Simple rules, O-RADS, ADNEX and SRR model: Single oncologic center validation of diagnostic predictive models alone and combined (two-step strategy) to estimate the risk of malignancy in adnexal masses and ovarian tumors.

OBJECTIVE: To compare performance of Assessment of Different NEoplasias in the adneXa (ADNEX model), Ovarian-Adnexal Reporting and Data System (O-RADS), Simple Rules Risk (SRR) assessment and the two-step strategy based on the application of Simple Rules (SR) followed by SRR and SR followed by ADNEX in the pre-operative discrimination between benign and malignant adnexal masses (AMs). METHODS: We conducted a retrospective study from January-2018 to December-2021 in which consecutive patients with at AMs were recruited. Accuracy metrics included sensitivity (SE) and specificity (SP) with their 95% confidence intervals (CI) were calculated for ADNEX, O-RADS and SRR. When SR was inconclusive a "two-step strategy" was adopted applying SR + ADNEX model and SR + SRR assessment. RESULTS: A total of 514 women were included, 400 (77.8%) had a benign ovarian tumor and 114 (22.2%) had a malignant tumor. At a threshold malignancy risk of >10%, the SE and SP of ADNEX model, O-RADS and SRR were: 0.92 (95% CI, 0.86-0.96) and 0.88 (95% CI, 0.85-0.91); 0.93 (95% CI, 0.87-0.97) and 0.89 (95% CI, 0.96-0.92); 0.88 (95% CI, 0.80-0.93) and 0.84 (95% CI, 0.80-0.87), respectively. When we applied SR, 109 (21.2%) cases resulted inconclusive. The SE and SP of two-step strategy SR + SRR assessment and SR + ADNEX model were 0.88 (95% CI, 0.80-0.93) and 0.92 (95% CI, 0.89-0.94), SR + ADNEX model 0.90 (95% CI, 0.83-0.95) and 0.93 (95% CI, 0.90-0.96), respectively. CONCLUSIONS: O-RADS presented the highest SE, similar to ADNEX model and SR + ADNEX model. However, the SR + ADNEX model presented the higher performance accuracy with the higher SP and PPV. This two-step strategy, SR and ADNEX model applicated to inconclusive SR, is convenient for clinical evaluation.

A rare case of extrarenal Wilms tumor of the uterine corpus: comprehensive genomic profile and review of the literature.

Wilms tumor (WT), or nephroblastoma, is an uncommon malignant neoplasm occurring in the kidney of pediatric patients. Its extrarenal location is extremely rare and has been reported in various sites, including the female genital tract, with only 9 cases arising in the uterine corpus. We present the case of an adult woman who underwent total abdominal hysterectomy due to a uterine mass causing persistent abdominal pain. The characteristic triphasic morphology (composed of epithelial, stromal, and blastemal elements) supported by a broad immunohistochemical panel, along with the imaging exclusion of a renal neoplasm, was diagnostic of WT of the uterus. For the first time, a comprehensive genomic profiling of a uterine primary WT was also performed by next-generation sequencing, disclosing alterations at the level of copy number variations in the genes ERBB2, FGFR23, FGF6, FGFR2, and RPS6KB1. All previously reported uterine cases were reviewed, with a summary of their main clinicopathologic characteristics, and the main differential diagnoses are presented. Further reports are needed to improve our knowledge about prognostic factors, clinical behavior and molecular alterations that could guide appropriate therapeutic decision making.

A prospective study on the diagnostic pathway of patients with stage IIIC-IV ovarian cancer: Exploratory laparoscopy (EXL) + CT scan VS. CT scan.

