Role of V-Y flap reconstruction in vulvar cancer patients: multicenter retrospective study.

OBJECTIVE: To assess if the use of a V-Y reconstructive flap after excisional radical surgery positively influences the surgical outcomes in patients with vulvar cancer. METHODS: This was a multicenter, retrospective, controlled study. Surgical outcomes and complication rates of women with invasive vulvar cancer who underwent radical surgery and vulvar reconstruction and those who underwent radical surgery without the reconstruction step were compared. Only patients who underwent bilateral or unilateral V-Y advancement fascio-cutaneous flaps were included in the reconstruction group. Univariate and multivariate logistic regression models were used to analyze predicting variables for their association with complication rates. RESULTS: Overall, 361 patients were included: 190 (52%) underwent the reconstructive step after the excisional radical procedure and were compared with 171 (47.4%) who did not undergo the reconstructive step. At multivariate analysis, body mass index >30 kg/m2 (odds ratio (OR) 3.36, p=0.007) and diabetes (OR 2.62, p<0.022) were independently correlated with wound infection. Moreover, increasing age (OR 1.52, p=0.009), body mass index >30 kg/m2 (OR 3.21, p=0.002,) and International Federation of Gynecology and Obstetrics (FIGO) stages III-IV (OR 2.25, p=0.017) were independent predictors of wound dehiscence. A significant reduction in the incidence of postoperative wound complications among patients who underwent V-Y reconstructive flaps was demonstrated. This was correlated more significantly in women with lesions >4 cm. CONCLUSIONS: The adoption of V-Y flaps in vulvar surgery was correlated with reduced surgical related complications, particularly in vulnerable patients involving large surgical defects following excisional radical procedures.

Ten-year outcomes following laparoscopic and open abdominal radical hysterectomy for "low-risk" early-stage cervical cancer: A propensity-score based analysis.

OBJECTIVE: Accumulating evidence suggested the detrimental effects of adopting minimally invasive surgery in the management of early-stage cervical cancer. However, long-term evidence on the role of minimally invasive radical hysterectomy in "low-risk" patients exists. METHODS: This is multi-institutional retrospective study comparing minimally invasive and open radical hysterectomy in low-risk early-stage cervical cancer patients. A propensity-score matching algorithm (1:2) was used to allocate patients into the study groups. Kaplan-Meir model was used to estimate 10-year progression-free and overall survival. RESULTS: Charts of 224 "low-risk" patients were retrieved. Overall, 50 patients undergoing radical hysterectomy were matched with 100 patients undergoing open radical hysterectomy. Minimally invasive radical hysterectomy was associated with a longer median operative time (224 (range, 100-310) vs. 184 (range, 150-240) minutes; p < 0.001), lower estimated blood loss (10 (10-100) vs. 200 (100-1000) ml, p < 0.001), and shorter length of hospital stay (3.8 (3-6) vs. 5.1 (4-12); p < 0.001). Surgical approach did not influence the risk of having intra-operative (4% vs. 1%; p = 0.257) and 90-day severe (grade 3+) postoperative complication rates (4% vs. 8%; p = 0.497). Ten-year disease-free survival was similar between groups (94% vs. 95%; p = 0.812; HR:1.195; 95%CI:0.275, 5.18). Ten-year overall survival was similar between groups (98% vs. 96%; p = 0.995; HR:0.994; 95%CI:0.182, 5.424). CONCLUSIONS: Our study appears to support emerging evidence suggesting that, for low-risk patients, laparoscopic radical hysterectomy does not result in worse 10-year outcomes compared to the open approach. However, further research is needed and open abdominal radical hysterectomy remains the standard treatment for cervical cancer patients.

Laparoscopic Double Discoid Colorectal Resection for the Treatment of Two Distinct Deep Endometriotic Nodules.

