a lower rate of episiotomy and perineal lacerations ≥ 2nd degree.

Pregnancy after Endometriosis: Maternal and Neonatal Outcomes according to the Location of the Disease.

OBJECTIVE: To systematically evaluate pregnancy and labor course, obstetrical complications, and maternal and neonatal outcomes in women with endometriosis, stratifying according to the specific location of the disease. STUDY DESIGN: We retrospectively analyzed our prospectively maintained obstetrical database from January 2011 to August 2014 to identify all women with a previous histological diagnosis of endometriosis who delivered at our institution (cases). We divided the cases according to the specific location of the disease (deep infiltrating endometriosis, ovarian endometriosis, and peritoneal endometriosis). As controls, we identified all unaffected women who delivered in the year 2013. To avoid the confounding effect of parity, we limited our analysis to nulliparous women. RESULTS: A total of 118 nulliparous women with endometriosis and 1,690 nulliparous controls were identified. Women with endometriosis were significantly older, had a lower body mass index, and had a higher incidence of assisted reproductive technology. The duration of pregnancy was significantly shorter among women with endometriosis. A higher incidence of placenta previa (3.4 vs. 0.5%; p = 0.006), hypertension (11 vs. 5.9%; p = 0.04), cesarean section (41.5 vs. 24.2%; p < 0.0001), and vacuum delivery (10.1 vs. 2.9%; p = 0.006) was found in women with endometriosis. Neonatal outcomes were similar between groups. The incidence of placenta previa in patients with deep endometriosis was 11.7 versus 0.5% among controls (p < 0.0001), whereas in women with ovarian and peritoneal endometriosis, it was similar to the controls. CONCLUSION: Women with endometriosis have a higher incidence of vacuum delivery, cesarean section, and placenta previa compared with unaffected women. The higher risk of placenta previa is attributable exclusively to women with deep endometriosis. Neonatal outcomes are unaffected by the presence of the disease.

The role of sentinel node in early ovarian cancer: a systematic review.

INTRODUCTION: Early ovarian cancer (EOC) is defined as ovarian cancer macroscopically limited to the ovaries at the time of initial diagnosis. Approximately only 25% of patients with ovarian cancer are affected by EOC. This condition requires complete surgical staging, including systematic lymphadenectomy up to the level of the renal vessels, with the consequent risk of complications and morbidity. With the aim to reduce the procedure-related morbidity, sentinel lymph node mapping (SLNm) has been introduced as an experimental procedure in EOC staging. The aim of the present study is to systematically review the available series on this interesting issue. EVIDENCE ACQUISITION: Studies were identified by searching electronic databases. The search was systematically applied to PubMed, ClinicalTrials.gov, Scopus and Web of Science looking for records describing the use of sentinel lymph node technique in EOC from January 1st, 1989 to January 1st, 2019. A total of 10 studies were identified for inclusion. Of the 121 patients involved in these studies, only 43 had a histologically-confirmed diagnosis of EOC and were included in the present analysis. EVIDENCE SYNTHESIS: SLN (paraaortic and/or pelvic) overall detection rate (DR) was of 97.6%. The overall sensitivity (SS) and negative predictive value (NPV) of the included cases were 66.7% and 96.6%, respectively. We calculated also NPV, SS and DR based on the anatomical lymph node district, with a value of 100% both in the lumbo-aortic and in the pelvic district and a DR of 83.3% and 43% respectively. CONCLUSIONS: This review shows that evidence on SLNm in EOC is still scant. Based on the limited data available, SLNm may provide potentially useful information on nodal status in patients affected by this disease.