OBJECTIVE: To compare the diagnostic power of CT scan to a combination of exploratory laparoscopy (EXL) and CT scan in patients with stage IIIC-IV Ovarian Cancer (OC) by anatomic areas. To investigate if adding EXL to CT can reduce unnecessary laparotomy. METHODS: In the period 2009-2017, 350 consecutive patients with FIGO Stage IIIC-IV OC underwent CT and EXL prior to Visceral-Peritoneal debulking (VPD) and were included in the study. Radiologist and surgeons filled an ad-hoc form to report CT scan and EXL of eleven key anatomic areas. The decision to proceed to EXL was based on the CT scan and the decision to proceed to laparotomy (LPT) on CT and EXL. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity, and accuracy of CT, EXL and CT + EXL were calculated. We broke down the diagnostic outcomes by anatomic areas and determined the rate of unnecessary laparotomy avoided with the findings of EXL. RESULTS: Median time for the EXL was 14 min (SD +/- 3). No complication related to EXL occurred. At EXL, 325 out of 350 patients (93%) proceeded to LPT and 25 patients (7.1%) did not because of exclusion criteria. In 307 patients out of 325 (94.4%) EXL was followed by VPD. Eighteen patients had exclusion criteria found at LPT and had no VPD. EXL reduced the rate of unnecessary/futile laparotomy from 12.2% to 5.1%. CT + EXL showed a significantly higher sensitivity for all anatomic areas except for the lymph nodes. Specificity was not significantly improved. PPV was significantly improved for small bowel, porta hepatis and stomach. NPV displayed a statistical improvement in all anatomic areas except lymph nodes, stomach, and liver. CONCLUSION: The combination CT + EXL has a higher diagnostic power than CT alone, particularly on diaphragm, small bowel serosa and mesentery. The rate of unnecessary laparotomy decreased by almost 60%.

The "CIV Classification," a New Proposal for the Architectural Grading of Vulvar Lichen Sclerosus.

OBJECTIVES: The purpose of this cross-sectional study was to prepare a reliable and easy-to-use architectural classification for vulvar lichen sclerosus (VLS) aimed at defining the morphological patterns of this condition. MATERIALS AND METHODS: An expert panel composed by 7 physicians with expertise in clinical care of vulvar conditions outlined the architectural criteria for the definition of VLS severity (phimosis of the clitoris, involvement of the interlabial sulci, narrowing of the vulvar introitus), identifying 5 grades to build up a classification. Thirteen physicians with 2-30 years expertise in vulvar diseases (nonexpert group) were asked to evaluate 3-5 pictures from 137 patients. Each physician individually assigned a grade to each case, according to the previously mentioned criteria. Interrater reliability was analyzed by means of intraclass correlation coefficient (ICC). The reliability concerning the 2 classifications of each rater was analyzed by means of κ statistic. Intraobserver and interobserver reliability in vivo was analyzed by means of κ index. RESULTS: This study provides a new classification of VLS, based on defined anatomical criteria and graded into mutually exclusive progressive classes.The ICC analysis showed a substantial interrater reliability of the classification, ICC = 0.89 (0.87-0.91), both in the expert panel and in the nonexpert group (ICC = 0.92 and 0.87, respectively). An "almost perfect" intraobserver and interobserver reliability was achieved among physicians in vivo (κ = 0.93). CONCLUSIONS: Our classification showed a high reliability. It is easy to use, and it can be applied in clinical practice and eventually, in the evaluation of regenerative and cosmetic surgery.

Comparison of surgical and pathological parameters after laparoscopic transperitoneal pelvic/para-aortic lymphadenectomies.

OBJECTIVE: Lymphadenectomy is an integral part of surgical staging and treatment for patients with gynecologic malignancies. Since its introduction, laparoscopic lymphadenectomy has proved feasible, safe, and oncologically adequate compared with open surgery while morbidity is lower and hospital stay considerably shorter. The aim of this study was to examine if surgical outcomes may be improved after the initial learning curve is complete. METHODS: An analysis of 2535 laparoscopic pelvic and/or para-aortic lymphadenectomies was performed between July 1994 and March 2018 by one team of gynecologic oncology surgeons but with the consistent supervision of a consultant surgeon. Data were collected prospectively evaluating operative time, intra-operative and post-operative complications, number of lymph nodes, and body mass index (BMI). Previously published data of 650 patients treated after introduction of the method (period 1, 1994-2003) were compared with the latter 524 patients (period 2, 2014-2018). RESULTS: The median age of the 2535 patients was 43 years (IQR 34-57). The most common indication for pelvic and/or para-aortic lymphadenectomy was cervical cancer (n=1893). Operative time for para-aortic lymph node dissection was shorter in period 2 (68 vs 100 min, p<0.001). The number of harvested lymph nodes was increased for pelvic (19.2 (range 2-52) vs 21.9 (range 4-87)) and para-aortic lymphadenectomy (10.8 (range 1-52) vs 14.4 (range 4-64)), p<0.001. BMI did not have a significant influence on node count or operative time, with BMI ranging from 14.6 to 54.1 kg/m2. In contrast to period 1 (n=18, 2.9%), there were no intra-operative complications in period 2 (n=0, 0.0%, p<0.001) whereas post-operative complications were similar (n=35 (5.8%) in period 1; n=38 (7.6%) in period 2; p=0.32). CONCLUSION: In this large cohort of patients who underwent laparoscopic transperitoneal lymphadenectomy, lymph node count and peri-operative complications improved after the initial learning curve.

