Robotic radical stump trachelectomy: Critical steps of a radical procedure without normal anatomical landmarks.

Background: Cervical stump malignancies are an uncommon finding post subtotal hysterectomy. Tumors arise from a primary cervical origin with an incidence of 1-5%. Other described malignancies can include uterine origin, ovarian origin or as metastases from another primary site. A uterine primary is an extremely rare entity and can result from remnant endometrial tissue at the stump apex. Case: 70yo female with a history of remote supracervical hysterectomy for benign indication who presented with postmenopausal spotting. Endocervical curettage of the endocervical stump revealed a grade 2 endometrioid endometrial adenocarcinoma. She was taken to the operating for a robotic radical stump trachelectomy and sentinel lymph node dissection. Conclusions: The surgical video delineates key surgical steps of robotic radical stump trachelectomy including robotic port placement and injection of ICG dye, adhesiolysis and restoration of normal anatomy, opening of the pelvic spaces and exposure of the retroperitoneum, identification and excision of pelvic sentinel lymph nodes, bladder dissection, ureterolysis and ligation of uterine remnant, ureteric tunnel dissection and mobilization of parametrial wing, delineation of a vaginal margin, colpotomy and specimen removal, and vaginal cuff closure.

Cross-sectional survey of surgical practices among gynecologic oncologists in the United States.

OBJECTIVE: We sought to document current surgical practices among gynecologic oncologists in the United States. METHODS: In March/April 2020, we conducted a cross-sectional survey among members of the Society of Gynecologic Oncology to identify gynecologic oncology practice trends in the United States. The survey collected demographic data and queried participants on types of surgical procedures performed and chemotherapy use. Univariant and multivariant analyses were used to evaluate the association between surgeon practice type, region of practice, working with gynecologic oncology fellows, time in practice, and dominant surgical modality of practice on performance of specific procedures. RESULTS: Among 1199 gynecologic oncology surgeons who were emailed the survey, 724 completed the survey (60.4% response rate). Of these respondents, 170 (23.5%) were within 6 years of fellowship graduation, 368 (50.8%) identified as female; and 479 (66.2%) worked in an academic setting. Surgeons who worked with gynecologic oncology fellows were more likely to perform bowel surgery, upper abdominal surgery, complex upper abdominal surgery, and prescribe chemotherapy. Surgeons who were ≥ 13 years out from fellowship graduation were more likely to perform bowel surgery and complex abdominal surgery and less likely to prescribe chemotherapy and perform sentinel lymph node dissections (P < 0.05). CONCLUSIONS: These findings highlight the variation in surgical procedures performed by gynecologic oncologists in the United States. These data support that there are practice variations that would benefit from further investigation.

Case Report: Durable complete pathologic response and organ preservation following ipilimumab and nivolumab for locally advanced primary vaginal mucosal melanoma.

Optimal management of locally advanced vaginal mucosal melanoma is poorly understood because of its rarity and unique biology. Patients have a poor prognosis despite aggressive management approaches including pelvic exenteration and adjuvant radiation that carry major morbidities. We report a case of a patient in early 40's who experienced complete pathologic response and organ preservation following immunotherapy consisting of 3 cycles of ipilimumab and nivolumab. Treatment was complicated by a high-grade immune mediated hepatitis that eventually resolved with immunosuppressive therapy. Immune monitoring studies utilizing vaginal tumor biopsies showed evidence of enhanced infiltration by CD3+/CD8+ cytotoxic T-cells and increased expression of MHC-I/PD-L1 within the tumor microenvironment following immunotherapy. The patient continues to be without evidence of disease recurrence by radiologic and gynecologic examinations with more than 2 years of follow up from the time of immunotherapy initiation. To our knowledge, this is the only case report in the literature of a patient with locally advanced vaginal mucosal melanoma experiencing a durable complete pathologic response and organ preservation following immune checkpoint blockade as the only treatment approach.

The impact of distance to closest negative margin on survival after pelvic exenteration.

