Robotic surgery in the management of complex pelvic endometriosis.

INTRODUCTION: Endometriosis consists in the proliferation of endometrial tissue outside of the uterine cavity, predominantly in the ovaries but also in the urinary bladder or bowel. About 10% of fertile women are affected and the main symptoms are pain, menstrual disorders and infertility. Surgery is the treatment option for those symptomatic patients in which medical treatment had no success. MATERIAL AND METHODS: We report on a case of a 43 - years - old patient without urologic personal history submitted to our office because of a grade - III right - hydronephrosis. The patient, with an endometriosis diagnosis since years, presents chronic pelvic pain with the daily necessity of strong opioids intake. CT scan revealed several endometriosis implants in the uterine wall and rectum that caused right ureteral entrapment. Renography revealed a 24% function in the right kidney. After right nephrostomy a multidisciplinary committee decided surgical intervention. With robotic approach, we performed an hysterectomy with right salpingo - oophorectomy; release, resection and right ureteral reimplantation; anterior resection of the rectum and protective ileostomy. Vaginal extraction of the specimen. In this video we show the key steps of the procedure. RESULTS: Total operative time: 330 minutes. Total bleeding: 250 cc. Nephrostomy removal: 4 th day. Urethral catheter removal: 5 th day. Patient was discharged in the 7 th day. Ureteral JJ - stent removal: 30 th day. CT urography reveals a permeable ureteral tract with no urine leakage. Renography shows a progressive improvement of the kidney function. CONCLUSIONS: Robotic surgery allows a correct handling of endometriosis, mainly in complex cases. It is a safe and reproducible technique with correct outcomes in selected patients. A multidisciplinary team is required.

Fine-needle aspiration cytology in the diagnosis of salivary gland lesions. The role of the Milan system for reporting cytopathology.

BACKGROUND: Fine needle aspiration cytology (FNAC) is an established technique in the management of salivary gland lesions. The Milan System for reporting salivary gland cytopathology (MSRSGC) intents to standardize diagnostic categories. Current studies are trying to evaluate the diagnostic approach of this system. METHODS: FNAC of salivary gland lesions were retrieved over an 11-year period. 185 FNAC specimens from 182 patients were reviewed blindly and classified according to the criteria established by the MSRSGC. 136 (74.7%) patients had follow-up of their processes. RESULTS: The total number of diagnostic categories and risk of malignancy (ROM) in 185 specimens were the following: non-diagnostic 39 (21.1%; ROM 12%), non-neoplastic 35 (18.9%; ROM 0%), atypia of undetermined significance (AUS) 17 (9.2%; ROM 46.1%), benign neoplasm 75 (40.5%; ROM 4.9%), salivary gland neoplasm of uncertain malignant potential 4 (2.2%; ROM 100%), suspicious for malignancy 7 (3.8%; ROM 100%), malignant 8 (4.3%; ROM 100%). No false positives were observed in groups IVb, V, and VI in this series. The overall sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy were 88%, 91.8%, 96.3%, 76.7%, and 91% respectively. CONCLUSION: The ROM reported in our study was in keeping with ROM published by the MSRSGC. This system provides standardized information for risk stratification. The category AUS encompassed cases causing uncertainty representing a challenge in management. Defining criteria for AUS category need to be refined. The system facilitates communication between pathologists and clinicians favoring improvement in patient care.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the diagnosis of the gastrointestinal stromal tumor of the stomach.