OBJECTIVE: To show the surgical steps used to perform a laparoscopic double discoid colorectal resection for the excision of 2 distinct deep endometriotic nodules (DENs). DESIGN: Stepwise demonstration of the technique with narrated video footage. SETTING: To date there is agreement that discoid resection should be the first choice procedure in patients eligible for surgical treatment with rectal, unifocal DENs measuring ≤ 3 cm [1-3]. For surgical management of lesions of the sigmoid colon, current international guidelines suggest to perform segmental resections [3]. Data on surgical treatment of multiple colorectal DENs separated by a great distance from each other are very limited, mostly owing to the rarity of such a diagnosis. In particular, there is paucity of data concerning the efficacy and safety of a double discoid resection for surgical management of distinct DENs found in the sigmoid colon and rectum [4]. In a context of multiple colorectal DENs, the decision-making process with respect to a double discoid excision must take into consideration both the distance between the 2 nodules and the nodules' distance from anal verge. When technically feasible, such organ-sparing surgery allows preserving the healthy bowel interposed between the endometriotic lesions, seeming to offer advantages in terms of quicker return of bowel function and better rectal functional outcomes than segmental colorectal resection. INTERVENTIONS: The patient was a 36-year-old woman experiencing drug treatment failure and presenting with refractory constipation, dyschezia, dysmenorrhea, dyspareunia, cyclical abdominal bloating, and chronic pelvic pain. Preoperative ultrasonography revealed the presence of an endometriotic nodule of 19 × 6 × 16 mm deeply infiltrating the tunica muscularis of the sigmoid colon. A second DEN was found at the level of the rectum, the latter measuring 19 × 5 × 12 mm and having a distance of 9 cm from the anal verge. Both the intestinal lesions resulted to have a circumferential extent of 30%. The distance between the 2 nodules was 15 cm. A 3-dimensional laparoscopy was performed. Sigmoid colon and rectal mobilization were performed according to our standardized technique [5-7]. A 31-mm circular stapler was used to excise first the nodule of the sigmoid colon. The stapler, in its closed position, was gently introduced into the rectum via the anus and then progressively advanced inside the large bowel up to the level of the sigmoid nodule. After correct positioning, the stapler was completely opened and the nodule was imbricate between the anvil and staple housing of the stapler. Then, the stapler was closed and fired. The procedure was repeated using a second 31 mm circular stapler to resect the rectal endometriotic nodule. The overall operative time was 90 minutes. The estimated blood loss was 5 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 3 days after surgery. The sigmoid colon and rectal endometriotic nodules measured, respectively, 20 × 6 × 15 mm and 20 × 5 × 12 mm on fresh unfixed specimens. Both nodules were found to have endometriosis-free surgical margins on definitive pathology. CONCLUSIONS: The operative technique displayed in this video may contribute to the standardization of a procedure, which could be included among the options available in the surgical armamentarium, to be used in selected cases of multiple colorectal DENs each having 3 cm or less in diameter. Surgeon experience and an adequate preoperative evaluation are of utmost importance to plan the operative strategy and have the best chance of surgical success.

Evaluation of Peri-Operative Management in Women with Deep Endometriosis Who are Candidates for Bowel Surgery: A Survey from the Italian Society of Gynecologic Endoscopy.

STUDY OBJECTIVE: There is great consensus that the implementation of the enhanced recovery after surgery (ERAS) approach is beneficial for surgical patients, but there is a paucity of data concerning its application in women with deep endometriosis (DE) who are candidates for bowel surgery. The survey described herein was aimed at gathering detailed information on perioperative management of DE patients who were undergoing sigmoid/rectal (discoid or segmental) resection within the Italian Society of Gynecologic Endoscopy (SEGI) group. DESIGN: Baseline survey. SETTING: National survey conducted within the main Italian cooperative group in minimally invasive gynecologic surgery (SEGI). PATIENTS: The study did not involve patients. INTERVENTIONS: A 63-item questionnaire covering ERAS items for gynecologic/elective colorectal surgery was sent to SEGI centers. Only questionnaires from centers that reported performing ≥10 sigmoid/rectal resections per year were considered for this analysis. MEASUREMENTS AND MAIN RESULTS: Thirty-three of 38 (86.8%) of the questionnaires were analyzed. The rates of concordance with the ERAS guidelines were 40.4%, 64.4%, and 62.6% for preoperative, intraoperative, and postoperative items, respectively. The proportion of overall agreement was 56.6%. Preoperative diet, fasting and bowel preparation, correction of anemia, avoidance of peritoneal drains, postoperative feeding, and early mobilization were the most controversial items. Comparative analysis revealed that the referred rates of complete disease removal and conversion to open surgery were significantly different depending on case volume (p = .044 and p = .003, respectively) and gynecologist's/surgeon's experience (p = .042 and p = .022, respectively), with higher chances of obtaining a complete laparoscopic/robotic excision of endometriosis in centers that reported ≥30 DE surgeries performed per year and/or ≥90% of bowel resections performed by a gynecologist/general surgeon specifically dedicated to DE management. In contrast, the rates of concordance with the ERAS guidelines were not significantly different according to case volume (p = .081) or gynecologist's/surgeon's experience (p = .294). CONCLUSION: This is the first study on DE conducted on a national scale. The current survey results revealed suboptimal compliance with the ERAS recommendations and underline the need to improve the quality of perioperative care in DE patients undergoing sigmoid/rectal resection. This study is a first step toward building a consistent, structured reporting platform for the SEGI units and facilitating wide implementation and standardization of the ERAS protocol for DE patients in Italy.

Surgical Outcomes and Complications of Laparoscopic Hysterectomy for Endometriosis: A Multicentric Cohort Study.

