Faculty Bibliography

Adnexal masses are identified in pregnant patients at a rate of 2 to 20 in 1000, approximately 2 to 20 times more frequently than in the age-matched general population. The most common types of adnexal masses in pregnancy requiring surgical management are dermoid cysts (32%), endometriomas (15%), functional cysts (12%), serous cystadenomas (11%), and mucinous cystadenomas (8%). Approximately 2% of adnexal masses in pregnancy are malignant. While most adnexal masses in pregnancy can be safely observed and around 70% spontaneously resolve, a minority warrant surgical intervention due to symptoms, risk of torsion, or suspicion for malignancy. Ultrasound is the mainstay of evaluation of adnexal masses in pregnancy due to accuracy, safety, and availability. Several ultrasound mass scoring systems, including the Sassone, Lerner, International Ovarian Tumor Analysis (IOTA) Simple Rules, and IOTA Assessment of Different NEoplasias in the adneXa (ADNEX) scoring systems have been validated specifically in pregnant populations. Decisions regarding expectant versus surgical management of adnexal masses in pregnancy must balance the risks of torsion or malignancy with the likelihood of spontaneous resolution and the risks of surgery. Laparoscopic surgery is preferred over open surgery when possible due to consistently demonstrated shorter hospital length of stay and less post-operative pain, as well as some data demonstrating shorter operative time, lower blood loss, and lower risks of fetal loss, pre-term birth, and low birth weight. Best practices for laparoscopic surgery during pregnancy include left lateral decubitus positioning after the first trimester, port placement with respect to uterine size and pathology location, insufflation pressure of less than 12-15 mm Hg, intraoperative maternal capnography, pre- and post-operative fetal heart rate and contraction monitoring, and appropriate mechanical and chemical thromboprophylaxis. While planning surgery for the second trimester generally affords time for mass resolution while optimizing visualization with regards to uterine size and pathology location, necessary surgery should not be delayed due to gestational age. When performed at a facility with appropriate obstetric, anesthetic, and neonatal support, adnexal surgery in pregnancy generally results in excellent outcomes for mother and fetus.

BACKGROUND:Congenital müllerian anomalies are found in 8.0% of women with infertility and up to 5.5% of women in a general population. Cervical diverticulum is a type of cervical malformation that can be congenital or acquired, with only select cases documented in the literature. Cervical diverticulum can be asymptomatic or present with abnormal uterine bleeding, pelvic pain, or infertility. Previously described management options are largely limited to observation or exploratory laparotomy. CASE:A 35-year-old woman, gravida 2 para 2, presented with persistent menorrhagia, pelvic pain, and abdominal bloating and was found to have an 8-cm right adnexal mass on pelvic ultrasonography. Magnetic resonance imaging showed a hemorrhagic cervical mass communicating with the uterine cavity. The mass was resected laparoscopically, and pathology revealed fibromuscular tissue with endocervical epithelium consistent with a cervical diverticulum. CONCLUSION:Isolated cervical diverticula are rare but should be considered in the differential diagnosis of adnexal masses. Laparoscopic surgery is a safe, minimally invasive approach for evaluation and repair of cervical diverticula.

INTRODUCTION:Cutaneous gluteal vaginal fistula is a rare but significant postoperative complication which may present years after sacrospinous ligament fixation (SSLF) surgery There is limited data on the management of cutaneous vaginal fistula following SSLF. CASE DESCRIPTION:This case report describes a 77-year-old who presents twenty years after SSLF with cutaneous gluteal vaginal abscess and fistula. She underwent successful management with CT-guided percutaneous drainage of gluteal abscess and placement of guiding cutaneous vaginal catheter, laparoscopic pelvic wall dissection and evaluation, and transvaginal localization and removal of the infected permanent suture. DISCUSSION:Multi-disciplinary approach should be considered in the treatment of chronic fistula status post SSLF, including interventional radiology, urogynecology, and minimally invasive gynecologic surgery.

In this review, we aim to evaluate the current literature on reproductive and oncologic outcomes after fertility-sparing surgery for early-stage cervical cancer (stage IA1-IB1). This is a systematic review of the existing literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist to report on fertility-sparing surgery and its outcomes in early-stage cervical cancer. Outcomes of interest were subsequent clinical pregnancy rate, reproductive outcomes, and cancer recurrence outcomes. Included in this systematic review were 68 studies encompassing 3,592 patients who underwent fertility-sparing surgery. Of these, reproductive outcomes were reported in 1096 pregnancies. The mean clinical pregnancy rate was 53.2%. Those who underwent vaginal radical trachelectomy had the highest clinical pregnancy rate (67.5%). The mean live birth rate was 67.8% in our study. Twenty-one percent of pregnancies after fertility-sparing surgery required assisted reproductive technology. The mean cancer recurrence rate was 3.2%, and the cancer death rate was 0.6% after a median follow-up period of 40.1 months with no statistically significant difference across surgical approaches. Offering fertility-sparing surgery in early-stage cervical cancer is reasonable. Highest clinical pregnancy rate is associated with vaginal radical trachelectomy. Moreover oncologic outcomes of minimally invasive approaches were comparable with abdominal approaches. We encourage detailed preoperative counseling and multidisciplinary approach to achieve best outcomes.

