Laparoscopic-Assisted Vaginal Hysterectomy With Dense Bladder Adhesions and Absent Cervix: A Case Report With a Descriptive Video of the Entire Procedure.

Hysterectomy is one of the most frequently performed surgical procedures in the United States. Hysterectomy for benign gynecological reasons can be performed through several approaches: abdominal, laparoscopic, laparoscopically assisted vaginal, robotic-assisted, and vaginal natural orifice hysterectomy. The choice of approach is strongly influenced by factors such as previous procedures, safety, and recovery process. Currently, vaginal hysterectomy, laparoscopic-assisted vaginal hysterectomy (LAVH), assisted vaginal hysterectomy, and robotic-assisted vaginal hysterectomy are considered minimally invasive approaches with multiple benefits to the patient such as less trauma, shorter operative time, and shorter postoperative period. However, in patients with pelvic adhesions, adhesions within the abdominal cavity, especially omental adhesions to the abdominal wall, and adhesions between the uterus and the bladder caused by multiple cesarian sections or prior surgery on the cervix, these minimally invasive approaches are problematic. In this report, we describe in detail our approach to LAVH in a patient with severe abdominal adhesions and an absent cervix. We believe that our approach is safe and relatively fast compared to an open abdominal procedure and, therefore, it may help gynecologic surgeons-in-training nationwide.

A rare simultaneous occurrence of splenic and ovarian hydatid cyst: A case report.

INTRODUCTION AND IMPORTANCE: Hydatid disease is an infectious illness caused by a parasite called Echinococcus. It can affect any organ, primarily the liver and lungs. The occurrence of splenic or ovarian hydatid cyst is rare; simultaneous involvement of both is extremely uncommon. This case report provides valuable insights to clinicians, guiding them to consider a hydatid cyst as a potential differential diagnosis in the presence of a cystic mass lesion. CASE PRESENTATION: A 33-year-old female presented with abdominal pain of 10 years duration. The past medical and surgical history was negative. Ultrasound and CT scans of the abdomen showed double-layered splenic (15.3 cm × 12.8 cm × 15 cm) and pelvic (8.4 cm × 10.3 cm × 9 cm) cysts. Laparotomy revealed splenic and ovarian hydatid cysts with adhesions to surrounding structures. We performed total splenectomy and left salphingo-opherectomy, yielding excellent outcome. DISCUSSION: Hydatid cysts of the spleen and ovary are rare, with few case reports. It is usually secondary to systemic dissemination or intra-peritoneal spread from a ruptured hepatic cyst. Imaging modalities such as ultrasound and CT scans can aid in reaching a diagnosis. The standard treatment for a hydatid cyst is surgery. CONCLUSION: The simultaneous occurrence of hydatid cysts in the spleen and ovary is rare. The diagnosis is challenging due to nonspecific clinical presentations, necessitating a high level of suspicion. Surgery is the primary treatment for hydatid cysts.

Ovarian cancer risk management in BRCA-mutation carriers: A comparison of six international and national guidelines.

OBJECTIVE: Germline mutations in the BRCA gene account for most hereditary ovarian and breast cancer. Management of healthy carriers aims to prevent and allow early detection of breast and ovarian cancer. This study compares six different hereditary ovarian cancer management guidelines, highlighting areas of controversy between different societies. We aim to compare international and national guidelines regarding BRCA carriers' management. STUDY DESIGN: A comparative study. We retrieved, reviewed, and compared the most recent guidelines of BRCA mutation carriers from the specializing societies NCCN (National Comprehensive National network) and ESMO (European society of medical oncology), and national societies of the United States (American College of Obstetricians and Gynecologists), England (the Royal College of Obstetricians and Gynecologists), Canada (the Society of Obstetricians and Gynaecologists of Canada) and Spain (Sociedad Española de Oncología Médica). RESULTS: There is a broad consensus regarding the limited role of screening for early ovarian cancer detection (4 out of 6) (4/6) and regarding the recommendation for implementation of Risk-reducing salpingo-oophorectomy (RRSO) (6/6), some variations exist for age at RRSO. It is widely accepted that risk reducing salpingectomy should be performed only as part of research (5/6), and that the addition of risk-reducing hysterectomy should be individualized (3/6). Not all guidelines address fertility issues, and controversy exists regarding hormone replacement therapy (HRT) recommendations in unaffected young BRCA-mutation carriers following RRSO. CONCLUSION: BRCA carrier's management guidelines consist of well-agreed topics such as the ineffective screening for early detection of ovarian cancer and the recommendation of RRSO. HRT remains controversial. Conforming unified recommendations is needed for providing evidence-based recommendations.

