Surgical Technique for Sentinel Lymph Node Sampling in Presumed Early-stage Ovarian Cancer.

STUDY OBJECTIVE: Surgical staging for apparent early-stage ovarian cancer includes systematic pelvic and para-aortic lymph node evaluation to detect occult stage III disease [1]. Although, lymphadenectomy procedure is associated with increased duration of surgery and a 13% risk of lymphocyst formation [2]. Sentinel lymph node (SLN) biopsy is still investigational, and no standardized approach has been studied. Recent mounting evidence has approved the applicability of SLN technique in early-stage ovarian cancer [3,4]. The objective of this video is to demonstrate a surgical technique for robotic performance of SLN biopsy in presumed early-stage ovarian cancer. DESIGN: Stepwise demonstration of the robotic technique for SLN sampling in presumed early-stage ovarian cancer. This video report is part of an institutional, investigational review board-approved study. SETTING: Academic tertiary referral center. INTERVENTIONS: This video presents our team's robotic technique for SLN sampling in a 37-year-old woman who presented to our center with a 10-cm right complex adnexal mass, suspicious for malignancy. A 27-gauge spinal needle was inserted through the abdominal wall under direct visualization. We injected 0.5 mL of dilute indocyanine green solution (Novadaq Technologies, Mississauga, Ontario, Canada) (1.25 mg/mL) subperitoneally into the utero-ovarian ligament. The SLN was checked with the fluorescence-guided camera of the Xi DaVinci robotic system (Sunnyvale, CA). Eight to 10 minutes after the injection, a right para-aortic SLN was identified, and dissection was performed. After dissection, the node was extracted and sent to pathology for evaluation by ultra-staging. The final pathology revealed a stage IA low-grade serous ovarian cancer. CONCLUSION: SLN sampling appears to be feasible in presumed early-stage ovarian cancer and may allow the avoidance of systematic lymph node dissection in this set of patients.

Sentinel Lymph Node Sampling as an Alternative to Lymphadenectomy in Patients With Endometrial Cancer and Obesity.

OBJECTIVE: Although its use in endometrial cancer staging is relatively new, sentinel lymph node (SLN) sampling has been shown to be highly accurate and is associated with few complications. However, some studies report lower rates of detection with SLN sampling among patients with obesity. The aim of the current study is to evaluate the feasibility of SLN sampling in endometrial cancer for patients with obesity, and to determine whether omitting lymph node dissection (LND) in surgical staging using SLN sampling impacts oncologic outcomes. METHODS: we conducted a retrospective study of patients with obesity (BMI ≥35 kg/m2), diagnosed with endometrial carcinoma between 2007 and 2017, that compared surgical and oncologic outcomes of 2 cohorts: patients who underwent LND and patients who underwent SLN without lymphadenectomy. The primary outcome was operative time. Secondary outcomes included intraoperative bleeding; lymph node assessment information; intraoperative and postoperative adverse events; and oncologic outcomes including progression-free survival (PFS), overall survival (OS), and disease-specific survival (DSS). PFS was defined as the time from surgery to the recurrence or death from any cause. OS was defined as time from diagnosis to death or the last date the patient was known to be alive, and DSS was defined as the time from the surgery to death from the disease. RESULTS: Out of 223 patients with a median BMI of 40.6 kg/m2, 140 underwent LND and 83 underwent SLN alone. The median operative time for patients in the SLN group was shorter than that of patients in the LND group (190.5 [range 108-393] vs. 238 [131-440] min; P < 0.001), and the SLN group had lower median estimated blood loss than the LND group (30 [range 0-300] vs. 40 [range 0-800] mL; P = 0.03). At the 24-month follow-up cut-off, 98% of patients were alive and 95.5% were disease free, with no significant differences in OS, DSS, and PFS between the 2 groups (P = 0.7, P = 0.8, and P = 0.4, respectively). CONCLUSIONS: In patients with obesity, omitting LND from surgical staging with SLN sampling was associated with shorter operative times and less bleeding and did not affect survival at 2 years.

The rectus abdominus myoperitoneal flap for vaginal reconstruction.

