Retroperitoneal Major Pelvic Arteries' Anatomic Variation: Pictorial Essay and Significance in Obstetrical and Gynecological Surgery.

INTRODUCTION: Congenital anomalies of the iliac arteries are rare, and are usually discovered incidentally or infrequently intraoperatively. AIM: To show the retroperitoneal major pelvic blood vessels anatomical variation during gynecologic and obstetrics surgeries in cases of retroperitoneal dissection. PATIENTS: We report three cases with incidental finding of anatomical variation in retroperitoneal major pelvic blood vessels. One patient underwent staging laparotomy for endometrial cancer with intraoperative finding of bilateral long internal iliac artery with short common iliac artery. The second patient underwent staging laparotomy for suspicious ovarian mass and mesh sacrocolpopexy for uterine prolapse with accidental finding of kinked long external iliac artery with short common iliac artery. The third patient underwent total hysterectomy with pelvic lymphadenectomy for endometrial cancer with incidental finding of bilateral absent internal iliac artery with common iliac artery continuing as external iliac artery. CONCLUSIONS: Anatomical variations in the major retroperitoneal pelvic vasculature should be familiar with during surgeries to avoid inadequate management. Internal iliac artery ligation should be done as low as possible close to the bifurcation in case of long internal iliac artery as in case of bleeding, slipped uterine or injured vesical vessels. Kinked external iliac artery should not be considered as anomaly or swollen node with trial of excision in dissection of lymph nodes in gynecological cancer or a thrombosed vessel but continue as usual in dissection and preserve any branches arising from it which is a normal variation. Also, the absent internal iliac artery is no problem as its branches may arise from the aorta or the external iliac artery. The uterine artery can be traced in this condition from the uterine side and any branches from external iliac artery in pelvis can be a normal variation.

Surgical Approaches for Common Gynecologic and Obstetrics Surgeries.

Common obstetrics and gynecology operations have different approaches and techniques and variations in the procedure. We aimed to discuss different approaches and variations in the techniques of the procedures as cystectomy, myomectomy, laparoscopy entry technique, sacrospinous ligament fixation, uretherocele, and rupture uterus.

Correction to: Surgical Approaches for Common Gynecologic and Obstetrics Surgeries.

[This corrects the article DOI: 10.1007/s13193-019-00987-6.].

Gynecological and postpartum ultrasonography of cesarean uterine scar defects: a pictorial essay.

There is an increasing incidence of cesarean scar defect. This article will discuss and show different and variable sonographic presentations of scar niches and uterine postpartum ultrasonography with vaginal birth after cesarean section that can be confusing and many should be unaware of. This brief review aims to help practitioners to avoid confusion and be aware and acquainted with the different sonographic findings encountered in practice related to cesarean scar. It can lead to uterine rupture I labour, dehiscence in pregnancy and placenta accreta in the future pregnancy, but this is not evidence-based and not even a contraindication for pregnancy. It is neither an indication of repair for the presenting patient nor an indication to screen these patients for such complications. It is treated if associated with infertility or bleeding and not in asymptomatic ones.

Sonographic Criteria for Uterine Curettage: Suspecting Endometrial Neoplasia.

The aim of the work is to determine the Suspicious sonographic findings associated with endometrial hyperplasia or cancer in premenopausal and perimenopausal women requiring uterine curettage other than endometrial thickness. Transvaginal ultrasonography examinations of premenopausal and perimenopausal women were reported here. These women underwent endometrial biopsy based on abnormal uterine bleeding or discharge and sonographic endometrial abnormalities. Histologically, hyperplasia was found in PCOS patients, endometrial cancer on top of tamoxifen therapy was found in others. The highly related ultrasound criteria are thick irregular endometrium, ill-defined endometrial myometrial junction, myometrial invasion with pseudowidening of the endometrium, turbid intrauterine fluid collection, associated complex adnexal masses, and cystic areas in the endometrium. Endometrial stripe abnormality by transvaginal ultrasonography is considered to be important in the recommendation of endometrial biopsy to exclude cancer along with positive complains in addition to thickness abnormalities.

Asymptomatic Auto Amputation of Normal Ovary.

Free-floating intraperitoneal mass is rare and mostly is  related to the ovary. Asymptomatic auto amputation of the ovary is extremely rare that may be due to torsion or inflammation and usually is diagnosed incidentally . We report an interesting case of this rare pathology. A 50-year-old female with postmenopausal bleeding prepared for hysterectomy is presented here. Intraperitoneal free-floating auto-amputated right ovary was encountered. During surgery, we can suspect it from free-floating mass intraperitoneal with failure to detect one of the ovaries attached to the uterus and the related infundibulopelvic ligament.