OBJECTIVE: To determine the effect of distance to closest negative margin on survival after pelvic exenteration (PE). METHODS: In this retrospective analysis of PE at Moffitt Cancer Center from 2000 to 2019, baseline characteristics, clinical details, and outcomes were ascertained. Distance to closest negative margin was measured. Close and distant negative margins were defined as <3 mm and ≥3 mm from malignancy to nearest surgical margin, respectively. Overall survival (OS) and progression-free survival (PFS) were determined, and Kaplan-Meier curves were compared. Cox proportional hazards regression was used to examine the association of margin status with OS and PFS. RESULTS: Of 124 PEs with malignancy, 80 (64.5%) had negative margins. Median survival was 62 (95% confidence interval [CI] 27-70) months for negative and 21 (95% CI 15-29) months for positive margins. Of 76 with negative margins and documented margin length, 26 had close and 50 had distant margins. Median survival was 32 (95% CI 14-62) months for close and 111 (95% CI 42-166) months for distant margins. Distant margins were associated with improved OS (p = 0.0054) and PFS (p = 0.0099) compared to close margins. After adjusting for other prognostic factors, patients with distant margins had significantly decreased risk of all-cause mortality (HR 0.39, 95% CI 0.19-0.78; p = 0.008) and progression (HR 0.48, 95% CI 0.23-0.99; p = 0.04) compared to positive margins. No significant differences in OS or PFS were observed between close and positive margins. This survival benefit remained among those with cervical cancer. Median survival in this cohort was 34.1 (95% CI 2.0-69.8) months for close and 165.7 (95% CI 24.5-165.7) for distant margins. CONCLUSIONS: Distant margins following PE are associated with improved OS and PFS compared to close margins.

Trends in ureteral surgery on an academic gynecologic oncology service.

OBJECTIVE: To describe the incidence, complications, and trends associated with ureteral surgeries on a gynecologic oncology service in the context of a fellowship training program over a 24-year period. METHODS: We conducted a retrospective cohort analysis of ureteral surgeries by gynecologic oncologists at either Moffitt Cancer Center or Tampa General Hospital from 1997 to 2020. Patient characteristics, predisposing factors, location and type of injury, repair method, postoperative management and complications were abstracted from the medical record. The recent cohort (2005-2020) was compared to our prior series (1997-2004). RESULTS: Eighty-eight cases were included. The average number of ureteral surgeries per year decreased from 5.75 (1997-2004) to 2.63 (2005-2020). Of 46 iatrogenic injuries, 45 were recognized and repaired intraoperatively. Ureteral transection was the most common type (85% [39 of 46]) and the distal 5 cm was the most common location of injury (63% [29 of 46]). Ureteroneocystostomy was the most common method of repair (83% [73 of 88]). Postoperative management, including stenting and imaging, has not changed significantly. Length of urinary catheter usage decreased in the recent cohort without associated complications. Five patients had major postoperative complications and 4 involved the urinary tract. Of those with follow-up, 96% (66 of 69) of ureteroneocystostomies and 75% (9 of 12) of ureteroureterostomies had radiologically normal urinary tracts. CONCLUSIONS: Ureteral surgery is necessary in the case of injury or involvement with invasive disease. There has been a decrease in number of procedures. Ureteroneocystostomy has remained the most common method of reconstruction for both injury and resection with acceptable postoperative complication rates.

Major vascular injury during gynecologic cancer surgery.

OBJECTIVE: Vascular injury during major gynecologic cancer surgery is a rare but potentially fatal complication. The purpose of this study was to review our experience with major vascular injury during gynecologic cancer surgery. METHODS: This was a retrospective chart review of women undergoing surgery by our gynecologic oncology department from 7/1/99 to 6/30/20 who had a major vascular injury. We identified women who sustained a vascular injury by a combination of CPT code and medical record searches, fellow case logs and a list maintained for an ongoing quality assurance program. Data were expressed as median and range for continuous variables and as frequency and percentage for categorical variables. Fisher's exact test was used to analyze differences in complication rates between groups. RESULTS: Major vascular injury was identified in 52 patients and procedures. The inferior vena cava was the most common site of injury, 32.7% (17/52), followed by the external iliac vein, 23.1% (12/52). Lymph node dissection was the most common time for a vascular injury to occur 51.9% (27/52). The majority of injuries required suture repair, 80.8% (42/52). Estimated blood loss in cases with vascular injury ranged from 100 mL to massive unquantifiable blood loss in the case of an aortic injury. Patients required a median of 2units of packed red blood cells. Postoperative complications included anemia requiring blood transfusion, 19.6% (9/46) and venous thromboembolism, 19.6% (9/46). CONCLUSIONS: Vascular injury remains a rare but potentially morbid complication of gynecologic oncologic surgery. Prompt recognition and management are imperative in minimizing persistent bleeding and complications.

