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Retroperitoneal Lymph Nodes: Cytoreduction in a Patient with Ovarian Cancer
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 laparoscopic was necessary as the para-aortic lymphadenectomy was completed because of a vessel injury that was repaired without difficulty. The median operative timewas 265 minutes (range 210−320) for radical surgery and 218 minutes (range 120−240) for the conservative approach. The mean hospital stay was 3 days. Of the 21 total patients, 6 (28.6%) were upstaged. The median follow-up was 24.7 months (range 1−27), with a disease-free survival of 100% and an overall survival of 100%. No recurrence was observed. Conclusion: A comprehensive surgical staging procedure is clearly indicated in cases of early ovarian cancer and oncologic guidelines should be respected. The Single-site laparoscopic approach could be a valid alternative to laparoscopic or laparotomy. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:07 AM Case Report: Ureteral Obstruction at the Time of Hysterectomy after Uterine Artery Embolization Touchan F,*,1 van der Does L,1 Haworth L,1 Wahbe C2. 1Research, The Center for Innovative GYN Care, Rockville, MD; 2Research, Clara Maass Medical Center, Belleville, NJ *Corresponding author. Study Objective: To report ureteral obstruction at the time of hysterectomy following uterine artery embolization (UAE). Design: Case report. Setting: Clara Maass Medical Center. Patients or Participants: 42 year-old African-American woman. Interventions: Hysterectomy following UAE. Measurements and Main Results: Patient presented for total laparoscopic hysterectomy (TLH) for abnormal uterine bleeding and dysmenorrhea. Patient had a history of UAE two years prior, which resolved her symptoms. MRI during UAE showed no kidney abnormalities. Preoperative TLH evaluation included bimanual exam and transvaginal ultrasound, which showed a globular uterus. TLH with bilateral salpingectomy, adhesiolysis, and minor endometriosis excision were performed uneventfully. A routine post-procedural cystoscopy showed no jet from the right ureter. A stent was attempted, but obstruction was noted at the mid-ureter, 6 cm from the vesicoureteral junction. Retroperitoneal dissection showed a dilated distal ureter but no injury noted. Urology was consulted and intraoperative retrograde pyelogram showed dilated distal ureter with complete obstruction. Ureteroscopy showed a complete obstruction at the level of pelvic brim. Postoperative CT with IV contrast showed severe right renal atrophy. Labs showed normal BUN and creatinine levels, but a renal scan showed a non-functioning right kidney. Nephrology concluded that no surgery was needed to resect the atrophic kidney, and the patient was discharged on postoperative day one. Conclusion: Our experience is similar to a 2005 Canadian case report, in which a patient had complete ureteral obstruction following UAE, requiring nephrectomy. Although ureteral obstruction that results in unilateral non-functioning kidney following UAE is rare, it is likely an under-reported complication. As the uterine arteries supply the lower ureters, embolization could lead to segmental infarction of the ureter. Similarly, as leiomyoma necrose following UAE, peri-ureteral inflammation and infarction could occur. Physicians should be aware of these potential complications, and renal imaging may be indicated before hysterectomy in patients with prior UAE. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:14 AM Occult Uterine Malignancy at the Time of Surgery for Benign Gynecologic Indications: An Updated Systematic Review
