Giant splenic cyst with expectant management in pregnancy: A case report and review of the literature.

A 22-year-old primigravida was diagnosed with an 18-cm splenic cyst during routine third-trimester routine ultrasound examination. She was referred to a tertiary obstetric hospital and after multidisciplinary consultation, expectant management was decided on. Induction of labour was performed at term and she delivered vaginally with vacuum extractor application without complications. Percutaneous aspiration and sclerotherapy of the cyst was performed one week after delivery. She was hemodynamically stable throughout.

Colon Adenocarcinoma during Pregnancy: A Case Report and Review of the Literature.

Colorectal cancer (CRC) during pregnancy presents an estimated incidence of 1 : 13,000, and it is associated with diagnostic and therapeutic challenges. Here, we present the case of a 38-year-old woman, 25 weeks and 5 days pregnant, who was transferred to our Obstetrics and Gynecology Department from a local hospital with the diagnosis of intestinal obstruction. Magnetic Resonance Imaging (MRI) showed marked distension with hydroaerial levels of the enterocolic loops upstream of a concentric parietal thickening of the descending colon, stenosing, extended longitudinally for about 4 cm. An exploratory laparotomy was performed with resection of the colon splenic flexure and mechanical end-terminal anastomosis. Histological examination of the operating piece highlighted the presence of moderately differentiated (G2) colon adenocarcinoma (stage pT3N1b). The operation was followed by a single course of oxaliplatin and 5-FU plus leukovorin. The patient had a vaginal delivery at 37 weeks + 2 days of gestational age, following induction of labor and giving birth to a male infant whose weight was 2670 gr with apgar 9/9. We underline the pivotal role of attention to unspecific symptoms, early diagnosis, and active treatment in changing the clinical course of CRC.

"Single center experience of laparoscopic hysteroannessiectomy and histopathological outcomes in transgender men".

This article presents a retrospective descriptive analysis about female-to-male (FtM) gender-affirmation nongenital surgical procedures involving the gynecological team at the CIDIGeM (Centro Interdipartimentale Disturbi di Identità di Genere Molinette) Center in Turin. From 2004 to 2019, seventy FtM transsexual patients underwent hysteroannessiectomy: the chosen surgical technique involved a Total Laparoscopic Hysterectomy. The patients presented a median age of 30.5 years (range 21-53). No patients presented intraoperative complications, the median of surgery time was 80 min (range 40-150) and the hospital stay median was 5 days (range: 2-25). Histopathological examinations were negative for cancer in all patients except for one unknown case of grade 3 cervical intraepithelial neoplasia. Total Laparoscopic Hysterectomy is confirmed to be the method of choice in the group of FtM transsexuals: this approach has several advantages over abdominal hysterectomy, including more rapid recovery, fewer wound or abdominal wall infections; moreover, it has enabled us to preserve the vital structures needed for reconstruction of external genitalia. Cancer risk is still considered an area of priority in transgender research; thus, we underline the importance of performing a histopathological examination of the surgical specimen.

Arteriovenous uterine malformation developed from an interstitial pregnancy on residual tubal stump: A critical managment in a fertile woman.

Uterine arteriovenous malformations are rare conditions with diverse clinical presentation that range from asymptomatic patients to different degrees of menorrhagia, commonly associated with previous pregnancy or uterine trauma. This case report describes a 36-year-old woman who presented with ultrasound diagnosis of interstitial pregnancy on residual right tube stump 4 months after a laparoscopic salpingectomy for extrauterine pregnancy. She started treatment with methotrexate; afterwards serum human chorionic gonadotropin levels and ultrasound follow-ups were scheduled. While serum human chorionic gonadotropin levels were progressively reducing, transvaginal ultrasound follow-ups showed a persistent anechoic mass on right rube stump, with increased peripheral high flow vascularity: highly suspicious for a uterine arteriovenous malformation. A laparoscopy was performed with a tumorectomy of the mass. The histopathological exam of the specimen confirmed uterine arteriovenous malformation. Patient successfully became pregnant 2 years later, with an eventless pregnancy and a vaginal delivery without complications.