BACKGROUND: This study aims to evaluate the usefulness of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in the diagnosis of the gastric gastrointestinal stromal tumor (GIST). METHODS: We retrospectively investigated the efficacy and accuracy of EUS-FNAC in the diagnosis of gastric GIST. Cytological smears and cytoblock sections including immunohistochemistry and mutational studies from patients diagnosed as gastric GISTs were retrieved. RESULTS: Thirty patients (mean age 68.8 years, range 32-88 years, Male:Female 1:1.7) were diagnosed by cytological and cytoblock study to have GIST. The size of tumors ranged from 1.6 to 25 cm (mean 6.0 cm). 7 (23%) cases were incidentally discovered. Location was: gastric body 13 (43.3%), fundus 8 (26.7%), antrum 7 (23.3%), cardia 2 (6.7%). The study of removed tumors was correlated with the cytological findings. The sensitivity, specificity, positive predictive value, negative predictive value, and diagnostic accuracy were 75%, 100%, 100%, 46%, and 96%. There were no false-positive cases. The preoperative risk assessment of 27 cases with cytoblock were: none 3 (11.1%), very low 8 (29.6%), low 12 (44.4%), high 3 (11.1%), insufficient clinical data 1 (3.7%). The follow-up varied from 2 to 120 months (mean 46.7 months). Only 1 patient of the high-risk group died. The most frequent mutations found were those of c-KIT in exon 11. CONCLUSIONS: Pathological diagnosis was based on a combination of cytological, histopathological, and immunohistochemical features. EUS-FNAC is a reliable, accurate, and safe method for the diagnosis of GIST. The cytoblock allows tumor risk classification and mutational study of the cases.

Endoscopic ultrasound-guided fine-needle aspiration cytology in the diagnosis of leiomyomas of the gastrointestinal tract.

We investigated the efficiency and accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in the diagnosis of gastrointestinal leiomyoma (GIL). Between January 2009 and May 2018 we performed 795 EUS-FNAC studies of lesions of the gastrointestinal (GI) tract for various clinical indications. A diagnosis of GIL by cytological and cell block study was made in 14 patients (57.1% males, mean age 53.6 years, range 22-84 years). 7 tumors (50%) were detected incidentally. The lesions ranged in size from 2 to 10cm (mean size 4.4cm). The location of the tumors was: esophagus 7 (50%), stomach 6 (42.9%) and rectum 1(7.1%). The mean size of the symptomatic tumors was 5.2cm (range 3-10cm). The follow-up of the 14 patients varied from 1 to 108 months (median 39.5 months), during which no recurrence or evidence of lesion progression was observed. Imaging alone was not sufficient for an accurate diagnosis to be made. The pathological diagnosis was based on a combination of cytological, histopathological, and immunohistochemical features. The intracytoplasmic eosinophilic globule is a useful marker of paucicellular GIL differentiating it from gastrointestinal stromal tumor and leiomyosarcoma. EUS-FNAC is a reliable, accurate, and safe method for the diagnosis of GIL.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration in the Diagnosis of Hilar and Mediastinal Lymph Node Metastases of Melanoma.

OBJECTIVE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive technique for investigating hilar and mediastinal lymphadenopathy. This study reports eleven cases in which EBUS-TBNA was used to assess mediastinal and hilar lymph nodes for the presence of metastatic melanoma. MATERIAL AND METHOD: A retrospective study was performed of all patients who had a history of melanoma and underwent EBUS-TBNA to assess hilar or mediastinal lymphadenopathy for the presence of metastatic melanoma. In seven cases, molecular analysis to detect mutations in the BRAF gene was also used. RESULTS: Eight patients had been diagnosed with malignant melanoma in the past (mean 54.4 months, range 18 to 115 months) while in the other three this tumor was primarily diagnosed in the staging phase. The male-female ratio was 6:5, and the mean age was 60.3 years (range 42 to 88 years). The mean hilar or mediastinal lymph node size detected with computed tomography was 3.0 cm (range 1.1 to 8.1 cm). Eight (72.7%) cases had metastases to the lung associated with metastases in the mediastinal lymph nodes. In four (50%) of these cases, the lung metastasis was solitary. Three (27.3%) cases had metastases in the mediastinal lymph nodes in absence of lung metastases. Metastatic melanoma was diagnosed by cytology and confirmed by cell block study with immunohistochemistry in all cases. BRAF mutations were detected in two (28.6%) of seven cases studied. CONCLUSION: Cytology and tissue samples obtained from EBUS-TBNA are adequate to detect metastatic melanoma and permit in some cases the determination of biomarkers and identify the presence or absence of mutations in the BRAF gene. The procedure is safe, fast, and precise for the staging of melanoma.

Endobronchial ultrasound-guided transbronchial needle aspiration in the diagnosis of mediastinal metastases of clear cell renal cell carcinoma.