Surgical treatment of large adnexal masses: a retrospective analysis of 330 consecutive cases.

Introduction: In the present study, perioperative outcomes of laparoscopy (LPS) were compared to open surgery (OS) for the treatment of large adnexal masses (AM).Material and methods: Retrospective observational cohort study. Data of consecutive patients who underwent ovarian cystectomy or salpingo-oophorectomy for large AM (diameter ≥10 cm) at a referral minimally invasive gynecologic center were analyzed. Propensity score match (PSM) analysis was used to minimize covariate imbalances between the two groups.Results: Overall 330 patients, 285 (86.4%) LPSs and 45 (13.6%) OSs were included. PSM showed LPS (vs. OS) to be associated with less intraoperative blood loss (mL: 131.1 ± 52.6 vs. 545.5 ± 101.2; p = .007), shorter operative time (min: 84.8 ± 77.9 vs. 123.7 ± 70.1; p < .001), but higher rate of spillage (54.5% vs. 12.1%; p < .001). Among the LPS group, a positive correlation between AM size and both conversion to open surgery and need for mini-laparotomy was found (p < .05).Conclusions: An accurate patient selection, a dedicated workup, and an appropriate counselling are mandatory before LPS for large AM. The increased risks of intraoperative spillage associated with the minimally invasive approach should be acknowledged.

Diagnostic flow-chart to identify bowel involvement in patients with stage IIIC-IV ovarian cancer: Can laparoscopy improve the accuracy of CT scan?

OBJECTIVE: This study investigates the diagnostic power of CT scan combined with exploratory laparoscopy (EXL) at identifying large bowel involvement in patients with stage IIIC-IV primary Epithelial Ovarian Cancer (EOC) by comparing with the macroscopic surgical findings at laparotomy. METHODS: All patients with FIGO Stage IIIC-IV EOC who had Visceral Peritoneal Debulking (VPD) were included in the study. Results of CT scan, EXL and laparotomy (LPT) with regards to the bowel involvement were prospectively recorded in an ad hoc study form. Setting LPT findings as the gold standard, positive and negative predictive value (PPV/NPV), sensitivity, specificity and accuracy of CT and EXL were calculated. In addition, the diagnostic power of the combination CT scan + EXL was investigated. RESULTS: Ninety-four out of 177 patients (53.2%) had a bowel resection during VPD. CT-scan alone had sensitivity, specificity, PPV, NPV and accuracy of 56.7%, 72.4%, 70.8%, 58.5% and 63.8% respectively. EXL alone 84.4%, 93.8%, 93.8%, 84.3%, 88.8%. CT combined with EXL detected bowel involvement with a sensitivity, specificity, PPV, NPV and accuracy of 87.5%, 70.4%, 77.8%, 82.6% and 79.6% and respectively. The combined tests showed a statistically significant improvement vs. CT scan alone (p < 0001) in sensitivity, NPV and accuracy, with non-significant difference in specificity and PPV. CONCLUSIONS: CT-scan alone shows a limited diagnostic power at detecting large bowel involvement in patients with stage IIIC-IV EOC. The combination of CT scan with EXL increases the diagnostic power and enables to appropriately plan the bowel resection and consent the patients.

Morbidity and reversal rate of ileostomy after bowel resection during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer.