Surgical training in gynecologic oncology: Past, present, future.

The purpose of this paper is to review the surgical care related to training in gynecologic oncology, from past, present and future perspectives. A marked decline in the incidence of cervical cancer as well as improvements in radiation therapy have led to a reduction in the numbers of radical hysterectomies and exenterations being performed. Utilization of neoadjuvant chemotherapy is reducing the extent of cytoreductive operations, including intestinal surgery. The incorporation of sentinel lymphatic mapping has reduced the number of pelvic, paraaortic and inguinal lymphadenectomies being performed. Coupled with these changes are other factors limiting time for surgical training including an explosion in targeted anticancer therapies and more individualized options beyond simple cytotoxic therapy. With what is likely to be a sustained impact on training, gynecologic oncologists will still provide a broad range of care for women with gynecologic cancer but may be quite limited in surgical scope and rely on colleagues from other surgical disciplines. Enhancement of surgical training by off-service rotations, simulation, attending advanced surgical training courses and/or a longer duration of training are currently incorporated into some programs. Programs must ensure that fellows take full advantage of the clinical materials available, particularly those related to the potential deficiencies described. Changing required research training to an additional elective year could also be considered. Based on the perspectives noted, we believe it is time for our subspecialty to reevaluate its scope of surgical training and practice.

High-dose intensity-modulated chemoradiotherapy in vulvar squamous cell carcinoma: Outcome and toxicity.

INTRODUCTION: To evaluate clinical outcomes, pattern of failure, and toxicity after high-dose intensity-modulated radiation therapy (IMRT) for advanced vulvar cancer. METHODS: In this IRB approved retrospective study, the charts of women with histologically confirmed, non-metastatic vulvar cancer consecutively treated at our institution from 2012 to 2018 were reviewed to identify patients that received high-dose IMRT with curative intent. The treatment compliance, toxicities, and patterns of failure were investigated. Actuarial local, regional and distant recurrence and survival were estimated using Kaplan-Meier method and compared using log rank test. RESULTS: Twenty-six patients were identified, 23 were unresectable, and 3 refused surgery. Fifteen patients (58%) had inguinal node metastases; 10(38%) had pelvic node metastases. Elective surgical staging of groins was performed in 9-patients. Median tumor dose was 65.4Gy. Concurrent platinum-based chemotherapy was administered in 22(84.6%) patients. Complete response (CR) was achieved in 21/26 (80.7%) patients. Five patients had persistent disease following treatment and one sustained recurrence 5-months following radiotherapy. All persistent or recurrent disease occurred inside the irradiated volume. Median follow-up was 19 months (3-52 months). Actuarial 1-year local, regional and distant controls were 72.4%, 85.4%, and 86%, respectively. One and 2-year overall survivals were 91% and 62%, respectively. Complete response at 3-months was a strong predictor for overall survival (1-yr OS 73% vs 27%, HR 7.1 (95% CI 1.2-44); p = 0.01). Lymph node metastases adversely affected overall survival (2-yr OS 49% vs. 83%, p = 0.09). Grade 3-4 late urinary and soft-tissue toxicity was seen in 5 patients. Tumor doses >66 Gy (p = 0.03) and prior pelvic radiotherapy (p = 0.002) predicted grade 3-4 toxicity. CONCLUSION: High-dose IMRT for vulvar cancer achieves high rates of local control with acceptable dose dependent long-term toxicity.

Simulated management of inferior vena cava injury during robotic paraaortic lymphadenectomy utilizing the porcine model.

