A Rare Presentation of Polypoid Endometriosis of the Douglas Pouch: Case Report.

A case is reported of a 46-year-old woman referred to a magnetic resonance imaging (MRI) for menometrorrhagia. MRI revealed a mass lesion lateral to the uterus fundus, suspicious of an ovarian granulosa cell tumor. Extensive surgery was performed. Histological examination revealed a polypoid endometriosis lesion arising from the Douglas pouch. Teaching point: Polypoid endometriosis is a rare benign entity with a challenging differential diagnosis from malignancy. Specific MRI features can contribute to the diagnosis and thus avoid excessive surgical resection.

Extraperitoneal Para-Aortic Lymphadenectomy by Robot-Assisted Laparoscopy.

STUDY OBJECTIVE: To evaluate the outcomes of extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy. DESIGN: A retrospective study (Canadian Task Force classification III). SETTING: An academic institution. PATIENTS: Twenty-three consecutive patients with gynecologic cancer who presented for para-aortic lymphadenectomy between March 2016 and May 2017 were reviewed retrospectively. INTERVENTIONS: Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was performed. MEASUREMENTS AND MAIN RESULTS: Of the 23 patients reviewed retrospectively, 10 had cervical cancer, 7 had endometrial cancer, 5 had adnexal cancer, and 1 had vaginal cancer. Data regarding patient characteristics, indication for para-aortic lymphadenectomy, type of surgery (infrarenal or inframesenteric), operative time, surgical complications, number of nodes retrieved, and postoperative hospital length of stay were collected. Two patients were excluded because of early perforation of the peritoneum. In total, 21 para-aortic lymphadenectomies were performed (16 infrarenal and 5 inframesenteric). The median skin-to-skin operating time of infrarenal extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 170 minutes (range, 90-225 minutes), the median lymph node count was 18 (range, 11-38), and the median estimated blood loss was 50 mL (range, 10-600 mL). The median skin-to-skin operating time of inframesenteric extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy was 120 minutes (range, 90-220 minutes), the median lymph node count was 10 (range, 7-19), and the median estimated blood loss was 30 mL (range, 10-100). Intraoperative complications included 1 thermal lesion of the left genitofemoral nerve, 1 thermal lesion of the left mesoureter (a ureteral stent was placed to avoid ureteric necrosis and fistula without after effect), and 1 lesion of the inferior vena cava that was sutured by robot-assisted laparoscopy. There were 2 additional cases of perforation of the peritoneum that occurred in the infrarenal group. The median hospital length of stay was 1 day (range, 0-7 days). Three patients were readmitted for symptomatic lymphocysts. CONCLUSION: Extraperitoneal para-aortic lymphadenectomy by robot-assisted laparoscopy provides good visualization of the operative field without arm conflict. Still, perforation of the peritoneum and symptomatic lymphocysts are a postoperative concern.

Pretherapeutic staging of locally advanced cervical cancer: Inframesenteric paraaortic lymphadenectomy accuracy to detect paraaortic metastases in comparison with infrarenal paraaortic lymphadenectomy.

BACKGROUND: Extended-field chemoradiation therapy is usually performed in patients with locally advanced cervical cancer (LACC) and paraaortic (PA) node metastases. Considering the very low rate of skip metastases above inferior mesenteric artery, ilio-inframesenteric paraaortic lymph node dissection (IM-PALND) seems to be an adequate pattern of PALND. Our objective was to assess the accuracy of this management to determine PA nodal status in comparison with infrarenal paraaortic lymphadenectomy (IR-PALND) in case of squamous or glandular cervical cancer. METHODS: All patients with LACC and negative MRI and PET/CT imaging at paraaortic level had laparoscopic staging (followed, if negative, by extraperitoneal paraaortic lymphadenectomy). From January 2011 to September 2015, patients who had IM-PALND were included and were compared to a previous historical series of IR-PALND patients. The two groups differed only at the upper level of dissection. Characteristics of nodal involvement at paraaortic level depending on level of dissection, PET/CT imaging and histology were studied. RESULTS: 119 women were included in our study, with 56 patients in the IM-PALND group and 63 in the IR-PALND group. In the IM-PALND group, fewer nodes were resected (p<0.001). There was no difference between the two groups regarding nodal status at paraaortic level (p=0.77). Patterns of nodal involvement were similar whichever the histological subtype of cervical cancer (squamous or glandular). CONCLUSION: IM-PALND appears to be equally effective to assess paraaortic nodal involvement in LACC for both histological subtypes - glandular and squamous carcinomas - and to select patients for extended-field chemoradiation therapy.