Simplified laparoscopic sacropexy avoiding deep vaginal dissection.

OBJECTIVE: To evaluate the safety and efficacy of a "simplified" laparoscopic sacropexy approach. METHODS: Data were retrospectively assessed from women with apical prolapse of stage 2 or higher who underwent "simplified" laparoscopic sacropexy between October 1, 2010, and May 31, 2017 at the St Anna Hospital, City of Health and Science, Torino, Italy. Patients were treated with the "simplified" laparoscopic sacropexy, where meshes were anchored solely to the vaginal apex, even in the presence of advanced multi-compartment vaginal prolapse. Data on prolapse stage and urogenital functions collected through clinical examinations, and questionnaires at baseline, 6 months, 12 months, and annually thereafter were examined. RESULTS: Overall, 121 women were included in the analysis; the mean follow-up was 33.2 months. Mean operative time was 135.1 minutes; there were no intraoperative visceral or vascular injuries. There was 1 (0.8%) patient who experienced recurrence, and 2 (1.7%) who experienced vaginal erosion. Both urogenital symptom scores (all P<0.05) and quality of life scores (all P<0.05) improved significantly. CONCLUSION: Adequate re-suspension of only the apex was sufficient to correct other vaginal compartments, even for women with preoperative multi-compartment prolapse higher than POP-Q stage 2. The "simplified" laparoscopic sacropexy was an efficacious intraoperative time-saving technique; it could reduce adverse events caused by deep vaginal dissection up to puborectal muscles and the bladder trigone.

Nerve preserving vs standard laparoscopic sacropexy: Postoperative bowel function.

AIM: To compare our developed nerve preserving technique with the non-nerve preserving one in terms of de novo bowel symptoms. METHODS: Patients affected by symptomatic apical prolapse, admitted to our department and treated by nerve preserving laparoscopic sacropexy (LSP) between October, 2010 and April, 2013 (Group A or "interventional group") were compared to those treated with the standard LSP, between September, 2007 and December, 2009 (Group B or "control group"). Functional and anatomical data were recorded prospectively at the first clinical review, at 1, 6 mo, and every postsurgical year. Questionnaires were filled in by the patients at each follow-up clinical evaluation. RESULTS: Forty-three women were enrolled, 25/43 were treated by our nerve preserving technique and 18/43 by the standard one. The data from the interventional group were collected at a similar follow-up (> 18 mo) as those collected for the control group. No cases of de novo bowel dysfunction were observed in group A against 4 cases in group B (P = 0.02). Obstructed defecation syndrome (ODS) was highlighted by an increase in specific questionnaires scores and documented by the anorectal manometry. There were no cases of de novo constipation in the two groups. No major intraoperative complications were reported for our technique and it took no longer than the standard procedure. Apical recurrence and late complications were comparable in the two groups. CONCLUSION: Our nerve preserving technique seems superior in terms of prevention of de novo bowel dysfunction compared to the standard one and had no major intraoperative complications.

Laparoscopic Nerve-Preserving Sacropexy.