Large Multilocular Cystic Lesions in the Uterine Cervix: Differential Diagnosis and Significance.

INTRODUCTION: Cervical nabothian cysts are common in women of reproductive age. Although cysts are generally small and asymptomatic, large ones are extremely rare and may be misdiagnosed as malignancy. CASE STUDY: We report a case of large multiple complex nabothian cyst, which was suspected as malignant one on imaging and examination. Pelvic examination and ultrasonography revealed ballooned cervix with multiple large complex nabothian follicles. There was an associated large adnexal mass with ascites. The patient was treated with total hysterectomy and omentectomy after aspiration of the fluid from the cervical cysts for debulking and limiting complications. Pathology revealed granulosa cell ovarian tumor, omental panniculitis, and cervical nabothian follicles. CONCLUSION: Large nabothian cysts should be kept in mind for differential diagnosis of cervical tumors. Ultrasonography is of value for the diagnosis of giant nabothian cysts and can aid in exclusion of malignancy. Differentiation between a malignant cystic lesion, such as an adenoma malignum, and a benign cystic lesion is crucial but difficult. Cervical nabothian follicles can be multiple and attain a large size up to 4 cm each. It is commonly benign but we should keep in mind the rare adenoma malignum on imaging and histopathology.

Laparoscopy and Computed Tomography Imaging in Advanced Ovarian Tumors: A Roadmap for Prediction of Optimal Cytoreductive Surgery.

INTRODUCTION: Comprehensive staging laparotomy and cytoreductive surgery followed by chemotherapy has been the standard of care in advanced ovarian cancer. Neoadjuvant chemotherapy is an alternative in inoperable advanced cases. To select patients amenable for successful cytoreduction, major determinants including CT imaging and laparoscopy could be of value. There is no general accepted model for selection and reproducibility of techniques are a major challenge due to different clinical practice and complexity of scoring systems. Some lesions as small size (<5 mm) peritoneal deposits and mesenteric affection are hard to see on CT so, complementary laparoscopy may play a role in the preoperative assessment. The aim of this study was evaluation of the role of laparoscopy in advanced ovarian tumors for prediction of optimal cytoreductive surgery in relation to CT and surgical peritoneal carcinomatosis index (PCI). AIM: Was to evaluate laparoscopic assessment in advanced ovarian tumors for prediction of optimal cytoreductive surgery in relation to CT and surgical peritoneal carcinomatosis index (PCI). SETTING: Gyne-oncology specialized center, El-Shatby maternity university hospital, Alexandria Egypt. METHODS: From January 2016 to December 2016, 15 patients were recruited from gyne-oncology specialized center, Alexandria, Egypt. Patients underwent a special design described later then laparoscopy using palmar point entry was done for assessing small lesions and the extent of affection in surface peritoneal, mesentery, serosa of the gut especially small intestine (terminal ileum affection, more or less than 50% affection) mainly with evaluating other sites as liver surface and diaphragm peritoneal surface affection after removal of ascites by aspiration. Findings were correlated with laparotomy and CT scan findings. Surgery was performed in the same setting which is better or with in two weeks. RESULTS: There were two cases with upper abdominal surgeries (cholecystectomy and splenectomy) where no visualization of liver and stomach on laparoscopy but were free on CT scan and surgical evaluation. Douglas pouch was not assessed in two patients with large fixed bilateral ovarian masses on laparoscopy. Two cases with diaphragmatic affection on CT scan related to the posterior surface were not detected on laparoscopy. These findings were correlated with surgical findings as the gold standard. The pathology was ranging from low grade to high grade serous cyst adenocarcinoma. CONCLUSIONS: Laparoscopic evaluation is a useful adjunct with CT prior to performing ovarian cancer cytoreductive surgery for assessment of operability. Laparoscopy is better for evaluating extent of serosal affection in advanced tumors in cases with omental cakes on CT. A roadmap for prediction of operability in advanced ovarian cancer can be used by combing CT PCI and laparoscopic assessment.

Huge Broad Ligament Fibroid with Paracervical Extension: A Safe Approach by Same Setting Myomectomy before Hysterectomy.