S25 Davenport ER,*,1 James L,2 Howard DL3. 1Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, NV; 2School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV; 3Obstetrics and Gynecology, LVMIS-UNLV, Las Vegas, NV *Corresponding author. Study Objective: To conduct an updated systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for benign gynecologic conditions. Design: Systematic review. Setting: N/A Patients or Participants: Women undergoing surgery for presumed benign gynecologic conditions. Interventions: Hysterectomy or Myomectomy. Measurements and Main Results: The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. There were 339,420 patients across 9 countries that were included in these 27 studies. As a comparison, the previous systematic review done by the Agency for Healthcare Research and Quality (AHRQ) only included a total of 136,195 patients. There were a total 2,479 occult uterine malignancies (all subtypes combined) among these 339,420 patients. The crude unadjusted occult uterine malignancy rate was 0.73% (95% CI 0.70 − 0.76%). When we examined a subset of the included studies that reported specific data on women undergoing morcellation, there were 82 occult malignancies among a total of 25,422 patients (Crude proportion = 0.32% [95% CI 0.25 − 0.39%]). Conclusion: Based on this systematic review, incorporating over 300,000 patients, the overall prevalence of occult uterine malignancy at the time of surgery for benign gynecologic indications is approximately 0.73%. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:21 AM Retroperitoneal Lymph Nodes: Cytoreduction in a Patient with Ovarian Cancer Suhner J,*,1 Tomita S,2 Kolev V2. 1Obstetrics and Gynecology, Mount Sinai St. Luke’s-West, New York, NY; 2Obstetrics and GynecologyGynecologic Oncology, Mount Sinai Hospital, New York, NY *Corresponding author. Video Objective: This video will exemplify the techniques necessary to safely complete a difficult dissection and debulking procedure in the obturator fossa in a patient with high-grade serous fallopian tube carcinoma. Setting: This patient is a 67-year-old who presented with a right sided complex adnexal mass and elevated CA-125 of 1300 with concern for malignancy. She was taken to the operating room for laparoscopic right salpingo-oophorectomy with possible hysterectomy and staging. The frozen section was consistent with high-grade serous fallopian tube carcinoma. A bulky retroperitoneal mass was found in the right obturator fossa and the patient underwent debulking procedure.
S26 Interventions: The patient underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, debulking and omentectomy. The bulky retroperitoneal mass was carefully removed using a combination of sharp and blunt dissection, with special care to avoid the nerves and vasculature of the obturator fossa. At the conclusion of the surgery, there was no further evidence of disease. Conclusion: In order to properly treat and stage ovarian cancer, a complete staging and debulking procedure must be performed. This video emphasizes the importance of a thorough understanding of retroperitoneal pelvic anatomy and highlights the utilization of impeccable surgical technique to safely perform a pelvic side wall dissection and debulking in the presence of abnormal pathologic findings.
Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:00 AM Transvaginal Natural Orifice Transluminal Endoscopic Surgery Tubal Reanastomosis: A Novel Route for Tubal Surgery Liu J,*,1 Bardawil E,2 Lin Q,3 Liang B,1 Wang W,3 Wu C,3 Guan X4. 1 Gynecology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; 2Baylor Coll Med, Houston; 3Guangzhou Med Univ, Affiliated Hosp 3, Guangzhou, China; 4Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX *Corresponding author. Video Objective: To demonstrate how a transvaginal natural orifice transluminal endoscopic surgery (NOTES) tubal reanastomosis is a novel route for tubal surgery. The surgical technique is a combination of traditional vaginal surgery with single-site surgical skills. Design: The surgical technique is explained in a stepwise fashion with the use of surgical video footage. The video uses a surgical case to demonstrate the specific techniques necessary to perform a NOTES tubal reanastomosis. Setting: Teaching university. Patients: A 42-year-old female G2P2 with a history of tubal ligation 11 years before presentation requesting a tubal recanalization. Interventions: Transvaginal NOTES tubal reanastomosis was initiated with a posterior colpotomy. A single-site gelport was placed. The fallopian