Risk-reducing salpingo-oophorectomy and breast cancer incidence among Jewish BRCA1/BRCA2-mutation carriers-an Israeli matched-pair study.

OBJECTIVE: To study the association of risk-reducing bilateral salpingo-oophorectomy (RRBSO) and breast cancer risk among BRCA pathogenic sequence variants (PSV). METHODS: Jewish Israeli BRCA carriers who underwent RRBSO were matched with those who did not-by the mutated gene and year of birth (±1 year). Breast cancer rates were compared. RESULTS: Overall, 127 pairs met the inclusion criteria, 79 (60.6%) pairs harbored BRCA1 PSV and 50 (39.4%) pairs harbored BRCA2 PSV. Median follow up was 8.7 years (interquartile range 4.6-16.1 years). Breast cancer rate for all BRCA carriers combined was not affected by RRBSO (RRBSO 21 [16.5%] versus no RRBSO 31 [24.4%], hazard ratio [HR] for breast cancer 0.61, 95% confidence interval [CI] 0.33-1.14, P = 0.127). No association between RRBSO and breast cancer incidence was noted among BRCA1 PSV carriers. In BRCA2 PSV carriers, RRBSO was associated with a decreased overall breast cancer incidence (HR 0.20, 95% CI 0.44-0.91, P = 0.038), as well as after 5, 10, 15, and 20 years. Hormone replacement therapy was used by 62 PSV carriers, 52 in the RRBSO group and 10 in the no-RRBSO group and did not affect breast cancer risk (P = 0.463). CONCLUSION: RRBSO is associated with breast cancer risk reduction in Jewish Israeli BRCA2 PSV carriers. Risk-reducing bilateral salpingo-oophorectomy was associated with breast cancer risk reduction in Jewish Israeli BRCA2 pathogenic sequence variant carriers.

The largest reported papillary thyroid carcinoma arising in struma ovarii and metastasis to opposite ovary: case report and review of literature.

BACKGROUND: Malignant struma ovarii (MSO) is a very rare, germ cell tumor of the ovary, histologically identical to differentiated thyroid cancers. Struma ovarii (SO) is difficult to diagnose on clinical basis or imaging and is mostly discovered incidentally, with few published cases in the literature. CASE PRESENTATION: A 42-year old primiparous woman presented with abdominal pain and midline pelvic palpable firm mass arising from the pelvis. Imaging showed pelvic solid cystic mass. Total abdominal hysterectomy, bilateral salpingo-oopherectomy (TAH BSO) and infracolic omentectomy were performed. Histopathology revealed left ovary papillary thyroid carcinoma (PTC) arising in SO (11 cm) and metastatic papillary thyroid carcinoma in the right ovary. Thyroid functions tests were all normal, ultrasound thyroid showed two complex nodules in the left thyroid lobe. Total thyroidectomy was decided, but the patient refused further surgical management and was lost to follow up as she left the country. We undertook a comprehensive literature search, and MSO and thyroid management data from 23 additional publications were analyzed and tabulated. This PTC MSO is probably the largest reported in the literature. CONCLUSIONS: Among the different surgeries for MSO, TAH + BSO appears to have the best clinical outcome. However, unilateral salpingo-oopherectomy/ unilateral oophorectomy and bilateral salpingo-oopherectomy also seem effective. Ovarian cystectomy alone seems associated with higher recurrence. There remains no consensus on the associations between MSO tumor size and potential extent of metastasis, and about the management of thyroid gland. However, surveillance and thyroid gland work up to detect concurrent thyroid cancer are recommended.