STUDY OBJECTIVE: To demonstrate our developed nerve-preserving technique during laparoscopic sacropexy (LSP) for multicompartment pelvic organ prolapse. DESIGN: A step-by-step demonstration of our surgical procedure on video (Canadian Task Force classification II-2). Informed consent was obtained from the subject, and the applicable Institutional Review Board provided approval. SETTING: Although sacropexy does remain the 'gold standard' procedure for apical prolapse [1], the subjective outcome of the procedure has been reported to be not so satisfactory as its anatomic outcome [2]. New onset bowel symptoms have been observed with voiding and sexual dysfunctions [3]. Published data revealed a correlation between iatrogenic denervation during LSP and postoperative dysfunctions [4-6]. We adopted a nerve-preserving approach with the aim of reducing the iatrogenic morbidity. INTERVENTIONS: Our surgical nerve-preserving LSP technique from the promontory down to the right uterosacral ligament and the rectovaginal space proceeds in 3 steps: Step 1: Opening the peritoneum. The peritoneum is opened just medial to the right common iliac artery, approximately 20 to 30 mm above the sacral promontory, allowing a safe approach in an area far from nerves and vascular structures. Peritoneal incision is extended toward the promontory. The underlying presacral fascia containing the right hypogastric nerve (rHN) is identified and incised longitudinally. The presacral fascia and the rHN are then pushed medially to expose the longitudinal anterior vertebral ligament; the finding of the middle sacral veins represents the limit of any further medial dissection. Opening and displacement of the prevertebral fascia are not mandatory. Step 2: Opening the peritoneum of the right pelvic sidewall, respecting the integrity of the presacral fascia and of the rHN contained within it. An inverted L-shaped peritoneal incision extending from the sacral promontory up to the left uterosacral ligament is completed, with care taken to preserve the rHN identified previously. In proximity to the uterus, the dissection line crosses the upper edge of the right uterosacral ligament at its proximal third and extends medially. The rectovaginal space is opened and joined to the peritoneal tunnel with a section of the superficial layer of the right uterosacral ligament, preserving its deep nervous portion. Step 3: Dissection of the rectovaginal space, respecting the integrity of the rectal fascia. The rectovaginal space is fully dissected, and at its caudal edge the dissection is carried out laterally to the rectum upward to identify the pelvic parietal fascia covering the levator ani muscle, in the middle to the cranial edge of the perineal body. Preservation of the rectal fascia prevents possible injury to the middle rectal vessels and the rectal branches of the inferior hypogastric plexus, which runs close to the pelvic floor. The complete dissection of the rectovaginal space appears in an inverted V-shaped space covering approximately two-thirds of the posterior vaginal wall, with the apex at the convergence of the uterosacral ligaments. The procedure is completed with dissection of the vesicovaginal space through the creation of an avascular triangular-shaped space with the apex at the dorsal end of the bladder trigone and laterally limited by the superficial vascular layer of the vesicouterine ligaments. The bladder branches of the inferior hypogastric plexus run far from the surgical field in the deep portion of the vesicouterine ligaments. CONCLUSION: A nerve-sparing approach to pelvic spaces during LSP is feasible following well-defined surgical steps, which allow the surgeon to visualize all of the nerve pathways and potentially dangerous anatomic structures.

Combined sacrospinous hysteropexy and cystopexy using a single anterior incision.

OBJECTIVE: To evaluate the safety, efficacy, and feasibility of a minimally invasive vaginal approach for treating advanced utero-vaginal prolapse. METHODS: A prospective study enrolled consecutive patients attending the Gynecology and Obstetrics Department, Turin University for treatment of Pelvic Organ Prolapse Quantification (POP-Q) stage III of higher symptomatic utero-vaginal prolapse between February 1, 2013 and November 30, 2014. Participants underwent a combined sacrospinous hysteropexy and cystopexy procedure using a single anterior vaginal incision. Surgical procedures were performed by one of two surgeons, either an experienced senior surgeon or a resident surgeon under supervision. POP-Q staging, patient symptoms, and quality of life were evaluated before and after surgery. RESULTS: The present study enrolled 42 patients and 19 (45%) were discharged on the first post-operative day. The mean operating time was 40.5±10.6minutes and there was no significant difference in operating time between the two surgeons. With an average follow-up duration of 13months, significant post-surgical improvements were recorded across both POP-Q anterior (P<0.001) and apical (P<0.001) domains, and in both prolapse impact (P<0.001) and urinary impact (P=0.001) quality-of-life measures; one apical recurrence and no major complications were recorded. CONCLUSIONS: Combined sacrospinous hysteropexy and cystopexy through a single incision appears to be a safe and efficacious procedure that was relatively easy for surgeons to learn and resulted in a fast post-surgical recovery.