STUDY OBJECTIVE: To investigate the postoperative morbidity of laparoscopic hysterectomy (LH) for endometriosis/adenomyosis in terms of operative outcomes and complications. DESIGN: Retrospective multicentric cohort study. SETTING: Eight European minimally invasive referral centers. PATIENTS: Data from 995 patients with pathologically confirmed endometriosis and/or adenomyosis who underwent LH without concomitant urological and/or gastroenterological procedures from January 2010 to December 2020. INTERVENTIONS: Total LH. MEASUREMENTS AND MAIN RESULTS: Demographic patients' characteristics, surgical outcomes, and intraoperative and postoperative complications were evaluated. We considered major postoperative surgical-related complications, any grade 2 or more events (Clavien-Dindo score) that occurred within 30 days from surgery. Univariate analysis and multivariable models fit with logistic regression were used to estimate the adjusted odds ratio (OR) and corresponding 95% confidence interval (CI) for major complications. Median age at surgery was 44 years (28-54), and about half of them (505, 50.7%) were on medical treatment (estro-progestins, progestin, or Gonadotropin hormone-releasing hormone-analogues) at the time of surgery. In association with LH, posterior adhesiolysis was performed in 387 (38.9%) cases and deep nodule resection in 302 (30.0%). Intraoperative complications occurred in 3% of the patients, and major postoperative complications were registered in 93 (9.3%). The multivariable analysis showed an inverse correlation between the occurrence of Clavien-Dindo >2 complications and age (OR 0.94, 95% CI 0.90-0.99), while previous surgery for endometriosis (OR 1.62, 95% CI 1.01-2.60) and intraoperative complications (OR 6.49, 95% CI 2.65-16.87) were found as predictors of major events. Medical treatment at the time of surgery has emerged as a protective factor (OR 0.50, 95% CI 0.31-0.81). CONCLUSION: LH for endometriosis/adenomyosis is associated with non-negligible morbidity. Knowing the factors associated with higher risks of complications might be used for risk stratification and could help clinicians during preoperative counseling. The administration of estro-progestin or progesterone preoperatively might reduce the risks of postoperative complications following surgery.

Fertility-sparing treatment for serous borderline ovarian tumors with extra-ovarian invasive implants: Analysis from the MITO14 study database.

OBJECTIVE: Only 10-15% of serous borderline ovarian tumors (BOTs) with extra-ovarian disease have invasive implants, and conservative treatments have been rarely reported. The MITO14 is a multi-institutional retrospective study conducted with the aim of systematically collecting data from consecutive BOT patients. The present analysis reports the oncological and reproductive outcomes of women with serous BOT and invasive implants registered into the MITO14 database and conservatively treated between August 2002 and May 2019. METHODS: Thirteen patients (FIGO2014 stage II-III serous BOT with invasive implants) were recruited. Primary and secondary endpoints were, respectively, recurrence and death rates, and pregnancy and live birth rates. Only patients undergoing fertility-sparing surgery (FSS) were included, while patients were excluded in case of: age > 45 years; second tumor(s) requiring therapy interfering with the treatment of BOT. RESULTS: Median follow-up time from primary cytoreduction was 146 months (range 27-213 months). Eleven patients (84.6%) experienced at least one recurrence (median time to first relapse 17 months, range 4-190 months), all of these undergoing secondary surgery (FSS in 7). Five patients attempted to conceive: 3 achieved at least one pregnancy and 2 gave birth at least to a healthy child. At the end of the observation period, all patients were alive with no evidence of disease. CONCLUSIONS: Fertility-sparing treatment should be considered in a context of serous BOT with invasive implants. Despite the high rate of recurrence, FSS provides good chances of reproductive success without a negative impact on overall survival.

Ultrasound Evaluation of Retrocervical and Parametrial Deep Endometriosis on the Basis of Surgical Anatomic Landmarks.

STUDY OBJECTIVES: To assess the value of combined transvaginal/transabdominal ultrasonographic evaluation performed by experienced examiners for deep infiltrating endometriosis (DIE) lesions of the retrocervical (torus uterinus and uterosacral ligaments) and parametrial areas and summarize the features and anatomic criteria for identification of these lesions and their extent in the above-mentioned pelvic compartments. DESIGN: Retrospective study. SETTING: A specialized endometriosis center in Avellino, Italy. PATIENTS: A retrospective cohort of patients who underwent laparoscopic surgery for clinically suspected DIE between January 1, 2014, and December 31, 2018, with a dedicated ultrasound (US) evaluation performed no more than 1 month before the intervention. INTERVENTIONS: Preoperative US findings and surgical reports were reviewed. Using the findings of laparoscopic surgery as the gold standard, the sensitivity and specificity of preoperative US evaluation for retrocervical and parametrial endometriotic lesions were calculated with the corresponding 95% confidence intervals. MEASUREMENTS AND MAIN RESULTS: A total of 4983 patients were included. US evaluation showed high diagnostic accuracy for DIE detection in the examined pelvic compartments, with sensitivity and specificity of 97% to 98% and 98% to 100%, respectively, for both retrocervical (torus uterinus and uterosacral ligaments insertion) and parametrial lesions. CONCLUSION: Parametrial extension of DIE indicates major surgical technical difficulties and risk of complications, and urologic and nerve-sparing procedures may be required in such cases. Preoperative evaluation of such scenarios will allow proper counseling of patients and facilitate adequate surgical planning in referral centers; moreover, when necessary, it can guide the constitution of a dedicated multidisciplinary surgical team as an alternative to treatment by a pelvic surgeon alone. Detailed imaging evaluation of DIE lesions and their extension is crucial for clinical management of affected patients. It can facilitate optimization of surgical timing and strategies, thereby potentially preventing ineffective, or even harmful, repeated procedures.