Analysis of the factors determining the type of surgical procedure in mature cystic teratomas.

OBJECTIVES: It was aimed to evaluate which factors determine the surgical procedure selected by surgeons for cases with mature cystic teratoma (MCT). MATERIAL AND METHODS: This study included 50 cases with histopathologically proven MCT between January 2011 and August 2016 at a tertiary reference hospital. Data related to demographic and clinical characteristics were retrieved from medical records. Multivariate logistic regression analysis was conducted to evaluate the independent factors determining the type of surgical procedure to be applied. RESULTS: A higher rate of patients with large cyst size and elevated CA 19-9 was determined in the postmenopausal patients compared to the premenopausal patients (p = 0.033, p = 0.035). Cystectomy and oopherectomy were applied to 72.55% and 27.5% of the cases respectively. No recurrence in the operated ovary was observed in the 1-year follow-up period in any of the cystectomy cases. The major and only independent variable for the preference of cystectomy over oopherectomy was found to be a younger age (≤ 40 years). There was no independent variable which predicted the selection of laparoscopy or laparotomy by surgeons. CONCLUSIONS: Cystectomy was seen to be preferred by surgeons in the majority of MCT patients aged ≤ 40 years regardless of the size of the cyst. This is plausible since these patients have greater concerns about future fertility compared to patients > 40 years old. No recurrence was detected in any of the cystectomy cases, which strengthens the feasibility of this procedure. No serious complications developed in laparoscopy which could render it a safe option for undertaking cystectomy/oopherectomy in MCT cases.

The Role of Routine Peritoneal and Omental Biopsies at Risk-Reducing Salpingo-Oophorectomy.

STUDY OBJECTIVE: To assess the potential role of peritoneal and omental biopsies in women undergoing risk-reducing salpingo-oopherectomy (RRSO) for prophylactic management of hereditary breast/ovarian cancer (HBOC) syndromes. DESIGN: A retrospective observational cohort (Canadian Task Force classification II.1). SETTING: An academic gynecology practice. PATIENTS: All women who underwent RRSO for a high-risk BRCA1/2 mutation or deletion at a single institution between January 2003 and June 2016. INTERVENTIONS: After obtaining institutional review board approval, patient demographics, types of surgical intervention, histopathology reports, and outcomes were abstracted. Bilateral fallopian tubes were histologically evaluated using the "sectioning and extensively examining of the fimbriated end" protocol. Descriptive statistics were used to summarize findings. MEASUREMENTS AND MAIN RESULTS: Seventy women underwent RRSO within the study window; 60% (n = 42) carried a high-risk mutation in BRCA1, 37.1% (n = 26) carried a high-risk mutation in BRCA2, and 2.9% (n = 2) had a high-risk BRCA deletion identified by BRAC analysis rearrangement testing (BART). Serous tubal intraepithelial carcinomas were identified in the distal fallopian tube of 3 subjects. In addition to RRSO, subjects underwent pelvic washings (n = 58, 82.9%), omental biopsy (n = 44, 62.9%), peritoneal biopsies of the bilateral paracolic gutters (n = 51, 72.9%), anterior and posterior cul-de-sac (n = 53, 75.7%), and rectosigmoid mesentery (n = 11, 15.7%). Rare atypical cells favoring reactive cells were identified in pelvic washings of 1 subject (1.7%) with histologically normal fallopian tubes. No evidence of atypical mesothelial proliferations or carcinoma was identified in any omental or peritoneal biopsies. The mean duration of follow-up was 32.5 ± 24.7 months. At the last contact, 3 women (4.3%) had died of metastatic breast cancer, whereas another 3 (4.3%) had been diagnosed with a recurrence of their breast cancer. All other subjects were alive and well (n = 64, 91.4%). CONCLUSION: The routine use of peritoneal and omental biopsies for women undergoing RRSO does not appear to improve detection of occult malignancy.