tubes were hydrodissected, the blocked portion of each tube was removed, an epidural catheter was threaded through each lumen, and the two remaining segments of each tube were sutured together in an end-to-end fashion using single-site suturing skills. Conclusion: Transvaginal NOTES tubal reanastomosis as an alternative route for tubal reanastomosis. The current preferred technique for reversal of a tubal sterilization is to perform a minimally invasive surgery with an end-to-end anastomosis. This gives the patient a 60%-90% intrauterine pregnancy rate postoperatively. NOTES has the benefits of a fast recovery, no abdominal incisional pain, and an extremely cosmetic outcome. Current research has shown a 0%3.1% range for the risk of pelvic infection in transvaginal NOTES if prophylactic antibiotics are administered during the surgery. The NOTES tubal reanastomosis combines the traditional vaginal surgery technique of creating a posterior colpotomy with single-site surgical skills like suturing and knot tying. The surgery is completed through a single transvaginal port without an abdominal incision. In the hands of a skilled minimally invasive surgeon, transvaginal NOTES tubal reanastomosis is a feasible and alternative route for this procedure.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:07 AM Transvaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) For Endometrial Carcinoma: A Feasibility and Safety Study Wang Y*. Department of Obstetrics and Gynecology, Southwest Hospital, Third Military Medical University, Chongqing, China *Corresponding author. Study Objective: To investigate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for endometrial carcinoma (EC). Design: Retrospective study. Setting: The First Affiliated Hospital of Third Military Medical University, Chongqing, China Patients or Participants: Women with federation international of gynecology and obstetrics (FIGO) stage IA endometrial cancer. Interventions: vNOTES surgery consist of hysterectomy, bilateral salpingo- oophorectomy and bilateral pelvic and para-aortic lymph node dissection were performed by by a gynecologic oncologist. Clinicopathologic, surgical, and perioperative outcomes were analyzed. Measurements and Main Results: All the 12 patients were successfully operated. Vaginal hysterectomy was performed in five patients, and vNOTES hysterectomy was performed in seven patients. All the 12 cases underwent bilateral salpingo-oophorectomy under vNOTES. Pelvic lymph node dissection was performed in six patients, sentinel lymph node biopsy was performed in four patients, and pelvic lymph node dissection plus para-aortic lymphadenectomy was performed in two patients. The median operative time was 172 minutes (94-235 minutes), the median blood loss was 117 (50-200) ml, and the median postoperative hospital stay was 5 (49) days. The median time for postoperative recovery of gastrointestinal function was 21 hours (12-40 hours), the median pain score at postoperative 12 hours was 2 (1-4) and 1 (1-2) at postoperative 24 hours. The median follow-up time was 5 months. The vaginal stump incision healed well in all the patients. Conclusion: vNOTES is a safe and effective method for comprehensive surgical staging of EC. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.
Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:14 AM Hysteroscopic Removal of Intrauterine Contraceptive Device During the First Trimester. Procedure Description and Pregnancy Outcomes Nassie DI,*,1,2 Borovich A,1,2 Cohen G,1 Peled Y,1,2 Krissi H,1,2 Goldchmit C1,2. 1Obstertics & Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tiqva, Israel; 2Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel *Corresponding author. Study Objective: To evaluate the efficacy and safety of intrauterine contraceptive device (IUD) removal during the first trimester for desired pregnancies. Design: prospective cohort study. Setting: single tertiary, university affiliated, medical center. Patients or Participants: 7 first trimester gravid women who underwent hysteroscopic removal of an IUD at an operating room (OR) setting.
