The objective of the study is to show some small tricks for bilateral sentinel lymph node (SLN) uptake in endometrial cancer.
Each step of the sentinel lymph node technique was analyzed. The cervix ...was exposed through the use of vaginal valves and by Martin pliers stapling of the anterior cervical lip. Fifty mg Indocyanine Green (ICG) powder was diluted with 10 ml of physiological solution. The spinal needle was marked at 15 mm with a steri-strip. After 20 min from the administration, in case of no LNS identification, an additional 1 ml in the non-detected side was administered in the superficial cervical area. All cervical injections were made by a single (BR) surgeon experienced in oncological gynecology.
Fifty patients undergoing sentinel lymph node research for endometrial cancer. The uptake of at least one side of the sentinel node was 98% (49 cases). Forty-six (92%) patients had bilateral lymph node uptake and 3 patients (6%) had unilateral uptake. Only one patient with pelvic and metastatic aortic lymph nodes had no sentinel nodal uptake.
Little tricks can increase the bilateral uptake of the SLN up to 92%. The reinjection could be a key element for the success of the SLN technique. Experienced surgeons could certainly play a fundamental role in raising bilateral SLN detection. Further prospective randomized studies are needed to achieve the best SLN infiltration strategy.
Since the Food and Drug Administration's (FDA) approval in 2005, the application of robotic surgery (RS) in gynecology has been adopted all over the world. This study aimed to provide an update on RS ...in benign gynecological pathology by reporting the scientific recommendations and high-value scientific literature available to date.
A systematic review of the literature was performed. Prospective randomized clinical trials (RCT) and large retrospective trials were included in the present review.
Twenty-two studies were considered eligible for the review: eight studies regarding robotic myomectomy, five studies on robotic hysterectomy, five studies about RS in endometriosis treatment, and four studies on robotic pelvic organ prolapse (POP) treatment. Overall, 12 RCT and 10 retrospective studies were included in the analysis. In total 269,728 patients were enrolled, 1721 in the myomectomy group, 265,100 in the hysterectomy group, 1527 in the endometriosis surgical treatment group, and 1380 patients received treatment for POP.
Currently, a minimally invasive approach is suggested in benign gynecological pathologies. According to the available evidence, RS has comparable clinical outcomes compared to laparoscopy (LPS). RS allowed a growing number of patients to gain access to MIS and benefit from a minimally invasive treatment, due to a flattened learning curve and enhanced dexterity and visualization.
Introduction: In the last decades, the introduction of laparoscopy and, more recently, of robotic surgery, offered new options for surgical treatment also in gynecological malignancies, as an ...alternative to open surgery. When considering the best surgical treatment option for gynecological malignancies, evidence about safety, feasibility, and oncological outcomes must be taken into account, to offer the best treatment to the patient. The present review aims to provide an updated scenario over the available evidence in the use of minimally invasive surgery (MIS) in gynecological malignancies. Material and methods: An electronic search was performed using the following keywords: ‘minimally invasive surgery’ and ‘gynecology’, ‘minimally invasive surgery’ and ‘endometrial cancer’, ‘minimally invasive surgery’ and ‘ovarian cancer’, ‘minimally invasive surgery’ and ‘cervical cancer’. The agreement about potential relevance was reached by consensus of the researchers and according to PRISMA statement guidelines. Systematic reviews, meta-analyses, clinical trials, and original articles were included in the present review. Results: Fifty-eight studies were considered eligible for the study, 23 studies regarding MIS in endometrial cancer (EC), 19 studies on MIS in ovarian cancer (OC), and 16 studies regarding MIS in cervical cancer (CC). The total of patients enrolled was 180,057, 131,430 in the EC group, 23,774 in the OC groups, and 24,853 in the CC group. Conclusions: According to the available evidence and current clinical practice, MIS is undoubtedly the gold standard for early-stage EC treatment and may represent an acceptable option even in high-risk EC patients. Concerning OC, MIS is a safe and useful tool for staging purposes in advanced-stage disease, and a treatment option only in high volume centres with expert oncologic surgeons. On the contrary, MIS should be abandoned in the context of CC, exception made for well-selected patients, who received adequate counselling about current evidence.
Introduction:
Vulvar cancer is a rare condition affecting older women and accounts for 3–5% of all gynecological cancers. Primary surgical treatment involves the removal of a large amount of tissue ...for which reconstructive surgery is often necessary with a high rate of postoperative complications. Despite several techniques for the evaluation of vulvar flap viability have been proposed, many methods cannot be performed during surgery and require expensive devices often missing in a gynecological clinic. This study aims to verify the feasibility and the safety of the vulvar flap viability evaluation through a near-infrared endoscopic probe and Indocyanine green (ICG) tracer in a small group of patients and to evaluate long-term vulvar flap outcomes.