Operative and diagnostic hysteroscopy: A novel learning model combining new animal models and virtual reality simulation.

CONTEXT: Hysteroscopy is one of the most common gynaecological procedure. Training for diagnostic and operative hysteroscopy can be achieved through numerous previously described models like animal models or virtual reality simulation. We present our novel combined model associating virtual reality and bovine uteruses and bladders. STUDY DESIGN: End year residents in obstetrics and gynaecology attended a full day workshop. The workshop was divided in theoretical courses from senior surgeons and hands-on training in operative hysteroscopy and virtual reality Essure® procedures using the EssureSim™ and Pelvicsim™ simulators with multiple scenarios. Theoretical and operative knowledge was evaluated before and after the workshop and General Points Averages (GPAs) were calculated and compared using a Student's T test. RESULTS: GPAs were significantly higher after the workshop was completed. The biggest difference was observed in operative knowledge (0,28 GPA before workshop versus 0,55 after workshop, p<0,05). All of the 25 residents having completed the workshop applauded the realism an efficiency of this type of training. The force feedback allowed by the cattle uteruses gives the residents the possibility to manage thickness of resection as in real time surgery. Furthermore, the two-horned bovine uteruses allowed to reproduce septa resection in conditions close to human surgery CONCLUSION: Teaching operative and diagnostic hysteroscopy is essential. Managing this training through a full day workshop using a combined animal model and virtual reality simulation is an efficient model not described before.

Risk of cesarean delivery among pregnant women with class III obesity.

OBJECTIVE: To identify factors associated with cesarean delivery among women with class III obesity attempting vaginal delivery. METHODS: In a retrospective study, medical charts were reviewed for women aged 18 years or older with a singleton pregnancy of at least 37 weeks and a body mass index (calculated as weight in kilograms divided by the square of height in meters) of 40 or higher who were eligible to attempt vaginal delivery at a maternity hospital in Lille, France, between 1999 and 2012. RESULTS: Among 345 eligible women, 301 (87.2%) attempted vaginal delivery; 211 (70.1%) were successful and 90 (29.9%) delivered by cesarean. The frequency of nulliparity was higher among those undergoing cesarean after a trial of labor (64 [71.1%]) than among those who delivered vaginally (57 [27.0%]; P<0.001). Induction of labor was also more frequent among those who ultimately delivered by cesarean (61 [67.8%] vs 96 [45.5%]; P<0.001). In multivariate analysis, induction of labor was an independent predictor of cesarean among women attempting vaginal delivery (odds ratio [OR] 2.30, 95% confidence interval [CI] 1.25-4.22), whereas history of vaginal delivery was protective (OR 0.08, 95% CI 0.04-0.17). CONCLUSION: Nulliparous women with class III obesity attempting a vaginal delivery should be warned of the high risk of cesarean delivery, especially if they require induction.

Managing Endometrial Cancer: The Role of Pelvic Lymphadenectomy and Secondary Surgery.

PURPOSE: In November 2010, the French National Cancer Institute published new guidelines for managing endometrial cancer. Pelvic lymphadenectomy is not indicated for preoperative low-intermediate risk type 1 endometrial cancer, and high-risk patients should undergo secondary surgery with para-aortic lymphadenectomy. This study evaluated these new guidelines with regard to overall survival (OS), relapse-free survival (RFS), and morbidity for patients with low-intermediate risk disease. METHODS: We evaluated all type 1 endometrial cancer patients with low-intermediate risk of recurrence who were treated from 1 January 1997 through 31 December 2012. All patients were classified according to the 2009 International Federation of Gynecology and Obstetrics staging criteria and the European Society for Medical Oncology. RESULTS: Overall, 230 patients were included (159 before and 71 after the new guidelines were issued). Pelvic lymphadenectomies were performed before and after the new guidelines in 77.4 and 28.6 % of patients, respectively (p < 0.001). After 2010, eight patients also underwent secondary surgery, which consisted of a para-aortic lymphadenectomy for lymphovascular space invasion (LVSI). This second surgery changed the adjuvant treatment for one patient. OS and RFS were similar between both groups, and no difference in morbidity was observed between the groups. LVSI was an independent factor for OS [hazard ratio (HR) 7.2, 95 % CI 3.1-17; p < 0.001] and RFS (HR 3.7, 95 % CI 1.6-8.5; p < 0.003). CONCLUSIONS: Fewer pelvic lymphadenectomies in low-intermediate risk patients did not affect OS, RFS, or morbidity, including patients with secondary surgery. We must gather additional data with a longer follow-up period to not only confirm our results but to also fully investigate the paradoxical absence of decreased morbidity that our study has shown.