Evaluation of mediastinal lymphadenopathy in patients with a previous diagnosis of renal cell carcinoma (RCC) is critical for the determination of further treatment. A minimally invasive method of cytology sampling of mediastinal lymph nodes using endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has emerged as a useful tool in diagnosis. Between January 2010 and April 2018, we performed 1744 EBUS-TBNA studies of mediastinal and hilar lymph nodes for a variety of clinical indications including mediastinal malignancy. Sixteen patients (93.7% males, mean age 59.1 years, range 44-81 years) were diagnosed by cytological and cell block study to have metastatic clear cell RCC. Twelve patients had been diagnosed with clear cell RCC in the past (mean 39 months, range 4-89 months) while in four, the tumor was primarily diagnosed in the staging phase on the basis of EBUS-TBNA. The EBUS features of the mediastinal nodal masses included increase of size (mean 2.5 cm, range 1.6-3.8 cm), irregular, inhomogeneous, hypervascular, and hyperechoic echotexture. EBUS-TBNA is a procedure safe and effective for evaluating mediastinal lymphadenopathy in patients with clear cell RCC. Immunohistochemistry in the cell block is decisive for proper diagnosis. The cytologist plays a key role in the diagnosis of metastatic clear cell RCC due to the treatment implications that this neoplasm encompasses.

Fine-needle aspiration cytology in the diagnosis of salivary gland lesions. The role of the Milan system for reporting cytopathology / Citología por aspiración con aguja fina en el diagnóstico de las lesiones de las glándulas salivales. El papel del sistema Milán en citopatología

BACKGROUND: Fine needle aspiration cytology (FNAC) is an established technique in the management of salivary gland lesions. The Milan System for reporting salivary gland cytopathology (MSRSGC) intents to standardize diagnostic categories. Current studies are trying to evaluate the diagnostic approach of this system. METHODS: FNAC of salivary gland lesions were retrieved over an 11-year period. 185 FNAC specimens from 182 patients were reviewed blindly and classified according to the criteria established by the MSRSGC. 136 (74.7%) patients had follow-up of their processes. RESULTS: The total number of diagnostic categories and risk of malignancy (ROM) in 185 specimens were the following: non-diagnostic 39 (21.1%; ROM 12%), non-neoplastic 35 (18.9%; ROM 0%), atypia of undetermined significance (AUS) 17 (9.2%; ROM 46.1%), benign neoplasm 75 (40.5%; ROM 4.9%), salivary gland neoplasm of uncertain malignant potential 4 (2.2%; ROM 100%), suspicious for malignancy 7 (3.8%; ROM 100%), malignant 8 (4.3%; ROM 100%). No false positives were observed in groups IVb, V, and VI in this series. The overall sensitivity, specificity, negative predictive value, positive predictive value and diagnostic accuracy were 88%, 91.8%, 96.3%, 76.7%, and 91% respectively. CONCLUSION: The ROM reported in our study was in keeping with ROM published by the MSRSGC. This system provides standardized information for risk stratification. The category AUS encompassed cases causing uncertainty representing a challenge in management. Defining criteria for AUS category need to be refined. The system facilitates communication between pathologists and clinicians favoring improvement in patient care