OBJECTIVE: To investigate the morbidity of diverting loop ileostomy (DLI) performed during Visceral Peritoneal Debulking (VPD) for stage IIIC-IV ovarian cancer and to report the rate, timing, and morbidity of DLI reversal. METHODS: We retrieved the data of all consecutive patients who underwent sigmoid-rectum resection (SRR) followed by DLI. Morbidity was defined as any surgical/medical complications clearly correlated to the DLI. The reversal rate of DLI was defined as the number of patients who had the continuity of the gastrointestinal tract restored in the study period. Finally, we recorded the timing and the morbidity of the reversal surgery. Factors associated with non-reversal of DLI were reported. RESULTS: In the study period (01/2010-09/2016), complete data were available for 47 patients. Stoma-related complications occurred in 22 patients (46.8%). Eight patients (17.0%) were readmitted within 30days from surgery. Thirty-two patients (68.1%) had their stoma reversed. The primary cause of non-reversal was tumor recurrence/progression (7/15, 46.7%). Patient's age, length of hospitalization, complications after VPD were associated with non-reversal of DLI. The mean time from DLI formation to stoma reversal was 6months (±1.7). Post-reversal related complications occurred in 37.1% of the patients. CONCLUSIONS: In our series, 31.9% of the patients with FIGO stage IIIC-IV ovarian cancer who underwent SRR and DLI did not have stoma reversal. Overall they had approximately 45% risk of stoma-related morbidity and 37% risk of morbidity related to the stoma reversal. This information should be part of the consulting process when preparing for debulking surgery, particularly in patients who are likely to need a bowel resection.

Concomitant Laparoscopic and Thoracoscopic Resection of Recurrent High-Grade Ovarian Cancer.

STUDY OBJECTIVE: To describe the first case of combined endoscopic management of a thoracic and abdominal recurrence of ovarian cancer. DESIGN: An instructive video showing the combined thoracic and abdominal surgical procedure. SETTING: Department of Gynecological Oncology, Churchill Hospital, Oxford University, UK. PATIENTS: A 64-year-old woman undergoing endoscopic treatment for a third recurrence of ovarian cancer after a full surgical staging in 2007. The disease-free interval from the last recurrence was 31 months. INTERVENTION: The operation was performed by a multidisciplinary team of thoracic and gynecologic oncologist surgeons. Surgery started with thoracoscopic resection of a right enlarged paracardiac lymph node of 24 mm and a small wedge of the right lung, which was attached to the lymph node. At laparoscopy, 2 nodules of 3 and 5 mm were excised from the mesosigmoid and 1 nodule of 20 mm was resected from the right hemidiaphragm. MEASUREMENTS AND MAIN RESULTS: The total operative time was 251 minutes, and no intraoperative complication occurred. No conversion to open surgery was necessary. The estimated blood loss was 50 mL. There was no visible residual disease at the end of the surgery. The patient was discharged 4 days after surgery. The final pathology report confirmed the presence of endometrioid adenocarcinoma in all specimens removed. Adjuvant chemotherapy with carboplatin/paclitaxel was started 2 weeks later. At the 60-day follow-up, no complications were recorded. A computed tomographic scan performed after 6 cycles of chemotherapy did not reveal any evidence of relapse. CONCLUSIONS: The combined endoscopic approach might be feasible in selected patients.

En-bloc resection of the pelvis (EnBRP) in patients with stage IIIC-IV ovarian cancer: A 10 steps standardised technique. Surgical and survival outcomes of primary vs. interval surgery.

