Identifying women 45 years and younger at elevated risk for endometrial hyperplasia or cancer.

OBJECTIVE: To estimate the prevalence of, and identify risk factors associated with, endometrial hyperplasia and/or cancer (EH/EC) in patients ≤45 years old undergoing endometrial sampling for abnormal uterine bleeding (AUB). METHODS: We performed a retrospective cohort study of patients 18-45 years old with AUB who underwent endometrial sampling between 2016 and 2019 within a US-based multi-hospital system using billing code queries. We used multivariable Poisson regression to identify factors associated with EH/EC and calculated prevalence stratified by these factors. We estimated predicted probabilities within combinations of characteristics in order to examine the range of risk in this population. RESULTS: Among 3175 patients, median age was 39 years (interquartile range [IQR]:35-43) and BMI was 29.7 kg/m2 (IQR: 24.2-36.9). Thirty-nine percent were non-Hispanic White, 41% non-Hispanic Black, 9% Hispanic, and 11% Asian/Other/Unknown. BMI and polycystic ovarian syndrome (PCOS) were associated with higher EH/EC risk; non-Hispanic Black race was associated with lower risk. EH/EC prevalence ranged from 2% in BMI <25 to 16% in BMI ≥50 kg/m2 (p-trend <0.001). These prevalence estimates differed by race/ethnicity with the lowest estimates in non-Hispanic Black patients (0.5% BMI <25 vs. 9% BMI ≥50) and highest in Hispanic patients (1.5% BMI <25 vs. 33% BMI ≥50). Accounting for combinations of risk factors, predicted probabilities were highest - 34-36% - among patients with PCOS, diabetes, BMI ≥50, and Hispanic or Asian/Other/Unknown race/ethnicity. CONCLUSIONS: When accounting for combinations of key risk factors, risk of EH/EC in patients ≤45 years old with AUB ranges widely; the more nuanced estimates of risk presented here could help inform clinical decision-making about endometrial sampling in this population.

A Stepwise Strategy to Minimally Invasive Salpingo-Oophorectomy in the Post-Hysterectomy Patient.

Post-hysterectomy salpingo-oophorectomy can be surgically complex. Up to 9% of women who chose ovarian preservation at the time of hysterectomy require future adnexal surgery. Some of the common indications for post-hysterectomy salpingo-oophorectomy are persistent adnexal masses or masses with concern for malignancy, chronic pelvic pain, and risk-reducing surgery. This video presents a 5-step strategy to facilitate a post-hysterectomy bilateral salpingo-oophorectomy to include pelvic and abdominal exploration, restoring normal anatomy, identification of the ureter, isolation, coagulation and transection of the infundibulopelvic ligament, and, lastly, hemostasis with re-evaluation of ureter. This stepwise procedure was highlighted in a patient with a prior total abdominal hysterectomy and a complex adnexal mass. We utilize these techniques on the side without anatomic abnormality and then safely apply this same 5-step strategy to remove a more challenging adnexal mass on the opposite side. We describe a 5-step surgical strategy to ensure safe, efficient, and reproducible salpingo-oophorectomy in the post-hysterectomy patient using a minimally invasive approach. Although this surgery can be challenging to perform in post-hysterectomy patients given anatomical variance and adhesive disease, by following these 5 simple principles we aim to standardize and simplify this potentially difficult procedure.

Lipoma or Liposarcoma? Robotic Resection of a Retroperitoneal Mass.

This video demonstrates a robotic excision of a large retroperitoneal lipomatous mass in a 48-year-old female with a known fibroid uterus. Computed tomography was performed for nephrolithiasis, and an incidental 7-cm fatty prominence in the right hemipelvis was found. Retroperitoneal tumours like benign lipomas and low-grade liposarcoma are difficult to differentiate. The latter has a high rate of local recurrence if incompletely resected; therefore, complete resection should be the goal of surgery. The patient underwent robotic-assisted laparoscopy that revealed a large lipomatous mass in the right retroperitoneal space consistent with radiographic imaging. The lipomatous tumour was carefully dissected and resected from the pararectal space without complication. Pathology revealed partially encapsulated, mature adipose tissue consistent with lipoma with negative fluorescent in situ hybridization (FISH) analysis using a dual-colour MDM2/CEN12 probe set, confirming the likely benign behaviour of the mass. Retroperitoneal lipomatous tumours are rare. Distinguishing between lipomas and liposarcomas is a diagnostic challenge both radiographically and intraoperatively. Confirmatory histopathology and, often, molecular pathology is necessary for the final diagnosis. Knowledge of the differing pathology and disease processes of retroperitoneal lipomatous masses, related surgical anatomy, careful surgical technique, and goals for complete excision are imperative for optimal management.

Fertility-sparing Surgery for Patients with Cervical, Endometrial, and Ovarian Cancers.