Injury of the inferior vena cava is an infrequent but serious complication of paraaortic lymphadenectomy. Training in the management of this injury might be enhanced through animate simulation. Our objective was to assess a simulated animal model for training in intraoperative management of inferior vena cava injury in the context of robotic paraaortic lymphadenectomy. We used a female domestic pig to create an injury of the inferior vena cava, which was then managed two ways with robotically assisted surgery. Edited videos of the two models were assessed by 32 senior learners and 23 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The injury and management simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Specifically, a reduced rapidity of bleeding and a related greater ease of control contributed to lower ratings for some aspects of fidelity. Fidelity and addressing the key competency of suture repair also received some lower ratings, particularly from vascular surgeons and their trainees. The porcine model for simulation of inferior vena cava injury during robotically assisted paraaortic lymphadenectomy may be useful for training purposes.

Twenty-year surgical trends in a gynecologic oncology fellowship training program: Implications for practice.

OBJECTIVE: To assess whether there were any significant changes in surgical training volume over the past 20 years that might have ramifications toward preparedness for practice. METHODS: We used deidentified annual summaries of fellow case numbers for the academic years 1999 through 2018. Unpaired t-tests with Welch's correction were performed on all surgical categories for 10-year and 5-year periods. RESULTS: The total number of hysterectomies performed each year did not change significantly. The percent of hysterectomies performed by minimally invasive surgery increased significantly starting in 2008. There was a significant decline in the number of radical hysterectomies conducted starting after 2004, which then remained stable. There was also a significant decline in the number of bowel resections/anastomoses performed by fellows on the gynecologic oncology services that occurred and stabilized during the same time frame. There were other significant trends associated with the introduction of minimally invasive techniques. CONCLUSION: The results of this study suggest the need to reevaluate fellowship training and/or the scope of surgical practice in gynecologic oncology.

Simulated management of urinary tract injury during robotic pelvic surgery utilizing the porcine model.

Urologic injury is an infrequent but serious complication of pelvic surgery. Training in the assessment and management of this injury might be enhanced through animated simulation. Our objective was to assess the intraoperative management of urologic injury with robotic pelvic surgery using a simulated injury animal model. We used a female domestic pig to create three types of urologic injury, which we then managed with robotically assisted surgery. An edited video of the model was assessed by 14 senior learners and 10 attending faculty. The assessments included key competencies and domains of fidelity. A scale of poor, fair, or good was utilized. The defects and repairs simulated those seen in humans, both anatomically and surgically, although deficiencies were noted. Related to fidelity of the anatomy of the ureter and bladder, lower ratings were given for some of the key competencies (determining the relationship to the trigone, ureteral mobilization, repair of all 3 injuries). The porcine model for simulation of urologic injury during robotically assisted pelvic surgery may be useful for training purposes.

Increased RHAMM expression relates to ovarian cancer progression.

BACKGROUND: Elevated hyaluronan-mediated motility receptor (RHAMM) has been reported to contribute to disease progression, aggressive phenotype and poor prognosis in multiple cancer types, however, RHAMM's role in ovarian cancer (OC) has not been elucidated. Therefore, we sought to evaluate the role for RHAMM in epithelial OC. RESULTS: Despite little to no expression in normal ovarian surface epithelium, western immunoblotting, immunohistochemical staining and enzyme linked immunosorbent assay showed elevated RHAMM levels in clinical tissue sections, omental metastasis and urine specimens of serous OC patients, as well as in cell lysates. We also found that RHAMM levels increase with increasing grade and stage in serous OC tissues and that RHAMM localizes to the apical cell surface and inclusion cysts. Apical localization of RHAMM suggested protein secretion which was validated by detection of significantly elevated urinary RHAMM levels (p < 0.0001) in OC patients (116.66 pg/mL) compared with normal controls (8.16 pg/mL). Likewise, urinary RHAMM levels decreased following cytoreductive surgery in OC patients suggesting the source of urinary RHAMM from tumor tissue. Lastly, we validated RHAMM levels in OC cell lysate and found at least 12× greater levels compared to normal ovarian surface epithelial cells. CONCLUSION: This pilot study shows, for the first time, that RHAMM may contribute to OC disease and could potentially be used as a prognostic marker.

Urinary interleukin-1ß levels among gynecological patients.