Methods:
Patients with primary vulvar cancer who required surgical treatment and subsequent vulvar flap reconstructive surgery were prospectively included in the study. A 25 mg ICG vial diluted in 20 ml of saline solution was intravenously infused before closing the skin edges of the flaps. All patients were given 0.2 mg/kg body weight of intravenous ICG. After 10–15 min, a near-infrared endoscopic probe was used to evaluate the vulvar flap viability.
Results:
Of the 18 patients who underwent radical vulvectomy for vulvar cancer during the study period, 15 were included in the analysis. All packaged surgical flaps showed tracer uptake on the surgical margin. No intro-operative complications were recorded neither surgery-related nor to dye infusion. No surgical infection, dehiscence, or necrosis was recorded.
Conclusions:
Vulvar flap viability assessment using Indocyanine green and a laparoscopic infrared probe is a feasible method. All cases included in the analysis showed a dye uptake on the surgical edge of the flap. Further, prospective studies are needed to confirm the method in clinical practice and to evaluate its superiority over simple subjective clinical evaluation.
•Live births after CHM was statistically higher compared to live births after PHM.•Partial molar recurrence occurred more frequently after PHM than CHM.•There was no significant difference in adverse ...obstetric outcomes between CHM and PHM.
The hydatidiform mole is a rare gynecological disease rising from the trophoblastic. Post-molar pregnancies have an extremely variable course, varying from repeated abortions, stillbirths, preterm births, live births, or recurring in further molar pregnancies. Literature on obstetric outcomes following molar pregnancy is poor, often including monocentric studies, and with data collected from national databases. This review and meta-analysis aim to analyze the obstetric outcomes after conservative management of complete (CHM) and partial (PHM) molar pregnancies. The meta-analysis was performed following the Meta-analysis Of Observational Studies in Epidemiology (MOOSE) and the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). Six studies met the inclusion. Of the total 25,222 patients, 13,129 complete (52.1 %) and 12,093 partial (47.9 %) molar pregnancies were included. Live births rate after CHM was statistically higher (p = 0.002) compared to the live births after PHM (53.6 % vs. 51.0 %, 3266 vs. 1807 cases, respectively). Studies showed heterogeneity I2 = 57.7 %, pooled proportion = 0.2 %, and 95 % Confidence Interval (CI) 0.6 to 0.9. No statistically significant difference was demonstrated for ectopic pregnancies (p = 0.633), miscarriage (p = 0.637), preterm birth (p = 0.865), stillbirth (p = 0.911), termination of pregnancy (p = 0.572), and complete molar recurrence (p = 0.580) after CHM and PHM. Partial molar recurrence occurred more frequently after PHM than CHM (0.4 % vs. 0.3 %, 52 vs. 37 cases, respectively, p = 0.002). Careful counseling on the obstetric subsequent pregnancies outcomes should be provided to patients eager for further pregnancy and further studies are needed to confirm these results.
Since the first robotic single-site hysterectomy was performed, the research focused on the use of robotic single-site surgery (RSSS) for all gynecological conditions. This review aims to examine the ...studies available in the literature on RSSS in gynecology both for benign and malignant indications. The systematic review was carried out in agreement with the preferred reporting items for systematic reviews and meta-analyses statement (PRISMA). All the articles were grouped into three sets based on the surgical indication (Group 1, 2, and 3 for benign, malignant, and mixed diseases, respectively). Two hundred and fifty total studies were analyzed, and 27 articles were included in the review. A total of 1065 patients were included in the analysis. Of these, 605 patients were included in group 1, 260 in group 2, and 200 in group 3. Ten (1.7%) patients with benign pathology, 16 (6.2%) patients with malignant disease, and 5 (2.5%) patients with both diseases developed major complications. Two (0.3%) patients in group 1, 3 (1.2%) patients in group 2 and 5 (2.5%) in group 3 were converted to a different type of surgery. No significant differences were found between groups for BMI (
p
= 0.235), operative time (
p
= 0.723), estimated blood loss (EBL) (
p
= 0.342), and hospital stay (
p
= 0.146). The complications and conversions incidence through pooled analysis showed a higher general conversion rate (
p
= 0.012) in group 3 (3.0%) and higher complications rate (
p
= 0.001) in group 2 (5.3%) compared to the other groups. RSSS seems to be a feasible and safe procedure for all gynecological surgical procedures. A long-term analysis would be necessary before considering the RSSS oncologically safe for patients with malignant disease.