OBJECTIVE: Nearly 10% of the 1.3 million women living with a gynecologic cancer are aged <50 years. For these women, although their cancer treatment can be lifesaving, it's also life-altering because traditional surgical procedures can cause infertility and, in many cases, induce surgical menopause. For appropriately selected patients, fertility-sparing options can reduce the reproductive impact of lifesaving cancer treatments. This review will highlight existing recommendations as well as innovative research for fertility-sparing treatment in the 3 major gynecologic cancers. TABULATION, INTEGRATION, AND RESULTS: For early-stage cervical cancers, fertility-sparing surgeries include cold knife conization, simple hysterectomy with ovarian preservation, or radical trachelectomy with placement of a permanent cerclage. In locally advanced cervical cancer, ovarian transposition before radiation therapy can help preserve ovarian function. For endometrial cancers, fertility-sparing treatment includes progestin therapy with endometrial sampling every 3 to 6 months. After cancer regression, progestin therapy can be halted to allow attempts to conceive. Hysterectomy with ovarian preservation can also be considered, allowing for fertility using assisted reproductive technology and a gestational carrier. For ovarian cancers, fertility-sparing surgery includes unilateral salpingo-oophorectomy or bilateral salpingo-oophorectomy (with lymphadenectomy and staging depending on tumor histology). With higher-risk histology or higher early-stage disease, adjuvant chemotherapy is recommended-however, this carries a 3% to 10% risk of ovarian failure. Use of oocyte or embryo cryopreservation in patients with early-stage ovarian malignancy remains an area of ongoing research. CONCLUSION: Overall, fertility-sparing management of gynecologic cancers is associated with acceptable rates of progression-free survival and overall survival and is less life-altering than more radical surgical approaches.

A 20-Centimeter Peritoneal Inclusion Cyst Presenting as Vaginal Prolapse.

This video shows the surgical excision of a 20-cm peritoneal inclusion cyst with laparoscopic repair of pelvic floor defects caused by the mass effect of the cyst. A 44-year-old woman presented with bulge symptoms and a reducible posterior prolapse extending 4 cm beyond the introitus inconsistent with an enterocele/rectocele. Dynamic MRI revealed a 20-cm cystic mass surrounding the uterine fundus extending down the posterior wall of the vagina, anterior to the rectum. Robotic-assisted laparoscopy revealed stage-IV endometriosis and a large peritoneal inclusion cyst extending from the pelvic brim to the rectovaginal septum. The cyst was mobilized through retroperitoneal dissection. Redundant peritoneum was excised down to the perineal body, and the distended posterior vaginal wall was plicated laparoscopically. The peritoneum was closed in a purse-string fashion, obliterating any potential space. Resolution of the prolapse was confirmed along with restoration of normal anatomy. We managed a unique case of a large peritoneal inclusion cyst presenting as vaginal prolapse. To correct defects after cystectomy, laparoscopic repair was performed similarly to closing an enterocele. Repair of a high posterior defect can be performed laparoscopically when working abdominally to avoid vaginal incisions, allowing for excellent visualization and access.

Urinary symptoms in women receiving carboplatin/paclitaxel for treatment of gynecologic cancers.

OBJECTIVES: Urinary incontinence is estimated to affect up to 34% of women with gynecologic cancers. Chemotherapeutic effects on urinary symptoms have been scarcely studied. The aim of our study was to examine the impact of carboplatin/paclitaxel chemotherapy on urinary symptoms. METHODS: This was a prospective cohort study of all women undergoing adjuvant chemotherapy with carboplatin/paclitaxel after their primary debulking surgery for ovarian, fallopian tube, peritoneal, or endometrial cancers performed at a tertiary medical center by board certified gynecologic oncologists. We used validated questionnaires (incontinence impact questionnaire (IIQ-7), medical, epidemiologic, and social aspects of aging (MESA), urogenital distress inventory (UDI-6), the Sandvik severity index, and functional assessment of cancer therapy/GynecologicOncology Group-neurotoxicity (FACT/GOG-Ntx)) to assess the effects of carboplatin/paclitaxel therapy on the incidence and severity of urinary incontinence at three time points during the participants' chemotherapy regimen: start of chemotherapy (pretreatment), during the fifth chemotherapy cycle (mid-cycle), and during the 6-12 week post-chemotherapy visit (post-treatment). RESULTS: We identified 62 women with ovarian, fallopian, peritoneal, and endometrial cancer who received carboplatin/paclitaxel therapy between May 2009 and December 2012 who met all of the inclusion criteria. Analysis of median IIQ-7 scores, across all time points, showed a statistically significant difference (0.0 (0.0 to 4.8), 0.0 (0.0 to 7.1), 0.0 (0.0 to 0.0), p=0.002, respectively). Examining pairwise differences between two treatment points, IIQ-7 pretreatment versus mid-treatment and pretreatment versus post-treatment, did not achieve significance (0.0 (0.0 to 2.4), p=0.13 and 0.0 (0.0 to 0.0), p>0.999, respectively), but the decrease in IIQ-7 mid-treatment versus post-treatment was statistically significant (0.0 (-2.4 to 0.0), p=0.003). Generalized estimating equation model analysis also showed significant changes in both median MESA for urge urinary incontinence (MESA-UUI) and median MESA for stress urinary incontinence (MESA-SUI) across all time points (p=0.003 and p=0.009, respectively). MESA-UUI and MESA-SUI pretreatment versus mid-treatment analysis achieved significance (2.0 (0.0 to 4.0), p=0.003 and 0.0 (0.0 to 2.0), p=0.01, respectively), demonstrating an increase in the incidence of stress urinary incontinence and urge urinary incontinence. There was a statistically significant association between the changes in FACT and UDI-6 scores from pretreatment versus mid-treatment, with a correlation coefficient of 0.37 (95% CI 0.08 to 0.61, p=0.005). CONCLUSION: The study achieved its primary aim in demonstrating an impact of carboplatin/paclitaxel therapy on urinary incontinence severity and suggests if may be a factor leading to new onset or worsening urinary incontinence. As quality of life can be significantly impacted by these chemotherapeutic changes, further investigation is warranted to determine if the effects on urinary incontinence and neuropathy are transient or permanent.