BACKGROUND: Early detection of epithelial ovarian cancer (OC) is necessary to overcome the high mortality rate of late stage diagnosis; and, examining the molecular changes that occur at early disease onset may provide new strategies for OC detection. Since the deregulation of inflammatory mediators can contribute to OC development, the purpose of this pilot study was to determine whether elevated urinary levels of Interleukin-1beta (IL-1 beta) are associated with OC and associated clinical parameters. METHODS: Urinary and serum levels of IL-1 beta were analyzed by ELISA from a patient cohort consisting of healthy women (N = 10), women with ovarian benign disease (N = 23), women with OC (N = 32), women with other benign gynecological conditions (N = 22), and women with other gynecological cancers (N = 6). RESULTS: Average urinary IL-1 beta levels tended to be elevated in ovarian benign (1.26 pg/ml) and OC (1.57 pg/ml) patient samples compared to healthy individuals (0.36 pg/ml). Among patients with benign disease, urinary IL-1ß levels were statistically higher in patients with benign inflammatory gynecologic disease compared to patients with non-inflammatory benign disease. Interestingly, urinary IL-1 beta levels tended to be 3-6x greater in patients with benign ovarian disease or OC as well as with a concomitant family history of ovarian and/or breast cancer compared to similar patients without a family history of ovarian and/or breast cancer. Lastly, there was a pattern of increased urinary IL-1 beta with increasing body mass index (BMI); patients with a normal BMI averaged urinary IL-1 beta levels of 0.92 pg/ml, overweight BMI averaged urinary IL-1 beta levels of 1.72 pg/ml, and obese BMI averaged urinary IL-1 beta levels of 5.26 pg/ml. CONCLUSIONS: This pilot study revealed that urinary levels of IL-1 beta are elevated in patients with epithelial OC supporting the thought that inflammation might be associated with cancer progression. Consequently, further studies of urinary IL-1 beta and the identification of an inflammatory profile specific to OC development may be beneficial to reduce the mortality associated with this disease.

Elevated human chorionic gonadotropin and hyperandrogenemia in a woman with Müllerian agenesis.

BACKGROUND: Müllerian agenesis is a congenital malformation characterized by absence of the uterus, cervix, and upper vagina. A positive home pregnancy test in a woman with Müllerian agenesis mandated evaluation for malignancy. CASE: A woman with Müllerian agenesis presented with elevated levels of human chorionic gonadotropin (hCG), testosterone, and dehydroepiandrosterone sulfate. Pelvic magnetic resonance imaging (MRI), abdominal and pelvic computed tomography scan, chest computed tomography scan, brain MRI, and body positron emission tomography scan did not identify a malignancy. Human chorionic gonadotropin characterization revealed 74% hyperglycosylated and 1.6% free ß-hCG, suggesting a trophoblast-containing tumor. Interventional ovarian venous sampling and repeat pelvic MRI suggested a right adnexal source. After laparoscopic removal of a stage 1C right ovarian dysgerminoma, hCG and testosterone returned to normal. CONCLUSION: A dysgerminoma coincident with Müllerian agenesis expressed hCG before detection by MRI. Human chorionic gonadotropin molecular characterization, ovarian vein sampling, and repeat pelvic MRI led to successful treatment.

Ureteral transection repaired during robot-assisted surgery.

During robot-assisted surgery for endometrial cancer, a ureteral injury occurred in two women. Both injuries were repaired successfully with robot-assisted surgery. One of the injuries and its repair are shown in an edited video clip. Ureteral injury is a known complication of gynecologic surgery (Hoffman in OBG Manag 20:16-28, 2008). Transection of the pelvic ureter proximal to the parametrium may be repaired by reapproximation or reimplantation. Robot-assisted surgery has recently been established as useful for the performance of ureteral surgery (Kasturi et al. in Urology 79:680-683, 2012; Rehman et al. in Can J Urol 18:5548-5556, 2011; Patil et al. in Urology 72:47-50, 2008).

Simulation of robotic hysterectomy utilizing the porcine model.