OBJECTIVE: In this study we describe the technique of the En-bloc resection of the pelvis (EnBRP) in 10 standardised and reproducible steps, whereby all pelvic organs, except the bladder, are removed together with the peritoneum. In addition, we compare the surgical and survival outcomes of patients who underwent upfront vs. interval surgery. METHODS: Retrospective analysis of patients with FIGO Stage IIIC-IV ovarian cancer treated with Visceral Peritoneal Debulking (VPD) who had EnBRP. The study population was divided into Group 1 (up-front VPD) and group 2 (VPD after neo-adjuvant chemotherapy). The aim was to assess the incidence of EnBRP. We also assessed rate of complete resection (CR), procedure-specific and overall morbidity, disease free and overall survival. Results were compared between group 1 and 2. RESULTS: Overall 92 out of 200 patients (46%) needed an EnBRP during the VPD. Forty-eight patients were in Group 1 and 44 patients in Group 2. CR was achieved in all patients. No intra-operative procedure specific morbidity was recorded. Dehiscence of bowel anastomosis was the only procedure specific morbidity. Rate was 2%, with 1 episode recorded in each group. Both patients were managed and settled with formation of a bowel diversion. The overall morbidity rate was 33%, 35% in group 1 and 31% in group 2. The mortality rate was 1%. Median disease free survival was 20months, 25 in group 1 vs. 15 in group 2 (P=0.009). CONCLUSIONS: EnBRP is a safe and effective technique to tackle the pelvic disease of patients with advanced ovarian cancer. The reduced blood loss, the high rate of clear margins and CR of the disease are accompanied by a low rate of surgical morbidity. These features are particularly suitable for patients who are due to start or re-start chemotherapy. The standardization of the technique will make it more reproducible and easier to be taught. In addition, it will facilitate comparison of results and the inclusion of this technique in the portfolio of procedures as part of debulking surgery.

Interval Laparoscopic En-Bloc Resection of the Pelvis (L-EnBRP) in patients with stage IIIC-IV ovarian cancer: Description of the technique and surgical outcomes.

OBJECTIVE: To describe the technique and evaluate the feasibility, efficacy and morbidity of the Laparoscopic En-Bloc Resection of the Pelvis (L-EnBRP) during Visceral-Peritoneal Debulking (VPD) at time of interval surgery. METHODS: This report is part of a prospective non randomized study (service evaluation protocol) on the feasibility and safety of laparoscopy in patients with stage IIIC-IV ovarian cancer and gross residual disease following neoadjuvant chemotherapy. Primary endpoints of this part of the study were the feasibility (rate of patients in whom the surgery could be completed by laparoscopy), efficacy (rate of patients ended with a complete resection) and morbidity (number of patients that suffered complications specifically associated to the procedure) of L-EnBRP. The results were compared between patients in group 1 (L-EnBRP+L-VPD), group 2 (L-EnBRP+VPD) and group 3 (VPD). RESULTS: Eighteen patients were in group 1, 8 in group 2 and 32 in group 3. Feasibility of L-EnBRP was 45% (26 patients out of 58), efficacy was 100% of the pelvic disease (94.4% overall disease) and morbidity was 5.5%. Main cause for conversion to laparotomy was high tumor load on diaphragm and/or mesentery. All but one patient had a complete resection (CR) of the disease. Group 1 patients had significantly earlier hospital discharge, lower blood loss and reduced overall morbidity than group 2 and 3. CONCLUSION: L-EnBRP was feasible in almost half of the patients. In these patients a CR was achieved with a low morbidity rate. The latter was significantly decreased when compared to the patients who had a laparotomy.

Diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking (VPD) in 100 consecutive patients with stage IIIC-IV ovarian cancer: A surgical-histological analysis.

OBJECTIVE: To compare the surgical and histological outcomes of diaphragmatic peritonectomy vs. full thickness resection with pleurectomy during Visceral-Peritoneal Debulking. METHODS: Service evaluation protocol (Trust number 3265). All patients with stage IIIC-IV ovarian cancer who had diaphragmatic surgery between April 2009 and November 2013 were included. Clinical notes and histology reports were reviewed. Additional histology sections were undertaken. Patients were divided in Groups 1 (peritonectomy) and 2 (pleurectomy). The outcomes of interest were: surgical (intra- and post-operative morbidity, pulmonary morbidity, mortality, rate of complete resection) and histological (rate of diaphragmatic peritoneum, muscle and pleural involvement, rate of microscopic diaphragmatic free margins). RESULTS: Sixty four patients had diaphragmatic peritonectomy (Group 1), 36 patients full thickness diaphragmatic resection with pleurectomy (Group 2). There was no significant difference in the rate of mortality (3% in both groups), overall intra- and post-operative morbidity (32.8% vs. 38.8%), pulmonary morbidity (9.3% vs. 19%, P=0.14). Histology showed tumor invasion in the diaphragmatic peritoneum (96%), muscle (28%) and pleura (19.4%). Microscopic free margins were seen in 86% vs. 92% in Groups 1 and 2. CONCLUSIONS: Our study demonstrated that, in patients with ovarian cancer, diaphragmatic involvement extends to the muscle in almost 30% and to the pleura in 20% of the patients. Overall and specific morbidity was not significantly different when comparing peritonectomy vs. pleurectomy.