Totally Laparoscopic Resection with Transanal Natural Orifice Specimen Extraction for Deep Endometriosis Infiltrating the Rectum.

OBJECTIVE: To show the surgical steps used to perform a totally laparoscopic segmental rectal resection, with intracorporeal anastomosis and transanal natural orifice specimen extraction (NOSE), in a context of deep endometriosis. DESIGN: Step-by-step video demonstration of the technique. SETTING: Even though the combined use of intracorporeal anastomosis and NOSE has increasingly been investigated during the last decade, there is still lack of defined consensus, both in terms of patient eligibility and operative technique. In particular, experience with intracorporeal anastomosis and NOSE for treatment of deep rectal endometriosis is very limited. Preliminary reports have documented that a totally laparoscopic rectal resection is equally effective and safe compared with the conventional approach using an abdominal minilaparotomy for extracorporeal anastomosis and specimen retrieval. In comparison to the latter, intracorporeal anastomosis with NOSE seems to offer advantages in terms of less postoperative pain, fewer wound-related complications, better cosmetic results, quicker return of bowel function and shorter hospital stay. PATIENT: A 31-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. Preoperative ultrasonography showed partial obliteration of the Douglas' pouch due to a rectal endometriotic nodule of 42 × 12 × 18 mm in contiguity with a deeply infiltrating retrocervical lesion of 13 × 3 × 17 mm. The rectal nodule resulted in the infiltration of the tunica muscularis with a distance of 12 cm from the anal verge and a circumferential extent of 45%. INTERVENTIONS: A 3-dimensional laparoscopic system was used. Rectal mobilization was performed according to our standardized technique [1]. After determining the proximal and distal resection margins, the rectum was transected using a tissue sealing-device. The resected specimen was placed in a retrieval bag and pulled out through the anus. Proximal and distal resection lines were closed using a 60 mm linear endo-stapler, and a totally intracorporeal, side-to-end anastomosis was performed using a 29 mm circular stapler. MAIN RESULTS: The overall operative time was 85 minutes. The estimated blood loss was 10 mL. Neither intra- nor postoperative complications occurred. The patient was discharged 5 days after surgery. The bowel endometriotic nodule measured 41 × 12 × 18 mm on the fresh unfixed specimen. CONCLUSIONS: Advanced surgical skills are needed to perform an effective and safe, totally laparoscopic rectal resection. The operative technique displayed in this video may contribute to the standardization of such surgical procedure. Accurate patient selection, including adequate preoperative evaluation, is of utmost importance for the best chance of surgical success.

Fertility-sparing treatment in advanced-stage serous borderline ovarian tumors. An analysis from the MITO14 study database.

OBJECTIVES: To evaluate oncological and reproductive outcomes of women undergoing fertility-sparing surgery (FSS) for stage II-III serous borderline ovarian tumors (BOTs). METHODS: A multi-institutional retrospective study was conducted within the MITO Group. RESULTS: A total of 91 patients were recruited. The median follow-up time from primary cytoreduction was 127 months (IQR range 91-179). Forty-nine patients (53.8%) experienced at least one recurrence (median time to first relapse 22 months, IQR range 9.5-57). At univariable analysis, significant predictors of relapse were: size of largest extra-ovarian lesion, peritoneal cancer index, completeness of cytoreduction, type of implants. After multivariable analysis, the size of extra-ovarian lesions and the presence of invasive implants resulted as the only independent predictors of recurrence. Median disease-free survival (DFS) was 96 months (95% CI, 24.6-167.3), while median disease-specific survival (DSS) was not reached. Twenty-nine patients (31.8%) attempted to conceive: 20 (68.9%) achieved at least one pregnancy and 18 (62%) gave birth to a healthy child. At the end of the observation period, 88 patients (96.7%) showed no evidence of disease, 2 (2.2%) were alive with disease, and 1 patient (1.1%) died from BOT. CONCLUSIONS: Despite the recurrence high rate, FSS provides good chances of reproductive success with no impact on DSS. The presence of invasive peritoneal implants affects the DFS but not DSS nor reproductive outcome. The risk of recurrence would not seem to be related to the ovarian preservation per se, but to the natural history of the initial peritoneal spread.