OBJECTIVE: This article describes the simulation of robotically assisted hysterectomy utilizing the porcine model. STUDY DESIGN: Utilizing 3 domestic pigs, a technique for robotically assisted hysterectomy was developed. An edited video clip of the model was assessed by 6 gynecological surgeons. RESULTS: The steps of the operation are described in detail and are shown in a video clip. Overall the procedure simulated that done in the human both anatomically and surgically. Some of the evaluators rated the identification of the cervicovesical junction to be more difficult and division of the paracervical ligaments to be relatively easier in the model. CONCLUSION: Reported here is a technique for robotically assisted hysterectomy in the domestic pig that may be useful for training purposes.

Preoperative enoxaparin is safe to use in major gynecologic surgery for prophylaxis of venous thromboembolism: a retrospective cohort study.

OBJECTIVE: To evaluate the safety of preoperative enoxaparin in patients undergoing major gynecologic oncology surgery. METHODS: We identified a retrospective cohort group of patients undergoing major gynecologic oncology surgery from June 2002 to June 2004. Exclusion criteria included laparoscopic surgery, inferior vena cava filter, history of venous thromboembolism, and current anticoagulation for prior venous thromboembolism. All patients received prophylaxis with sequential pneumatic compression devices and early ambulation. We identified patients who received (preoperative and postoperative) enoxaparin (20-40 mg) and compared them to patients who received no additional prophylaxis other than pneumatic compression alone. Patient outcomes including estimated blood loss, blood transfusions, operative time, and length of hospital stay were collected. Statistical analysis was performed using the χ Wilcoxon rank sum tests. This study was approved by the institutional review board. RESULTS: We identified 122 patients who met our study criteria; there were 63 patients who received preoperative enoxaparin and 59 patients who received no additional prophylaxis. Both groups were similar in age, body mass index, race, comorbidities, cancer diagnosis, and surgical procedure. There was no significant difference between the enoxaparin group and the sequential pneumatic compression devices-only group regarding transfusion rates (29% and 27%; P = 0.86), operating time (150 and 140 minutes; P = 0.16), blood loss greater than 500 cc (35% and 37%; P = 0.79), and length of stay (5 vs 6 days). CONCLUSION: The use of preoperative enoxaparin is not associated with increased blood loss, transfusion requirements, operative time, or hospital stay among patients having major gynecologic surgery.

Fallopian tube carcinoma in a patient with a pelvic kidney: surgical management with the da Vinci robot.

A patient with a known pelvic kidney and early fallopian tube carcinoma was managed with robotically assisted surgery. Associated conginital anomalies were noted and described. The final stage of the cancer was 1C, grade 3 and she is without evidence of recurrent cancer 2 years following completion of chemotherapy.

Venous injury during lymphadenectomy: management without laparotomy.

During robotically-assisted pelvic lymphadenectomy, four venous injuries occurred that did not resolve with pressure. After the application of tightly woven, oxidized regenerated cellulose and a fibrin sealant, all four venotomies were hemostatic. There were no sequelae.

Morbidity associated with nonemergent hysterectomy for placenta accreta.

OBJECTIVE: The purpose of this study was to report the morbidity of nonemergent hysterectomy for suspected placenta accreta. STUDY DESIGN: This was a retrospective study of all patients who underwent nonemergent hysterectomy for placenta accreta at Tampa General Hospital from June 1, 2003 to May 31, 2009. RESULTS: Twenty-nine patients were identified. Diagnosis was suspected on ultrasound scanning in 26 women (6 women also underwent magnetic resonance imaging) and on direct vision at repeat cesarean section delivery in 3 women. All of the women were multiparous, and 18 women had undergone > or =2 cesarean section deliveries. Twenty-one women had a placenta previa, and 8 women had a low anterior placenta. Final pathologic findings revealed accreta (20 specimens), increta (6 women), and percreta (3 women). Mean total operative time was 216 minutes; blood loss was 4061 mL. Two women had ureteral transection (1 was bilateral); 3 women had cystotomy, and 3 women had partial cystectomy. Postoperative hemorrhage occurred in 5 women; 1 hemorrhage resolved after catheter embolization, and the other 4 hemorrhage required reoperation. CONCLUSION: Nonemergent hysterectomy for placenta accreta is associated with significant morbidity in the forms of hemorrhage and urinary tract insult.