Incidental myomectomy at time of vaginal delivery contributing to postpartum hemorrhage: A case report and review of the literature.

BACKGROUND: Uterine leiomyoma are implicated in certain adverse pregnancy related outcomes such as postpartum hemorrhage. Large submucosal leiomyoma defined as greater than 5 cm, may have higher complication rates; however, high quality data is limited. CASE: A 44-year-old gravida 4 with history of two full-term vaginal deliveries presented at 40 and 2/7 weeks of gestation with premature rupture of membranes and delivered vaginally a viable female infant complicated by a postpartum hemorrhage due to uterine atony. During a manual uterine sweep for suspected retained products of conception, a submucosal leiomyoma was incidentally extracted. Uterine hemorrhage immediately ensued, requiring vasopressors, blood transfusion, and intensive care unit admission. Hemostasis was ultimately achieved with placement of a Bakri balloon. CONCLUSION: This case reaffirms the association of large (greater than five centimeters) submucosal leiomyoma with severe postpartum hemorrhage. Caution should be taken with patients who have leiomyoma with these characteristics. The use of balloon tamponade in such situations may aid in hemostasis and avoidance of postpartum hysterectomy.

A posterior uteroperitoneal fistula: an unexpected finding.

OBJECTIVE: To demonstrate a unique presentation and surgical treatment of a posterior uteroperitoneal fistula with excision of the fistula tract and repair in multiple layers. DESIGN: Illustrative video presentation. A case report is used to describe potential causes of an uteroperitoneal fistula found in a patient during evaluation of secondary infertility and to highlight surgical technique and management using the principles of fistula repair through a minimally invasive approach. The Institutional Review Board reviewed this video article and it was deemed "not human subject research." SETTING: Tertiary medical center. PATIENT(S): A 33-year-old G1P1001 woman with a history of a cesarean section presented with secondary infertility, pelvic pain, and dysmenorrhea and was found to have a posterior uteroperitoneal fistula at the time of hysterosalpingography. INTERVENTION(S): The patient underwent an uncomplicated robot-assisted laparoscopic excision of a posterior uteroperitoneal fistula with the use of careful dissection of the fistula tract, continuous reassessment, and tension-free closure in layers. MAIN OUTCOME MEASURE(S): Preoperative diagnosis and surgical management displaying intraoperative techniques for robot-assisted excision of fistula tract and repair of defect. RESULT(S): The patient underwent robot-assisted operative laparoscopy that revealed a 4-cm mass on the right posterior aspect of the uterus independent from her adnexa. Concomitant hysteroscopy revealed normal endometrium without an evident fistula. During chromopertubation, extravasation was seen into the peritoneal cavity from this mass. The mass and fistula tract were excised without a connection found from her cesarean scar, and reconstruction was performed in multiple layers. Endometriotic lesions were noted intraperitoneally in locations distant from the mass. The patient had significant improvement in her symptoms after surgery. CONCLUSION(S): We present a unique case of a suspected spontaneous posterior uteroperitoneal fistula in the presence of endometriosis without evidence of a connection to her prior hysterotomy scar. Possible etiologies include an undiagnosed, unrepaired hysterotomy extension or a result of chronic inflammation from deep infiltrating endometriosis. Adverse effects on fertility from uteroperitoneal fistulas may be due to disruption of sperm function or endometrial quality secondary to presence of old blood products sequestered in the fistula or due to resultant inflammation from the same. As in this video case, successful treatment of symptoms resulting from an uteroperitoneal fistula requires removal of the fistula tract. The constellation of pelvic pain, dysmenorrhea, postmenstrual bleeding, and infertility should raise suspicion for an uteroperitoneal fistula.