Obesity is a known independent risk factor for endometrial cancer (EC), and obese patients have a 4.7-fold increased risk compared to the general population to develop the neoplasm. To date, a ...general pre and postoperative tumor grading agreement from 53 % to 82 % is reported for endometrial analysis, and a consensus on which factors might influence the tumor grading discordance is still absent.
Furthermore, although obesity alters the endometrial microenvironment, no studies investigated the role of obesity in the grading agreement of EC patients. This study aims to analyze the role of obesity in the pre and postoperative tumor grading agreement.
A retrospective analysis was conducted on EC cancer women subjected to surgical treatment. Upgrading discordance was defined as higher tumor grading on final pathological analysis compared to tumor grading on the preoperative examination. Downgrading discordance was defined as a lower tumor grading at the postoperative surgical specimen analysis compared to the preoperative biopsy.
Of the 293 selected patients, 245 were included in the analysis. One hundred and forty nine (60.8 %) patients were tumor grade G1, 52 (21.2 %) G2, and 44 (18.0 %) G3. Grading agreement was 83.9 % for G1 patients, 51.9 % for G2 patients, and 83.3 % for G3 patients. The multivariate analysis showed obesity (BMI > 30 kg/m2) as significant factor influencing pre and postoperative grading agreement (p = 0.014, Odds Ratio 2.036, 95 % Confidence Interval 1.141–3.635).
Our study for the first time showed obesity as the only factor in the multivariate analysis lowering the pre and postoperative tumor grading concordance. Grade 2 tumor was the factor that most frequently disagreed with the final surgical specimen analysis both in the general and in obese patients.
Objective
Atypical polypoid adenomyoma (APA) is a rare uterine premalignant lesion mainly occurring in premenopausal and nulliparous women. Although hysteroscopic resection (HR) has showed promising ...results, the conservative management of APA in young women is not standardized, and few data are available in the literature. We aimed to assess oncologic outcomes of the conservative treatment of APA.
Methods
A multicenter observational retrospective cohort study was performed including all patients with APA who underwent conservative treatment from January 2006 to June 2020. Rates of each oncologic outcome (i.e. initial complete response, persistence, progression to cancer, recurrence, long‐term treatment success, and treatment failure) were calculated for all conservative treatment together and separately.
Results
Twenty‐five patients were included. Conservative treatments consisted of HR alone (n = 14) and HR + progestin (n = 11). Overall, 24 (96%) patients showed initial complete response, of which 21 (84%) showed long‐term treatment success; four (16%) patients had progression to cancer, of which two (8%) first recurred as APA. Long‐term treatment success was achieved in 13 of 14 (92.9%) patients with HR alone and 8 of 11 (72.3%) with HR + progestin.
Conclusion
Conservative treatment appears to be a safe option in women with APA. The four‐steps HR might be considered as the first‐line conservative approach, while the addition of progestin does not seem to improve oncologic outcomes. However, the risk of progression to cancer highlights the need for a close and long‐term follow up with ultrasonography and hysteroscopic biopsies, and for hysterectomy in patients not desiring pregnancy.
Conservative treatment appears safe in women with APA; four‐step HR might be a first‐line conservative approach, while adding progestins seems to not improve oncologic outcomes.
The natural history and patterns of ovarian cancer (OC) relapse are still unclear. Recurrent disease can be peritoneal, parenchymal, or nodal. This study aims to analyze the location and pattern of ...OC recurrence according to the primary site of disease and to the type of surgical approach used.
All OC patients underwent primary debulking surgery (PDS) or interval debulking surgery (IDS), with 2014 FIGO stage III-IV, and with platinum-sensitive recurrence were included in the study. Primary disease location and site of recurrences were divided into peritoneal, parenchymal, and nodal, according to the presence of peritoneal carcinomatosis, parenchymal metastasis, and nodal involvement, respectively.
A total of 355 patients were initially considered; of them, 295 met the inclusion criteria. Two hundred thirty-three patients obtained no macroscopic residual tumor at the end of primary surgical treatment. Primary parenchymal disease relapsed in 84.6% cases at a parenchymal site (p < 0.001), 97.2% of peritoneal diseases relapsed on the peritoneum (p < 0.001), and 100% of nodal diseases had a nodal recurrence (p < 0.001). Stratifying by the surgical approach all these correlations have been confirmed both in the PDS (p < 0.001) and IDS (p < 0.001) groups.
Our study shows that the site of relapse in cases of platinum-sensitive OC recurrence is closely related to the primary location of the disease, regardless of the type of initial treatment. Therefore, more attention during followup should be paid to areas where the initial tumor was present.
1.In 84.6% of cases, parenchymal disease recurred to parenchymatous organs;2.In 97.2% of cases, peritoneal disease relapsed on peritoneal surfaces;3.In 100% of cases, nodal disease relapsed on the lymph nodes.
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