High-risk HPV-positive and -negative high-grade cervical dysplasia: Analysis of 5-year outcomes.

OBJECTIVE: To evaluate the outcomes of high-risk (HR) HPV-positive and -negative women affected by high-grade cervical dysplasia. METHODS: This is a retrospective multi-institutional study. Medical records of consecutive patients with high-grade cervical dysplasia undergoing conization between 2010 and 2014 were retrieved. All patients included had at least 5 years of follow-up. A propensity-score matching was adopted in order to reduce the presence of confounding factors between groups. Kaplan-Meir and Cox hazard models were used to estimate 5-year outcomes. RESULTS: Overall, data of 2966 women, affected by high-grade cervical dysplasia were reviewed. The study population included 1478 (85%) and 260 (15%) women affected by HR-HPV-positive and HR-HPV-negative high-grade cervical dysplasia. The prevalence of CIN2 and CIN3 among the HR-HPV-positive and -negative cohort was similar (p = 0.315). Patients with HR-HPV-positive high-grade cervical dysplasia were at higher risk of 5-year recurrence (after primary conization) that HR-HPV-negative patients (p < 0.001, log-rank test). Via multivariate analysis, HR-HPV-negative women were at low risk of recurrence (HR: 1.69 (95%CI: 1.05, 4.80); p = 0.018, Cox Hazard model). A propensity-score matched comparison was carried out in order to reduce biases that are related to the retrospective study design. In comparison to HR-HPV-negative patients, thosewith HR-HPV-positive CIN3 was associate with a 8-fold increase in the risk of recurrence (p < 0.001, log-rank test). CONCLUSIONS: HR-HPV-negative high-grade cervical dysplasia is not uncommon, accounting for 15% of our study population. Those patients experience more favorable outcomes than patients with documented HR-HPV infection(s). Further prospective studies are needed to corroborate our data.

Laparoscopic Technique for Discoid Resection of Rectal Endometriotic Nodules.

OBJECTIVE: To show the surgical steps used to perform a rectal disc excision in the context of deep infiltrating endometriosis characterized by contiguity between an intestinal lesion and the retrocervical region. DESIGN: Step-by-step video demonstration of the technique. SETTING: Although surgical options for the management of rectosigmoid endometriosis have been investigated increasingly, there is no consensus regarding patient eligibility for shaving, discoid resection, or segmental resection. In our practice, women with nodules ≤3 cm in size and >7 mm deep were considered as candidates for rectosigmoid disc excision [1]. Therefore patients' selection, together with the adoption of a standardized surgical technique, has allowed us to maximize the chance of a successful discoid resection, minimizing the complications potentially derivable from this surgical procedure. INTERVENTIONS: The patient was a 30-year-old woman with a history of constipation, dyschezia, dysmenorrhea, dyspareunia, and chronic pelvic pain unresponsive to hormonal therapies. A preoperative ultrasonography showed complete obliteration of the pouch of Douglas owing to a rectal endometriotic nodule (21 × 7 × 12 mm) in contiguity with a deeply infiltrating retrocervical lesion (28 × 10 × 27 mm). As a result, the rectal nodule infiltrated the tunica muscularis with a distance from the anal verge of 9 cm and an estimated stenosis of 35%. A 3-dimensional laparoscopy was performed. After rectal mobilization and rectovaginal space opening, the intestinal nodule was isolated in its entire circumference (Fig. 1). A 33-mm transanal circular stapler was inserted into the rectum through the anus and used to perform disc excision and suture the rectal wall. The overall operative time was 55 minutes. No intraoperative complication occurred. A complete excision of endometriosis was achieved. The estimated blood loss was 10 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of the surgery. The patient was discharged 3 days after surgery and did not experience postoperative complications. The diameters of the bowel endometriotic nodule, on measuring fresh specimen, were 20 × 7 × 13 mm. CONCLUSIONS: Advanced laparoscopic surgical skills are needed to perform an effective and safe rectal discoid resection. Subspecialization and an adequate preoperative evaluation are of utmost importance to appropriately plan the treatment strategy against bowel endometriosis.

Recurrence rate after loop electrosurgical excision procedure (LEEP) and laser Conization: A 5-year follow-up study.