S25 Davenport ER,*,1 James L,2 Howard DL3. 1Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, NV; 2School of Medicine, University of Nevada, Las Vegas, Las Vegas, NV; 3Obstetrics and Gynecology, LVMIS-UNLV, Las Vegas, NV *Corresponding author. Study Objective: To conduct an updated systematic review to estimate the prevalence of occult uterine malignancy, of any subtype, among women undergoing surgery for benign gynecologic conditions. Design: Systematic review. Setting: N/A Patients or Participants: Women undergoing surgery for presumed benign gynecologic conditions. Interventions: Hysterectomy or Myomectomy. Measurements and Main Results: The PRISMA guidelines were followed in this systematic review. The search terms used were “occult malignancy” or “occult uterine pathology” paired with “morcellation” or “hysterectomy.” March 25, 2019 was the last date that articles were searched. We did not restrict articles based on language or publication date. Inclusion criteria included any peer-reviewed journal articles reporting occult uterine malignancy rates at the time of surgery for benign conditions, regardless of whether morcellation was used or not. We excluded articles that were reported exclusively on women with pre-operatively diagnosed or suspected uterine malignancies. Our search yielded a total of 233 journal articles, of which 53 met the criteria for a full-text review and 27 were included in the final systematic review. There were 339,420 patients across 9 countries that were included in these 27 studies. As a comparison, the previous systematic review done by the Agency for Healthcare Research and Quality (AHRQ) only included a total of 136,195 patients. There were a total 2,479 occult uterine malignancies (all subtypes combined) among these 339,420 patients. The crude unadjusted occult uterine malignancy rate was 0.73% (95% CI 0.70 − 0.76%). When we examined a subset of the included studies that reported specific data on women undergoing morcellation, there were 82 occult malignancies among a total of 25,422 patients (Crude proportion = 0.32% [95% CI 0.25 − 0.39%]). Conclusion: Based on this systematic review, incorporating over 300,000 patients, the overall prevalence of occult uterine malignancy at the time of surgery for benign gynecologic indications is approximately 0.73%. Open Communications 2: Oncology (11:00 AM — 11:30 AM) 11:21 AM Retroperitoneal Lymph Nodes: Cytoreduction in a Patient with Ovarian Cancer Suhner J,*,1 Tomita S,2 Kolev V2. 1Obstetrics and Gynecology, Mount Sinai St. Luke’s-West, New York, NY; 2Obstetrics and GynecologyGynecologic Oncology, Mount Sinai Hospital, New York, NY *Corresponding author. Video Objective: This video will exemplify the techniques necessary to safely complete a difficult dissection and debulking procedure in the obturator fossa in a patient with high-grade serous fallopian tube carcinoma. Setting: This patient is a 67-year-old who presented with a right sided complex adnexal mass and elevated CA-125 of 1300 with concern for malignancy. She was taken to the operating room for laparoscopic right salpingo-oophorectomy with possible hysterectomy and staging. The frozen section was consistent with high-grade serous fallopian tube carcinoma. A bulky retroperitoneal mass was found in the right obturator fossa and the patient underwent debulking procedure.
S26 Interventions: The patient underwent total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, lymph node dissection, debulking and omentectomy. The bulky retroperitoneal mass was carefully removed using a combination of sharp and blunt dissection, with special care to avoid the nerves and vasculature of the obturator fossa. At the conclusion of the surgery, there was no further evidence of disease. Conclusion: In order to properly treat and stage ovarian cancer, a complete staging and debulking procedure must be performed. This video emphasizes the importance of a thorough understanding of retroperitoneal pelvic anatomy and highlights the utilization of impeccable surgical technique to safely perform a pelvic side wall dissection and debulking in the presence of abnormal pathologic findings.
Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:00 AM Transvaginal Natural Orifice Transluminal Endoscopic Surgery Tubal Reanastomosis: A Novel Route for Tubal Surgery Liu J,*,1 Bardawil E,2 Lin Q,3 Liang B,1 Wang W,3 Wu C,3 Guan X4. 1 Gynecology, Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; 2Baylor Coll Med, Houston; 3Guangzhou Med Univ, Affiliated Hosp 3, Guangzhou, China; 4Department of Obstetrics and Gynecology, Baylor College of Medicine, Houston, TX *Corresponding author. Video Objective: To demonstrate how a transvaginal natural orifice transluminal endoscopic surgery (NOTES) tubal reanastomosis is a novel route for tubal surgery. The surgical technique is a combination of traditional vaginal surgery with single-site surgical skills. Design: The surgical technique is explained in a stepwise fashion with the use of surgical video footage. The video uses a surgical case to demonstrate the specific techniques necessary to perform a NOTES tubal reanastomosis. Setting: Teaching university. Patients: A 42-year-old female G2P2 with a history of tubal ligation 11 years before presentation requesting a tubal recanalization. Interventions: Transvaginal NOTES tubal reanastomosis was initiated with a posterior colpotomy. A single-site gelport was placed. The fallopian tubes were hydrodissected, the blocked portion of each tube was removed, an epidural catheter was threaded through each lumen, and the two remaining segments of each tube were sutured together in an end-to-end fashion using single-site suturing skills. Conclusion: Transvaginal NOTES tubal reanastomosis as an alternative route for tubal reanastomosis. The current preferred technique for reversal of a tubal sterilization is to perform a minimally invasive surgery with an end-to-end anastomosis. This gives the patient a 60%-90% intrauterine pregnancy rate postoperatively. NOTES has the benefits of a fast recovery, no abdominal incisional pain, and an extremely cosmetic outcome. Current research has shown a 0%3.1% range for the risk of pelvic infection in transvaginal NOTES if prophylactic antibiotics are administered during the surgery. The NOTES tubal reanastomosis combines the traditional vaginal surgery technique of creating a posterior colpotomy with single-site surgical skills like suturing and knot tying. The surgery is completed through a single transvaginal port without an abdominal incision. In the hands of a skilled minimally invasive surgeon, transvaginal NOTES tubal reanastomosis is a feasible and alternative route for this procedure.