To review the indications, technique and results of the rectus abdominis myoperitoneal (RAMP) flap for vaginal reconstruction from literature and at a single institution. A literature search was conducted of vaginal reconstruction to identify published cases using RAMP flaps. All cases of vaginal reconstruction at Sunnybrook Health Sciences Center (SHSC) from 2007 to 2019 were reviewed. Twenty-one published cases of vaginal reconstruction with RAMP flaps were identified. Eleven had partial longitudinal vaginal defects, 5 had circumferential defects and 5 had unspecified defects. Eight patients with circumferential (N = 3) or unspecified (N = 5) defects developed vaginal stenosis. None of the 11 patients with partial longitudinal defects developed vaginal stenosis and 8 resumed sexual activity. There were 2 cases of donor site hernia and 4 donor site infections, but no flap loss. At SHSC, 5 cases of RAMP flap vaginal reconstruction were identified. Cases 1-3 and 5 had circumferential vaginal defects and Case 4 had a partial longitudinal defect. There were no cases of flap necrosis or donor site hernia. Case 1 died 18 days after pelvic exenteration from bowel ischemia. Case 2 developed a rectovaginal fistula after an anastomotic leak from a low anterior resection. Case 3 had a wound infection and vaginal shortening to 3-4 cm. Cases 4 and 5 had no complications and the vagina appeared normal on exam post-operatively. The literature and our experience support the use of RAMP flaps for reconstruction of partial longitudinal vaginal defects but not circumferential defects where the risk of vaginal stenosis and shortening is high.

Algorithms Used in Ovarian Cancer Detection: A Minireview on Current and Future Applications.

BACKGROUND: Ovarian cancer is the 5th most common cause of cancer death among women in the US. Currently, there is no screening algorithm for asymptomatic women that has been shown to lower mortality rates. Screening is currently not recommended and has been shown to increase harm. Epithelial ovarian cancer (EOC) detection is reviewed, with a focus on high-grade serous, clear-cell, and endometrioid histotypes. CONTENT: A review of current literature surrounding tools used in detection of ovarian cancer will be presented. CA 125, HE4, risk of ovarian cancer algorithm (ROCA), risk of malignancy algorithm (ROMA), risk of malignancy (RMI), OVA1, and future potential biomarkers are reviewed. SUMMARY: Screening and early identification of EOC is currently managed as a single disease entity. However, recent evidence has shown ovarian cancer varies with relation to cellular origin, pathogenesis, molecular alterations, and prognosis, depending on histotype. There is a clear need for future studies identifying histotype-specific preclinical tumor markers to aid in detection and improvement of survival rates.

Resource development in otolaryngology-head and neck surgery: an analysis on patient education resource development.

BACKGROUND: There is a need for educational tools in the consenting process of otolaryngology-head and neck procedures. A development strategy for the creation of educational tools in otolaryngology-head and neck surgery, particularly pamphlets on the peri-operative period in an adenotonsillectomy, is described. METHODS: A participatory design approach, which engages key stakeholders in the development of an educational tool, is used. Pamphlets were created through a review of traditional and grey literature and then reviewed by a community expert in the field. The pamphlets were then reviewed by an interdisciplinary team including educational experts, and finally by less vulnerable members of the target population. Questionnaires evaluating the pamphlets' content, layout, style, and general qualitative features were included. RESULTS: The pamphlets yielded high ratings across all domains regardless of patient population. General feedback was provided by a non-vulnerable patient population and final pamphlets were drafted. CONCLUSIONS: By using a participatory design model, the pamphlets are written at an appropriate educational level to incorporate a broad audience. Furthermore, this methodology can be used in future resource development of educational tools.

Baseline urologic surgical skills among medical students: Differentiating trainees.

INTRODUCTION: Urology training programs seek to identify ideal candidates with the potential to become competent urologic surgeons. It is unclear whether innate technical ability has a role in this selection process. We aimed to determine whether there are any innate differences in baseline urologic technical skills among medical students. METHODS: Second-year medical students from the University of Toronto were recruited for this study and stratified into surgical and non-surgical cohorts based on their reported career aspirations. After a pre-test questionnaire, subjects were tested on several urologic surgical skills: laparoscopy, cystoscopy and robotic surgery. Statistical analysis was performed using chi-squared test, student t-tests and Spearman's correlation where appropriate. RESULTS: A total of 29 students participated in the study and no significant baseline differences were found between cohorts with respect to demographics and prior surgical experience. For laparoscopic skills, the surgical cohort outperformed the non-surgical cohort on several exercises: Lap Beans Missed (4.9 vs. 9.3, p < 0.01), Lap Bean Rating (3.8 vs. 3.1, p = 0.01), Lap Rings Error (0.2 vs. 1.22, p < 0.01), Lap Rings Rating (3.9 vs. 2.9, p < 0.01) and LapSim Grasping Score (64.3 vs. 46.4, p = 0.01). For cystoscopic skills, there were no significant differences between cohorts on any of the performance metrics. The surgical cohort also outperformed the non-surgical cohort on all measured robotic surgery performance metrics: Task Time (50.6 vs. 76.3, p < 0.01), Task Errors (0.2 vs. 3.1, p < 0.01), and Task Score (89.5 vs. 72.6, p < 0.01). DISCUSSION: Objective innate technical ability in urological skills, particularly laparoscopy and robotics, may differ between early trainees interested in a surgical career compared to those interested in a non-surgical career. Further studies are required to illicit what impact such differences have on future performance and competence.