Porta hepatis peritonectomy and hepato-celiac lymphadenectomy in patients with stage IIIC-IV ovarian cancer: Diagnostic pathway, surgical technique and outcomes.

OBJECTIVE: To report the surgical technique of ovarian cancer resection at the porta hepatis (PH) and hepato-celiac lymph nodes (HCL). To assess surgical and survival outcomes. Define the accuracy of an integrated diagnostic pathway. METHODS: Patients with FIGO stage IIIC-IV ovarian cancer that underwent Visceral-Peritoneal Debulking (VPD). Data of patients with disease at the PH/HCL during VPD were extracted from our database. The CT scan findings were compared with the exploratory laparoscopy. Accuracy of CT scan, intra- and post-operative morbidity, rate of complete resection (CR), disease free and overall survival are reported. RESULTS: Thirty one patients out of 216 (14.3%) had tumor at the PH and/or HCL. In 8 patients out of 31 (25.8%) it was only found with the aid of the exploratory laparoscopy. CR was achieved in 28 patients out of 31 (90.3%). Pathology confirmed disease in the PH/HCL specimens of all but one patient. Overall morbidity relating to the VPD was 29.2%. No complication was specifically related to the PH/HCL. Median disease free survival was 19months and median overall survival was 42months. CONCLUSION: PH/HCL surgery was required in 15% of patients with FIGO stage IIIC-IV. The surgery was feasible, safe and significantly contributed to CR. CT scan failed to identify the disease in 31% of the patients. CT and laparoscopy correctly identified all patients.

Neo-adjuvant chemotherapy does not increase the rate of complete resection and does not significantly reduce the morbidity of Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer.

OBJECTIVE: To measure the efficacy and the safety of Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer and to compare the outcomes before and after chemotherapy. METHODS: Between 2008 and 2013, 200 consecutive patients were offered VPD for stage IIIC/IV ovarian cancer. Exclusion criteria were: metastases in the lungs or 3 liver segments at CT review and/or disease on small bowel serosa or encasing the porta hepatis at explorative laparoscopy. The endpoints were efficacy (rate of complete resection, CR) and safety (morbidity and mortality). The results were compared between patients in group 1 (upfront surgery) and group 2 (during or after chemotherapy). RESULTS: Ninety-eight patients were in group 1 and 102 in group 2. Twenty out of 200 patients (10%) did not have VPD, 180 out of 200 patients (90%) had VPD and CR: 90.8% in group 1, 89.8% in group 2. The mortality (1%) and intra-operative complication rate (3.3%) were similar. Post-operative complications rate was 34.8% in group 1 vs. 30.7% in group 2 (P=0.669). The difference in grade III (15.7% vs. 5.5%, P=0.053) and grade IIIb complications (13.4% vs. 4.4%, P=0.062) approached statistical significance. All other outcomes were not significantly different in the 2 groups. CONCLUSION: VPD achieved CR in 90% of the patients. Neo-adjuvant chemotherapy did not increase the rate of CR and did not significantly decrease the morbidity or the complexity of the surgery.

Latest developments and techniques in gynaecological oncology surgery.

PURPOSE OF REVIEW: To highlight the advances and the data published in the field of gynaecological oncology surgery in the last few years. The review includes not only newly introduced surgical techniques but also data that consolidate recent developments. RECENT FINDINGS: Ultimate data on the use of laparoscopy in the treatment of gynaecologic malignancies have proven similar survival outcomes to the traditional surgical route and confirmed the benefits in terms of faster recovery and lower morbidity. Thanks to a faster learning curve, the use of robotic surgery has contributed to the increase in the number of surgeons who moved away from open surgery. A few pioneers are expanding the indications of laparoscopy to exenterative surgery and treatment of ovarian cancer. SUMMARY: Laparoscopic surgery has become the gold standard treatment for patients with primary endometrial or cervical cancer. The advent of robotic surgery has reinforced the domain of endoscopic surgery.