Abstracts / Journal of Minimally Invasive Gynecology 26 (2019) S1−S97 Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:07 AM Transvaginal Natural Orifice Transluminal Endoscopic Surgery (VNOTES) For Endometrial Carcinoma: A Feasibility and Safety Study Wang Y*. Department of Obstetrics and Gynecology, Southwest Hospital, Third Military Medical University, Chongqing, China *Corresponding author. Study Objective: To investigate the feasibility and safety of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) for endometrial carcinoma (EC). Design: Retrospective study. Setting: The First Affiliated Hospital of Third Military Medical University, Chongqing, China Patients or Participants: Women with federation international of gynecology and obstetrics (FIGO) stage IA endometrial cancer. Interventions: vNOTES surgery consist of hysterectomy, bilateral salpingo- oophorectomy and bilateral pelvic and para-aortic lymph node dissection were performed by by a gynecologic oncologist. Clinicopathologic, surgical, and perioperative outcomes were analyzed. Measurements and Main Results: All the 12 patients were successfully operated. Vaginal hysterectomy was performed in five patients, and vNOTES hysterectomy was performed in seven patients. All the 12 cases underwent bilateral salpingo-oophorectomy under vNOTES. Pelvic lymph node dissection was performed in six patients, sentinel lymph node biopsy was performed in four patients, and pelvic lymph node dissection plus para-aortic lymphadenectomy was performed in two patients. The median operative time was 172 minutes (94-235 minutes), the median blood loss was 117 (50-200) ml, and the median postoperative hospital stay was 5 (49) days. The median time for postoperative recovery of gastrointestinal function was 21 hours (12-40 hours), the median pain score at postoperative 12 hours was 2 (1-4) and 1 (1-2) at postoperative 24 hours. The median follow-up time was 5 months. The vaginal stump incision healed well in all the patients. Conclusion: vNOTES is a safe and effective method for comprehensive surgical staging of EC. Larger studies are needed to confirm whether the increased technical difficulty of this procedure justifies its use in routine gynecologic oncology practice.
Open Communications 3: Hysteroscopy (11:00 AM — 12:45 PM) 11:14 AM Hysteroscopic Removal of Intrauterine Contraceptive Device During the First Trimester. Procedure Description and Pregnancy Outcomes Nassie DI,*,1,2 Borovich A,1,2 Cohen G,1 Peled Y,1,2 Krissi H,1,2 Goldchmit C1,2. 1Obstertics & Gynecology, Helen Schneider Hospital for Women, Rabin Medical Center, Petach Tiqva, Israel; 2Sackler School of Medicine, Tel-Aviv University, Tel-Aviv, Israel *Corresponding author. Study Objective: To evaluate the efficacy and safety of intrauterine contraceptive device (IUD) removal during the first trimester for desired pregnancies. Design: prospective cohort study. Setting: single tertiary, university affiliated, medical center. Patients or Participants: 7 first trimester gravid women who underwent hysteroscopic removal of an IUD at an operating room (OR) setting.