OBJECTIVE: Conization aims to remove pre-neoplastic lesions of the uterine cervix. Several techniques for conization have been compared, but evidence regarding the most effective therapeutic option is scant. Here, we aimed to compare the recurrence rate following laser conization and loop electrosurgical excision procedure (LEEP) in patients with high-grade cervical dysplasia (HSIL/CIN2+). METHODS: This is a retrospective multi-institutional study. Medical records of consecutive patients with HSIL/CIN2+ undergoing conization between 2010 and 2014 were retrieved. A propensity-score matching (PSM) was applied in order to reduce allocation bias. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models. RESULTS: Overall, 2966 patients had conization over the study period, including 567 (20%) and 2399 (80%) patients having laser conization and LEEP, respectively. Looking at predictors of recurrence, diagnosis of CIN3 (HR:3.80 (95%CI:2.01,7.21); p < 0.001) and HPV persistence (HR:1.81 (95%CI:1.11,2.96); p < 0.001) correlated with an increased risk of recurrence. After applying a PSM we selected 500 patients undergoing laser conization and 1000 undergoing LEEP. Patients undergoing LEEP were at higher risk of having positive surgical margins in comparison to patients undergoing laser conization (11.2% vs. 4.2%). The risk of having persistence of HPV was similar between the two groups (15.0% vs. 11.6%;p = 0.256). Five-year recurrence rate was 8.1% and 4% after LEEP and laser conization, respectively (p = 0.023). HPV persistence was the only factor associated with [5-]year recurrence after both laser conization (p = 0.003) and LEEP (p = 0.001). CONCLUSIONS: HPV persistence is the only factor associated with an increased risk of recurrence after either laser conization or LEEP. Owing to the lack of data regarding obstetrical outcomes, we are not able to assess the best therapeutic option for women with cervical dysplasia.

Surgical Management of Early Cervical Cancer: When Is Laparoscopic Appropriate?

PURPOSE OF REVIEW: This paper reviews the recent literature data on minimally invasive surgical approach to early cervical cancer compared to abdominal approach, with the aim of evaluate the oncological outcomes and the appropriateness of current indications. RECENT FINDINGS: A recent multicenter randomized controlled trial and a concurrent large epidemiological study, contrary to the previous retrospective data, showed that minimally invasive surgery is associated with significantly poorer survival than the open approach. Open surgery is to be considered the standard of care for early cervical cancer as implemented in the current guidelines, and the patients must be carefully counseled if minimally invasive surgery is offered. Minimally invasive surgery can be considered safe only for sentinel lymph node mapping in a fertility-sparing setting and could be considered after preoperative conization and for small tumors, adopting preventive surgical maneuvers and in reference centers. However, prospective evidences about the suggested indications are not yet available.

Evaluation of surgical resection in advanced ovarian, fallopian tube, and primary peritoneal cancer: laparoscopic assessment. A European Network of Gynaecological Oncology Trial (ENGOT) group survey.

OBJECTIVE: Laparoscopy is one of the diagnostic tools available for the complex clinical decision-making process in advanced ovarian, fallopian tube, and peritoneal carcinoma. This article presents the results of a survey conducted within the European Network of Gynaecological Oncology Trial (ENGOT) group aimed at reviewing the current patterns of practice at gynecologic oncology centers with regard to the evaluation of resection in advanced ovarian, fallopian tube, and peritoneal carcinoma. METHODS: A 24-item questionnaire was sent to the chair of the 20 cooperative groups that are currently part of the ENGOT group, and forwarded to the members within each group. RESULTS: A total of 142 questionnaires were returned. Only 39 respondents (27.5%) reported using some form of clinical (not operative) score for the evaluation of resection. The frequency of use of diagnostic laparoscopy to assess disease status and feasibility of resection was as follows: never, 21 centers (15%); only in select cases, 83 centers (58.5%); and routinely, 36 centers (25.4%). When laparoscopy was performed, 64% of users declared they made the decision to proceed with maximal effort cytoreductive surgery based on their personal/staff opinion, and 36% based on a laparoscopic score. To the question of whether laparoscopy should be considered the gold standard in the evaluation of resection, 71 respondents (50%) answered no, 66 respondents (46.5%) answered yes, whereas 5 respondents (3.5%) did not provide an answer. CONCLUSIONS: This study found that laparoscopy was routinely performed to assess feasibility of cytoreduction in only 25.4% of centers in Europe. However, it was commonly used to select patients and in a minority of centers it was never used . When laparoscopy was adopted, the treatment strategy was based on laparoscopic scores only in a minority of centers.

Preoperative Ultrasound Indications Determine Excision Technique for Bowel Surgery for Deep Infiltrating Endometriosis: A Single, High-Volume Center.