Femoral nerve injury complicating surgery for gynecologic cancer.

OBJECTIVE: The aim of this study was to report the incidence, severity, and factors associated with femoral nerve injury during gynecologic cancer surgery. METHODS: All patients who underwent abdominal surgery for gynecologic cancer entered the study. A retrospective review of the medical records was carried out for patients operated on from 2003 to April 2011. After this analysis, the use of the Bookwalter retractor was modified and the data were prospectively recorded. RESULTS: In the first period, femoral nerve injury was observed in 11 (2.7%) of 406 patients, occurring with a significantly higher frequency when the Bookwalter retractor was used (5.1% vs 0%, P < 0.01) and when pelvic lymphadenectomy was performed (5.1% vs 0.9%, P < 0.01). The analysis of the 212 patients (52.2%) in the Bookwalter group showed higher frequency of nerve injury in the patients undergoing pelvic lymphadenectomy (7.8% vs 2.0%, P = 0.05). In the second period, femoral nerve injury was observed in 1 (0.7%) of 132 patients operated on and in 1 (2.3%) of 43 patients (32.6%) in the Bookwalter group. When comparing the 2 periods, the lesser use of the Bookwalter retractor and the reduced time of maximal traction of the pelvic blades decreased the nerve injury rate from 2.7% to 0.7% and, in the Bookwalter group, from 5.1% to 2.3%. These results, although not statistically significant, are clinically relevant. CONCLUSIONS: Femoral nerve injury during gynecologic cancer surgery was associated with the Bookwalter retractor. The pelvic blades of the retractor may exert a compression on the nerve. The weakened muscles suggest that the nerve compression occurred intrapelvically over the iliacus muscle. Shortening the time of maximal traction of the pelvic blades reduced the incidence of femoral nerve injury. When performing gynecologic surgery with the use of the Bookwalter retractor, care must taken with the placement of the pelvic blades.

Feasibility of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer: the ULTRA-LAP trial pilot study.

OBJECTIVE: A non-randomized prospective clinical trial (ULTRA-LAP) was registered to test safety, side effects and efficacy of laparoscopic Visceral-Peritoneal Debulking (L-VPD) in patients with stage III-IV ovarian cancer (OC). A pilot study was designed to identify which OC patients are suitable to undergo L-VPD. METHODS: Between March 2016 and October 2021, all consecutive patients with OC underwent exploratory laparoscopy (EXL). All patients whose disease was deemed amenable for a complete resection (CR) at imaging review and EXL, underwent VPD. In all patients a consistent attempt was made at completing L-VPD. RESULTS: Two hundred and eight OC had EXL in the study period: 121 underwent interval VPD and 87 up-front VPD. Overall, 158 patients had VPD by laparotomy (75.9%) and 50 (24.1%) had L-VPD, of which 34 patients as interval (iL-VPD) and 16 as up-front (uL-VPD). Intra- and post-operative morbidity was very low in the L-VPD group. CR rate was 98% in L-VPD group and 94% in VPD. Most common reason for conversion was diaphragmatic disease extending dorsally. CONCLUSION: In the pilot study of ULTRA-LAP, L-VPD was completed in 24,1% of OC. Initial analysis supports the feasibility of L-VPD in 2 groups of OC: those with no gross disease at interval surgery and those with gross visible disease at upfront or interval surgery, but limited to: pelvis (including recto-sigmoid), gastro colic omentum, peritoneum and diaphragm, the latter not requiring dorsal liver mobilization. Both groups had 100% feasibility and have been thus forth recruited to ULTRA-LAP. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05862740.

Laparoscopic en-bloc pelvic resection for advanced ovarian cancer.