The broad ligament is the most common extrauterine site for leiomyoma but with low incidence rate. We present a patient with complaints of lower abdominal pain and abdominal distension. Abdominal examination revealed a huge firm mass arising from the pelvis corresponding to 24-week size. The cervix was deviated and elevated but felt separable of the mass. Ultrasonographic examination showed 20 cm fibroid beside the uterus suggesting broad ligament fibroid. On laparotomy, the uterus was elevated up and deviated laterally by the mass. A 20 cm broad ligament fibroid was seen extending deep in the pelvis and up filling all the broad ligament. Myomectomy was performed initially to decompress the mass for easy hysterectomy and carefully evaluating the ureter avoiding its injury. Total hysterectomy with bilateral salpingo-oophorectomy was done. This case was reported because of the rare incidence of broad ligament leiomyoma and the difficulty in its operative management.

Conservative Management of Infected Postpartum Uterine Dehiscence after Cesarean Section.

There is an increase in cesarean rates worldwide. Parallel to this, the complications increased. Among these complications, uterine dehiscence and pelvic hematoma with abscess collection have increased. Diagnosis using methods such as ultrasonography, magnetic resonance imaging, and computer-aided tomography can be made. Treatment includes resuturing the uterine incision line, hysterectomy, or conservative treatment accompanied by broad-spectrum antibiotics administration. We evaluated three cases that were diagnosed by ultrasound as a dehiscent scar postpartum after cesarean section and they were managed conservatively with regular follow-up.

Recurrent Bilateral Mucinous Cystadenoma: Laparoscopic Ovarian Cystectomy with Review of Literature.

The second most common epithelial tumor of the ovary is the mucinous tumors, and it constitutes about 8-10% of all ovarian tumors. The recurrence of mucinous cystadenoma is very rare after complete excision. Few cases have been reported. The case presented had initial surgery for adenxal mass diagnosed as mucinous tumor, performed by laparotomy and was followed up. After recurrence, the patient underwent laparoscopic evaluation and bilateral ovarian cystectomy was performed as a fertility preservation for the patient young age. The histopathological diagnosis was mucinous cystadenoma, the same as the initial one. Management in young patients is challenging, especially in the case of recurrence. Follow-up of these patients is very important and transvaginal ultrasound seems to be currently the most effective diagnostic tool for the follow-up of young patients treated with cystectomy for benign mucinous cystadenomas. Total hysterectomy and bilateral salpingo-oophorectomy is recommended after completing family size or reaching age of 35 for fear of progression or incompliance.

Value and best way for detection of Sentinel lymph node in early stage endometrial cancer: Selective lymphadenectomy algorithm.

INTRODUCTION: The cornerstone of treatment for endometrial carcinoma is total abdominal hysterectomy and bilateral salpingo-oophoprectomy. Pelvic lymphadenectomy, with or without para-aortic lymphadenectomy, plays an important role in the surgical staging of endometrial carcinoma, and provides more accurate prognostic information. AIMS: We aimed to evaluate the value and techniques for SLN mapping in early stage endometrial cancer with low risk for lymph node metastasis and whether selective or systematic lymphadenectomy is needed according to the results of proposed algorithm. METHOD: Between June 2016 and June 2017, 120 patients with early stage endometrial cancer with low risk for nodal metastasis underwent surgical staging. Patients were classified equally according to SLN mapping technique used for injecting the methylene blue dye. Group A included hysteroscopic guided methylene blue injection, Group B included transcervical injection, Group C included subserosal uterine injection and Group D included combined transcervical and subserosal injection. Blue lymph nodes and enlarged suspicious whether stained or non stained ones were dissected for frozen section evaluation done then bilateral pelvic node dissection was done and tissues were sent for pathological examination. RESULTS: Clinical and pathological SLN detection were more with hysteroscopic technique than others and pathological detection was lower than clinical detection in all techniques. Metastatic disease was more common in nodes with suspicious appearance. About 10% of negative suspicious and mapped nodes were associated with positive other nodes for metastasis. CONCLUSION: SLN in endometrial cancer has a role in staging of endometrial cancer with best technique for detection, hysteroscopic guided blue dye injection. SLN can be used in patients with low risk for lymph node metastasis for selective lymphadenectomy. Blue dye labelling using methylene blue dye is good in low resource countries as it is cheap. We recommended the following algorithm for surgical staging in early endometrial cancer with better results than using SLN alone. Stage I type 1, grade 1,2 endometrial cancer should undergo surgical staging with initial evaluation of the peritoneum which if affected, it is stage III with no need for lymphadenectomy. Then, dissection of the blue and suspicious nodes which if any is positive on frozen section, selective same side pelvic and paraaortic nodal dissection should be done. If they are negative, no need for lymphadenectomy. This approach can help patients to avoid the side effects associated with a complete lymphadenectomy. The higher rate of detection using this algorithm is related to combining the suspicions nodes with the stained ones.