STUDY OBJECTIVE: To identify bowel nodule features of deep infiltrating endometriosis (DIE) measured through preoperative ultrasound scanning that influence laparoscopic surgical strategy. DESIGN: A retrospective study. SETTING: Malzoni Clinic-Endoscopica Malzoni Department, Center for Advanced Endoscopic Gynecological Surgery, Avellino, Italy. PATIENTS: Patients undergoing laparoscopic surgery between January 1, 2014, and December 31, 2018, for clinically suspected DIE with previous ultrasound evaluation ≤1 month before intervention. INTERVENTION: Use of sonographic measurements to determine laparoscopic excision technique (segmental bowel resection, discoid resection, shaving) for DIE with bowel involvement.``` MEASUREMENTS AND MAIN RESULTS: Of 5051 DIE surgeries, 4983 were included; 1494 (29.9%) bowel resections (512 bowel segmental resections and 982 nodulectomies [967 shaving and 15 discoid resections]) were performed, accounting for 34.3% and 65.7% of all bowel procedures, respectively. Preoperative sonographic findings and surgical reports were collected. Sensitivity and specificity of preoperative ultrasound evaluation for all types of DIE lesions were calculated, and sonographic measurements of bowel nodules and different surgical techniques were compared. According to preoperative sonographic measurements, most nodules excised by segmental resection had a longitudinal diameter of 3 to 7 cm, none were <3 cm; all nodules excised by nodulectomy (shaving or discoid resection) had a longitudinal diameter <3 cm. Mean thickness (maximum depth of muscular layer infiltration) of identified bowel nodules estimated through ultrasound scanning was 13.4 mm ± 4.8 mm (mean ± standard deviation) and 5.8 mm ± 2.7 mm for lesions removed by segmental resection and nodulectomy, respectively, and there was a statistically significant difference between them (p <.05). Of the 512 segmental resected bowel nodules, 143 (28%) had a maximum depth ≥9 mm, 354 (69%) had 7 to 9 mm, and 15 (3%) had <7 mm (6 mm, with length >4 cm). All shaved nodules had thickness ≤7 mm. The 15 nodules excised by discoid resection (1.5% of nodulectomies) were <25 mm, but thickness ranged from 7 to 9 mm. CONCLUSION: The need for segmental resection in DIE with bowel-infiltrating nodules depends on the degree of muscular layer infiltration and corresponding thickness (muscularis rule) in addition to nodule length and can be accurately identified by preoperative ultrasound evaluation.

Surgical Principles of Segmental Rectosigmoid Resection and Reanastomosis for Deep Infiltrating Endometriosis.

STUDY OBJECTIVE: To demonstrate the surgical steps involved in segmental rectosigmoid resection and reanastomosis in a deep infiltrating endometriosis (DIE) setting. DESIGN: Step-by-step video demonstration of the technique. SETTING: Despite efforts made to identify criteria able to reliably predict which patients would be more likely to benefit from segmental bowel resection, such predictability remains an area of controversy and ambiguity. Furthermore, a standardized surgical technique has not yet been defined. Based on our experience, patients with DIE and colorectal involvement should be considered for segmental resection followed by anastomosis if they present with lesions not suitable for shaving/nodulectomy (i.e., large, deeply infiltrating nodules with extensive circumferential involvement). In our practice, careful patient selection together with the adoption of a standardized surgical technique allowed us to minimize the potential complications associated with segmental bowel resection. INTERVENTION: The patient was a 27-year-old woman diagnosed by ultrasonography with a bowel endometriotic nodule of 33 × 8 × 14 mm infiltrating the inner layer of the muscularis propria at the rectosigmoid junction, with a distance from the anal verge of approximately 12 cm and an estimated stenosis of 50%. A 3-dimensional laparoscopic segmental rectosigmoid resection was performed, and indocyanine green-enhanced fluorescent angiography was used to assess perfusion of the bowel before completion of the anastomosis. The total operative time was 135 minutes, and no intraoperative complications occurred. Complete excision of endometriosis was achieved. The estimated blood loss was 30 mL. An intra-abdominal drain was not placed, and the urinary catheter was removed at the end of surgery. The patient was discharged at 6 days after surgery and did not experience any postoperative complications. The bowel endometriotic nodule measured 34 × 8 × 13 mm in a fresh specimen. CONCLUSION: Advanced laparoscopic surgical skills are needed to properly perform segmental rectosigmoid resection. Subspecialization and adequate pretreatment evaluation are crucial to ensure the correct decision making process within a complex algorithm for surgical management of bowel endometriosis.

Piconewton Mechanical Forces Promote Neurite Growth.

Investigations over half a century have indicated that mechanical forces induce neurite growth, with neurites elongating at a rate of 0.1-0.3 µm h-1 pN-1 when mechanical force exceeds a threshold, with this being identified as 400-1000 pN for neurites of PC12 cells. In this article, we demonstrate that neurite elongation of PC12 cells proceeds at the same previously identified rate on application of mechanical tension of ∼1 pN, which is significantly lower than the force generated in vivo by axons and growth cones. This observation raises the possibility that mechanical tension may act as an endogenous signal used by neurons for promoting neurite elongation.

Primary surgical cytoreduction in advanced ovarian cancer: An outcome analysis within the MITO (Multicentre Italian Trials in Ovarian Cancer and Gynecologic Malignancies) Group.