Effect of salpingectomy, ovarian cystectomy and unilateral salpingo-oopherectomy on ovarian reserve.

Pelvic surgery can affect ovarian reserve, but estimates of the potential effect of different surgical procedures are lacking. This study examines the markers of ovarian reserve after different procedures in order to help the provision of informed consent before surgery. Anti-Müllerian hormone (AMH), antral follicle count (AFC) and follicle-stimulating hormone (FSH) of women with a history of salpingectomy, ovarian cystectomy or unilateral salpingo-oophorectomy were compared to those without history of surgery using cross-sectional data adjusting for patient and clinical factors in multivariable regression model. There were 138 women who had had salpingectomy, 36 unilateral salpingo-oopherectomy, 41 cystectomy for ovarian cysts that are other than endometrioma and 40 women had had excision of endometrioma. There was no significant difference in AMH (9 %; p = 0.33), AFC (-2 %; p = 0.59) or FSH (-14 %; p = 0.21) in women with a history of salpingectomy compared to women without surgery. Women with a history of unilateral salpingo-oophorectomy were found to have significantly lower AMH (-54 %; p = 0.001). These women also had lower AFC (-28 %; p = 0.34) and higher FSH (14 %; p = 0.06), the effect of which did not reach statistical significance. The study did not find any significant associations between a history of cystectomy, for disease other than endometrioma and AMH (7 %; p = 0.62), AFC (13 %; p = 0.18) or FSH. (11 %; p = 0.16). Women with a history of cystectomy for ovarian endometrioma had 66 % lower AMH (p = 0.002). Surgery for endometrioma did not significantly affect AFC (14 %; p = 0.22) or FSH (10 %; p = 0.28). Salpingo-oopherectomy and cystectomy for endometrioma cause a significant reduction in AMH levels. Neither salpingectomy nor cystectomy for cysts other than endometrioma has appreciable effects on ovarian reserve.

An analysis of nine deaths due to chorio epithelioma occuring in the 5th series of a study of 52 cases in 1947-1949

Of the above nine fatalities, four deaths could have been averted if early complete radical treatment had been done in cases 1, 4, 5, and 6. These cases were operated on too late after metastasis had already occuredIn two cases-8 and 9 - only the hormonasl test, in conjunction with adbdominopelvic examination done bimonthly, if not monthly, after the abortion, could have diagnosed the disease at a time when the radical removal of the affected organ might have ended in cure. The only treatment of generalized abdominal chorioepithelioma is X-ray, not surgeryIn two patients - 2 and 7 - though the hysterectomy was done respectively 42 days and 29 days after the D & C for mole in case 2 and 1-1/2 months of incomplete abortion in case 7, the uterine growth was well advanced and metastasis had already occured in other parts of the body. These are the cases that should have been hysterectomized within five days, if not immediately, after the D & C. The responsibility of the early diagnosis lies in the ability of the pathologist to detect malignancy in the curettings. In elderly patients, as number 2, who show Acosta-Sisons clinical signs of malignant mole as (a) too great discrepancy in the size of the uterus (4-1/2 months pregnancy) and the age of amenorrhea (1 month); (b) the mole of the small cyst variety admixed with much placenta-like tissue, the safest treatment for the patient is complete hysterectomy either with the mole in the situ or immediately after D & C, in conjunction with blood transfusionWith patients like case 3 where in spite of the early subtotal hysterectomy done 32 days after the D & C for mole, the uterine growth was greatly advanced, besides showing smaller foci near the cut end of the uterus, one should consider the possibility of the presence of similar foci in the cervical stump which may later either grow in situ or be transported into other regions where they may grow. Such cases should be treated by deep X-ray post-operatively and should be followed up for at least two years for hormonal test and bimanual examination to detect the presence of any abnormality in the pelvic region.(summary)