Advanced utero-vaginal prolapse and vaginal vault suspension: synthetic mesh vs native tissue repair.

PURPOSE: To compare prosthetic and ligament vaginal vault suspension at vaginal hysterectomy in patients, with utero-vaginal stage III-IV pelvic organ prolapse quantification. METHODS: A retrospective case-control study was designed to compare 61 patients who had undergone Posterior intravaginal slingplasty (PIVS) with 61 patients in a matched control group who had undergone uterosacral ligament suspension (ULS). The primary outcome was to compare anatomic vaginal vault failure rate. The secondary outcomes were subjective cure and cure without adverse events. RESULTS: Follow-up mean duration for the PIVS and ULS groups was 56.2 and 57.7 months, respectively. Recurrent vault prolapse was observed more frequently in the ULS group with pre-intervention stage IV prolapse (0 vs 14.8 %; p = 0.04), while there was no difference in prolapse recurrence at any vaginal site. Although the subjective cure of PIVS and ULS was superimposable (91.8 vs 86.9 %; p = 0.25), there was a significantly higher cure rate, without adverse events, in the ULS group (90.2 vs 100 %; p = 0.01). CONCLUSIONS: Non-mesh vaginal vault repair should be considered the first-line measure at vaginal hysterectomy; prosthetic repair should be used for therapeutic purposes in patients with vaginal vault recurrence and considered at vaginal hysterectomy only in selected subjects with complete utero-vaginal eversion.

Laparoscopic sacropexy and obstructed defecation syndrome: an anatomoclinical study.

INTRODUCTION AND HYPOTHESIS: Laparoscopic sacropexy (LSP) is associated with obstructed defecation syndrome (ODS) in 10-50% of cases. An anatomoclinical study was carried out to investigate whether there is any correlation between iatrogenic denervation during LSP and ODS. METHODS: Five female cadavers were dissected to identify possible sites of nerve injury during LSP. Subsequently, the videos of 18 LSP were blindly reviewed to assess the location of sacral dissection and tacks, the position and depth of the peritoneal tunnel, and another 4 variables. An anatomical triangle was defined on the right lumbosacral spine so as to clearly describe the sites of the surgical variables, which were then statistically correlated with the patients' postoperative outcome. RESULTS: The only variable associated with postsurgical ODS was dissection in the 90° angle of the anatomical triangle, where the superior hypogastric plexus was observed in all cadavers. CONCLUSIONS: Medial and midline dissection over the sacral promontory might be associated with postoperative ODS.

Posterior intravaginal slingplasty: efficacy and complications in a continuous series of 118 cases.

INTRODUCTION AND HYPOTHESIS: Posterior intravaginal slingplasty (PIVS) is a minimally invasive procedure that aims to suspend vaginal vault. Our study evaluated efficacy and complications of PIVS at long-term follow-up. METHODS: One hundred eighteen consecutive women underwent PIVS operation for Pelvic Organ Prolapse Quantification stage 3 or 4 vaginal cuff prolapse (VCP; 25 patients) or utero-vaginal prolapse (UVP; 93 patients). Apical vaginal wall at stage 0 or 1 was considered as cured. RESULTS: Follow-up mean duration was 58.6 months (range, 24-84 months). The success rate of PIVS was 96.6%. Some 8.5% mesh erosion (20% in patients with VCP and 5.4% with UVP), 2.5% vaginal-perineal fistula, and 3.4% paravaginal hematoma occurred. Neither erosion nor fistulas occurred with monofilament polypropylene mesh. CONCLUSION: PIVS seems a safe and effective procedure for VCP and UVP. Vaginal erosion was mainly observed in patients with VCP treated with multifilament polypropylene mesh.