OBJECTIVE: To draw a reliable picture of the surgical management of advanced ovarian cancer (AOC) within the MITO Group, trying to correlate the disease extent at presentation, the category of center, and surgical outcome. METHODS: Three tertiary referral centers for gynecologic oncology and four non-oncologic referral gynecologic surgical centers, participated in the project. A questionnaire was adopted to register perioperative data on AOCs (FIGO Stage IIICIV) consecutively operated on for a period of 12months. RESULTS: A total of 205 patients were registered into the study: 140 and 65 were recruited in oncological referral centers and non-referral centers, respectively. Following a multivariate analysis, the Eisenkop score and the category of center resulted the most potent predictors of complete surgical cytoreduction followed by PCI, preoperative CA125, and ASA score. Complete surgical cytoreduction was associated with oncological referral centers (60% vs 24.6%, p<0.001). The proportion of patients undergoing additional surgical procedures was significantly different comparing the two categories of centers (at least one additional procedure was performed in 81.4% vs 50.8% in oncological referral centers compared to the others, p<0.001). Despite the more aggressive surgery performed in oncological referral centers, the perioperative outcome measures were not significantly different in the two groups. CONCLUSIONS: The chance of obtaining a complete cytoreduction mainly depends on patient characteristics, tumor spread, and quality of treatment. The latter is amenable for direct influence, and therefore, seems to be of utmost importance when considering efforts aiming at improvement in the outcome of this disease.

Long-Term Oncologic and Reproductive Outcomes in Young Women With Early Endometrial Cancer Conservatively Treated: A Prospective Study and Literature Update.

OBJECTIVE: This study aimed to analyze the long-term oncologic and reproductive outcomes in endometrial cancer (EC) in young patients conservatively treated by combined hysteroscopic resection (HR) and levonorgestrel intrauterine device (LNG-IUD). METHODS: Twenty-one patients (age ≤ 40 years; Stage IA, G1-2 endometrioid EC), wishing to preserve their fertility, were enrolled into this prospective study. The HR was used to resect (1) the tumor lesion, (2) the endometrium adjacent to the tumor, and (3) the myometrium underlying the tumor. Hormonal therapy consisted of LNG-IUD (52 mg) for at least 6 months. RESULTS: The median follow-up time is 85 months (range, 30-114). After 3 months from the progestin start date, 18 patients (85.7%) showed a complete regression (CR), 2 (9.5%) showed persistent disease, whereas 1 patient (4.8%) presented with progressive disease and underwent definitive surgery (Stage IA, G3 endometrioid). At 6 months, 1 of the 2 persistences underwent definitive surgery (Stage IA, G1 endometrioid), whereas the other was successfully re-treated. Two recurrences (10.5%) were observed, both involving the endometrium and synchronous ovarian cancer (OC) (atypical hyperplasia and Stage IIB G1 endometrioid OC; Stage IA endometrioid G1 EC, and Stage IA G1 endometrioid OC). The median duration of complete response was 85 months (range, 8-117). Sixty-three percent of complete responders attempted to conceive with 92% and 83% pregnancy and live birth rates, respectively. To date, all patients are alive and have no evidence of disease. CONCLUSIONS: After a long follow-up, combined HR and LNG-IUD would seem to improve the efficacy of progestin alone. High pregnancy and live birth rates were observed in women attempting to conceive. This approach is still experimental and should be offered only in the framework of scientific protocols conducted in cancer centers.

Surgical management of early endometrial cancer: an update and proposal of a therapeutic algorithm.

In the last few years technical improvements have produced a dramatic shift from traditional open surgery towards a minimally invasive approach for the management of early endometrial cancer. Advancement in minimally invasive surgical approaches has allowed extensive staging procedures to be performed with significantly reduced patient morbidity. Debate is ongoing regarding the choice of a minimally invasive approach that has the most effective benefit for the patients, the surgeon, and the healthcare system as a whole. Surgical treatment of women with presumed early endometrial cancer should take into account the features of endometrial disease and the general surgical risk of the patient. Women with endometrial cancer are often aged, obese, and with cardiovascular and metabolic comorbidities that increase the risk of peri-operative complications, so it is important to tailor the extent and the radicalness of surgery in order to decrease morbidity and mortality potentially derivable from unnecessary procedures. In this regard women with negative nodes derive no benefit from unnecessary lymphadenectomy, but may develop short- and long-term morbidity related to this procedure. Preoperative and intraoperative techniques could be critical tools for tailoring the extent and the radicalness of surgery in the management of women with presumed early endometrial cancer. In this review we will discuss updates in surgical management of early endometrial cancer and also the role of preoperative and intraoperative evaluation of lymph node status in influencing surgical options, with the aim of proposing a management algorithm based on the literature and our experience.