Progestin and aromatase inhibitor therapy in recurrent, estrogen/progestin receptor positive uterine carcinosarcoma: A case report.

•A subset of patients with uterine carcinosarcoma will have ER/PR positive disease.•Hormone receptor expression may serve as a therapeutic target in high-grade endometrial tumors.•Hormonal therapy and SBRT may have benefit in the management of recurrent uterine carcinosarcoma.

A stepwise approach to robotic assisted excision of a cesarean scar pregnancy.

OBJECTIVE: To develop a stepwise approach to robotic assisted excision of cesarean scar pregnancy (CSP) with metroplasty. METHODS: This illustrative video presentation demonstrating CSP, the criteria for ultrasound diagnosis, and a step-by-step approach for robotic assisted excision of CSP and multi-layer hysterotomy closure at a tertiary medical center. RESULTS: Robotic assisted resection is a safe and feasible method to treat cesarean scar ectopic pregnancies. Key ultrasonographic characteristics of CSP are highlighted to facilitate its diagnosis, thus allowing for early intervention with a minimally invasive surgical treatment as necessary. Our patient was a 30-year-old gravida 2 para 1 woman with a history of 1 prior-term low transverse cesarean delivery, who presented with vaginal bleeding in the first trimester and was ultimately diagnosed with CSP. After unsuccessful methotrexate therapy, the patient underwent an uncomplicated robotic assisted excision of her CSP and metroplasty in 2 layers using a stepwise approach: Step 1-Creation of a bladder flap; Step 2-Isolation and excision of CSP; Step 3-Hysterotomy closure in 2 layers; and Step 4-Hysteroscopy. CONCLUSION: When diagnosed late, cesarean scar ectopic pregnancy can cause a significant hemorrhage from rupture. Early radiologic diagnosis does not only indicate minimally invasive surgery as a treatment option but also assists with related surgical planning. This video demonstrates a stepwise approach to the robotic assisted excision of CSP with metroplasty. With these 4 simple steps, surgical procedure can be safe and efficient.

A four step strategy for robot assisted abdominal cerclage placement prior to pregnancy.

OBJECTIVE: To demonstrate a simple, stepwise strategy for robot-assisted abdominal cerclage placement before pregnancy. DESIGN: Demonstrative video presentation. Surgical footage surrounding a case report is used to describe a four-step technique for robot-assisted abdominal cerclage placement in women with recurrent pregnancy loss or other anatomic variants before pregnancy. This video article was reviewed by the Investigational Review Board and further investigation was waived because the study was "not considered human subject research." SETTING: Tertiary medical center. PATIENT(S): A 38-year-old G4P0220 (Gestations: 4, Term deliveries: 0, Preterm deliveries: 2, Abortions: 2, Living children: 0) with a history of two second trimester losses who had failed a prior history-indicated transvaginal cerclage (Fig. 1). INTERVENTION(S): The patient underwent an uncomplicated robot-assisted abdominal cerclage using a four-step strategy: Step 1, create the bladder flap; Step 2, identify pertinent anatomy; Step 3, place the cerclage; and Step 4, hysteroscopy. MAIN OUTCOME MEASURE(S): Intraoperative technique presenting a four-step method to ensure successful robot-assisted abdominal cerclage placement. RESULT(S): Robot-assisted abdominal cerclage is a safe, viable alternative to traditional abdominal cerclage placed via laparotomy. This video outlines four critical steps to facilitate placement and decrease patient morbidity. This patient did well operatively without increased blood loss or operative time and was discharged home on postoperative day 1. She went on to have a successful future pregnancy and currently is scheduled for an elective cesarean section at term. CONCLUSION(S): Abdominal cerclages significantly improve pregnancy and neonatal outcomes in women who previously have failed transvaginal cerclage. Robot-assisted abdominal cerclage placement allows a minimally invasive approach with enhanced dexterity and better visualization for the surgeon compared with conventional laparoscopy or laparotomy, as well as decreased pain and shorter recovery time for patients. This video demonstrates placement of a robot-assisted abdominal cerclage in a patient with recurrent pregnancy loss using a simple four-step strategy to ensure successful, correct, and easy placement. To our knowledge, this is the first video demonstrating a stepwise approach to robot-assisted abdominal cerclage placement.

Sixteen year-old with leiomyosarcoma in a prior benign myomectomy site.

Uterine leiomyosarcoma in a prior myomectomy site is a rare phenomenon. We report an unusual case of a leiomyosarcoma arising six months post myomectomy in a 16-year old female.