ANTECEDENTES: La citología por punción-aspiración con aguja fina (PAAF) está establecida en el tratamiento de las lesiones de las glándulas salivales. El sistema Milán (SM) intenta homogeneizar las categorías diagnósticas en los informes citológicos. Los estudios actuales están tratando de evaluar el enfoque diagnóstico de este sistema. MÉTODOS: Se revisaron las PAAF de las glándulas salivales obtenidas durante un período de 11 años. Se revisaron a ciegas 185 muestras de PAAF de 182 pacientes, y se clasificaron de acuerdo con los criterios establecidos por el SM. Se realizó seguimiento de los procesos de 136 (74,7%) pacientes. RESULTADOS: Los totales de categorías diagnósticas y el riesgo de malignidad (ROM) en 185 muestras fueron los siguientes: no diagnóstico 39 (21,1%; ROM 12%), no neoplásico 35 (18,9%; ROM 0%), atipia de significación indeterminada (ASI) 17 (9,2%; ROM 46,1%), neoplasia benigna 75 (40,5%; ROM 4.9%), neoplasia de potencial maligno incierto 4 (2,2%; ROM 100%), sospecha de malignidad 7 (3,8%; ROM 100%), malignidad 8 (4,3%; ROM 100%). No se observaron falsos positivos en los grupos IVb, V y VI. Los valores de sensibilidad, especificidad, el valor predictivo negativo, el valor predictivo positivo y la precisión diagnóstica fueron del 88%, 91,8%, 96,3%, 76,7% y 91%, respectivamente. CONCLUSIÓN: El ROM observado concordaba con el ROM publicado por el SM. Este proporciona información estandarizada para la estratificación del riesgo. La categoría ASI abarcó los casos que causaron incertidumbre, y representa un desafío en el manejo de los pacientes. Los criterios de definición de ASI deberían perfeccionarse. El sistema facilita la comunicación entre patólogos y clínicos, y mejora la atención al paciente

Endoscopic ultrasound-guided fine-needle aspiration cytology in the diagnosis of leiomyomas of the gastrointestinal tract / Citología por aspiración con aguja fina guiada por ecografía endoscópica en el diagnóstico de los leiomiomas del tracto digestivo

We investigated the efficiency and accuracy of endoscopic ultrasound-guided fine-needle aspiration cytology (EUS-FNAC) in the diagnosis of gastrointestinal leiomyoma (GIL). Between January 2009 and May 2018 we performed 795 EUS-FNAC studies of lesions of the gastrointestinal (GI) tract for various clinical indications. A diagnosis of GIL by cytological and cell block study was made in 14 patients (57.1% males, mean age 53.6 years, range 22-84 years).7 tumors (50%) were detected incidentally. The lesions ranged in size from 2 to 10cm (mean size 4.4cm). The location of the tumors was: esophagus 7 (50%), stomach 6 (42.9%) and rectum 1(7.1%). The mean size of the symptomatic tumors was 5.2cm (range 3-10cm). The follow-up of the 14 patients varied from 1 to 108 months (median 39.5 months), during which no recurrence or evidence of lesion progression was observed. Imaging alone was not sufficient for an accurate diagnosis to be made. The pathological diagnosis was based on a combination of cytological, histopathological, and immunohistochemical features. The intracytoplasmic eosinophilic globule is a useful marker of paucicellular GIL differentiating it from gastrointestinal stromal tumor and leiomyosarcoma. EUS-FNAC is a reliable, accurate, and safe method for the diagnosis of GIL

Hemos investigado la eficacia y la precisión de la citología por aspiración con aguja fina guiada por ecografía endoscópica (EUS-FNAC) en el diagnóstico del leiomioma gastrointestinal (LGI). Entre enero de 2009 y mayo de 2018 se realizaron 795 estudios EUS-FNAC de lesiones del tracto digestivo por una variedad de indicaciones clínicas. Catorce pacientes (57,1% varones, edad media: 53,6 años, rango: 22-84 años) fueron diagnosticados mediante estudio citológico y de bloque celular de LGI. Siete tumores (50%) fueron detectados de manera incidental. Las lesiones variaron en tamaño de 2 a 10cm (tamaño promedio: 4,4cm). La localización de los tumores fue: esófago 7 (50%), estómago 6 (42,9%) y recto uno (7,1%). El tamaño medio de los tumores sintomáticos fue de 5,2cm (rango: 3-10cm). El seguimiento de los 14 pacientes varió de uno a 108 meses (mediana: 39,5 meses). No se observó recurrencia o evidencia de progresión de la lesión. El estudio de las imágenes radiológicas por sí solo no permitió diagnosticar la lesión. El diagnóstico patológico se basó en una combinación de datos citológicos, histopatológicos e inmunohistoquímicos. El glóbulo eosinofílico intracitoplasmático es un marcador útil de LGI paucicelular que permite diferenciarlo del tumor del estroma gastrointestinal y del leiomiosarcoma. La EUS-FNAC es un método fiable, preciso y seguro para el diagnóstico del LGI