Introduction: Ovarian cancer (OC) exhibits an aggressive behavior, wherein the therapeutic approach always involves both surgery and chemotherapy. Survival outcomes are still related to comprehensive surgical excision of all macroscopic lesions (Rauh-Hain et al., 2017), increasing gynecologic oncologists' efforts to achieve the highest possible complete resection rate (Tozzi et al., 2024). The peritoneum serves as both a dissemination pathway and a barrier that restricts tumor spread beyond its confines. This understanding has prompted the adoption of en-bloc resection strategy for the entire pelvis, involving the removal of pelvic organs along with the surrounding peritoneum. The en-bloc pelvic resection procedure allows for the removal of pelvic disease in all cases of advanced ovarian cancer (Tozzi et al., 2017).Endeavors should be also directed towards minimizing surgical morbidity, by the adoption of minimally invasive surgery for debulking procedures (Tozzi et al., 2023). Case: This video demonstrates a laparoscopic en-bloc pelvic resection with creation of an end-to-end transanal anastomosis. The surgical specimen extraction and the placement of the anvil were performed through the vaginal route.A 75 year-old patient presented with FIGO stage IIIC OC with a 12 cm pelvic mass involving the whole pelvis. The patient was enrolled in the ULTRA-LAP trial and underwent laparoscopic primary debulking surgery with en-bloc pelvic resection. No protective ileostomy was performed and bowel opening occurred on the fifth postoperative day. The patient was discharged on the 11th postoperative day, thereafter completing a regimen of 6 cycles of carboplatin and paclitaxel chemotherapy. Conclusions: The en-bloc resection of the pelvis is a standardized procedure that consists of ten reproducible steps.

Peritonectomy and resection of mesentery during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer: A phase I-II trial.

OBJECTIVE: To describe the surgical technique, assess feasibility, efficacy, and safety of peritonectomy and/or resection of mesentery (P-Rme) during Visceral-Peritoneal Debulking (VPD) in patients with stage IIIC-IV ovarian cancer (OC). METHODS: In April 2009 we registered a protocol study on the safety and feasibility of P-Rme. In the period April 2009-December 2022, 687 patients with FIGO stage IIIC-IV ovarian cancer underwent VPD. One hundred and twenty-nine patients (18.7%) had extensive disease on the mesentery and underwent P-Rme. Feasibility was assessed as the number of procedures completed. Efficacy was measured as the rate of Complete Resection (CR). Safety was defined by the intra- and post-operative morbidity rate specifically associated with these procedures. RESULTS: In all patients P-Rme was successfully completed. P-me was performed in 82 patients and R-me in 47, both procedures in 23 patients. CR was achieved in all 129 patients with an efficacy of 100%. Intra-operatively 5 patients out of 129 experienced small bowel loop surgical devascularization. They required small bowel resection and anastomosis. The procedure specific morbidity was 3.8%. No post-operative complication was related to P-Rme. At 64 months median follow-up, survival outcomes in the study group were similar to patients in the control group. CONCLUSION: Overall, almost 20% of the VPD patients needed P-Rme to obtain a CR. P-Rme was a safe and effective step during VPD. The rate of CR in the study group was 100% achieved thanks to the addition of the P-Rme. No procedure specific post-operative complications occurred but 3.8% of the patients had unplanned additional surgery related to these procedures.

An Ultrasound-Based Preoperative Evaluation of the Endometriosis Fertility Index: A Further Step towards Personalized Treatment.

Background: The Endometriosis Fertility Index (EFI), is a crucial validated surgical tool used for predicting fertility outcomes in women with endometriosis. This study aims to assess the concordance between a preoperative clinical and instrumental EFI evaluation (uEFI) and the EFI score obtained during an exploratory laparoscopy prior to surgery (sEFI). Methods: This study presents preliminary data from a broader observational cohort study. The Least Function score for the uEFI was calculated using a modified version of the original surgical EFI by incorporating a clinical examination, advanced ultrasound, and hysterosalpingo-foam sonography (HyFoSy). Results: The preoperative estimation of the EFI (uEFI) demonstrated a high concordance (k = 0.695, ρs = 0.811) with the sEFI. Remarkably, the surgical interventions led to a significant improvement in the EFI values, with 80% of the intermediate EFI transitioning to a high level, thereby highlighting the positive impact of surgery on fertility outcomes. Conclusion: This study highlights the accuracy of preoperative EFI estimation (uEFI) and its strong agreement with intraoperative assessment. It underscores the potential of a preoperative management tool to guide the allocation of infertile women with endometriosis to operative laparoscopy, direct assisted reproductive technology (ART), or spontaneous attempts at pregnancy.