STUDY OBJECTIVE/OBJECTIVE:To demonstrate intra- and postoperative steps in a successful management of a complicated vesico-[utero]/cervicovaginal fistula. DESIGN/METHODS:Stepwise demonstration of the technique with narrated video footage. SETTING/METHODS:A urogenital fistula in developed countries mostly occurs after gynecologic surgeries but rarely from obstetric complications. The main treatment of a urogenital fistula is either transvaginal or transabdominal surgical repair. We present a case of a 36-year-old woman, gravida 3 para 3-0-0-3, who developed a complicated large vesico-[utero]/cervicovaginal fistula after an emergent repeat cesarean section. Robotic repair was performed 2 months after the injury using the modified O'Connor method. Blood loss was minimal, and the patient was discharged from the hospital 1 day postoperatively. Follow-up showed complete healing of the fistula with no urine leakage, frequency of urination, or dyspareunia. The patient resumed normal bladder function and menstrual period up to 4 months after the repair procedure. INTERVENTIONS/METHODS:The basic surgical principle of urogenital fistula repair is demonstrated: (1) development of vesicovaginal spaces by dissection of the bladder from the uterus and the vagina, (2) meticulous hemostasis, (3) adequate freshened of the fistula edges, (4) tension-free and watertight closure of the bladder. We also demonstrate some other techniques that have developed though our own practice: (1) facilitating bladder distention by temporarily blocking the fistula, (2) placement of a ureteral catheter to protect the ureters, (3) interposition with omental flap, (4) single layer through and through closure of a cystotomy with 2-0 V-Loc suture (Covidien, Irvington, NJ). CONCLUSION/CONCLUSIONS:Complicated urogenital fistulas may be repaired successfully using minimally invasive surgery using robotic assistance, enabling less blood loss, faster recovery, shorter hospital stay, and fewer complications, etc.

•Fertility treatment prior to definitive cancer therapy in stage IIB EOC.•Both fertility and oncologic outcomes were successful.•The role of Multidisciplinary team is critical.

Background and Objectives/UNASSIGNED:The rise in cesarean deliveries, has led to increase in maternal complications in subsequent pregnancies such as abnormal placental implantation, uterine rupture, hemorrhage and, less commonly, cesarean scar pregnancies (CSP). Our objective was to describe patient characteristics following a combined medical and surgical treatment approach to first trimester cesarean scar pregnancies. Methods/UNASSIGNED:This was a case series approved by the Institutional Review Board of cesarean scar pregnancies over a two-year period at a single academic institution. The study included five patients with diagnosed cesarean scar pregnancies opting for pregnancy termination with the desire for fertility preservation. Medical treatment involved intra-gestational sac injection of lidocaine followed by systemic injection of methotrexate. At a minimum of two months later, surgical resection of cesarean scar pregnancy and repair of the uterus was performed. Results/UNASSIGNED:Median patient age was 36 (range 34 - 42) years, with 4 (3 - 10) prior pregnancies and 2 (1 - 3) prior cesarean deliveries. 40% (2/5) were Hispanic, 20% (1/5) Caucasian, 20% (1/5) African-American, and 20% (1/5) South Asian. After medical intervention, patients waited on average 4.6 ± 2.3 months before surgery. No post-intervention complications or recurrences occurred. Two patients had a subsequent pregnancy. Conclusion/UNASSIGNED:This case series demonstrates an ideal management of cesarean scar pregnancy using combined medical and surgical approach in treating current ectopic pregnancy and repairing the uterine defect successfully without recurrence.

OBJECTIVE:To determine the incidence of fallopian tube endometriosis in patients undergoing laparoscopic surgery with a preoperative diagnosis of endometriosis, pelvic pain, infertility, or cystic adnexal mass. DESIGN/METHODS:Retrospective cross-sectional study. SETTING/METHODS:Gynecologic oncology and minimally invasive surgery practice. PATIENT(S)/METHODS:All patients who underwent surgery for endometriosis from July 2015 to June 2018 were included. Exclusion criteria were age ≥55 years, diagnosis of cancer, laparotomy, previous bilateral salpingectomy, and preoperative diagnosis other than endometriosis, pelvic pain, infertility, or cystic adnexal mass. INTERVENTION(S)/METHODS:Subjects were divided by those who did and those who did not have a salpingectomy at the time of surgery. MAIN OUTCOME MEASURE(S)/METHODS:Diagnosis of tubal endometriosis was based on macroscopic evidence of endometrial implants on the fallopian tube(s) noted within the operative report and microscopic evidence of endometriosis noted within the pathology report. RESULT(S)/RESULTS:A total of 444 surgeries were performed and 185 met the study criteria. Among those, 153 (82.7%) had histologically diagnosed endometriosis within the abdominopelvic cavity. The incidence of tubal endometriosis was 11%-12% macroscopically and 42.5% microscopically after salpingectomy. Patients with tubal endometriosis were more likely to have severe disease. CONCLUSION(S)/CONCLUSIONS:Among patients with endometriosis, the incidence of microscopic tubal endometriosis was significantly greater than that of macroscopic disease.