Faculty Bibliography

OBJECTIVE:Ovarian cancer laparoscopic staging of patient with intraperitoneal renal transplant. METHODS:43-year-old female with intra-peritoneal renal transplant was referred status post laparoscopic bilateral ovarian cystectomies. The pathology report revealed serous adenocarcinoma with clear cell and papillary features of ovaries and endometrium. She was asymptomatic with benign examination. PET/CT of chest/abdomen/pelvis showed area of metabolic activity in left ovary and right common iliac pelvic lymph nodes. RESULTS:During laparoscopic staging [1], the intraperitoneal kidney transplant was firmly adhered to the uterus, right pelvic sidewall and adnexa. Right pelvic lymph node debulking was performed but not paraaortic lymph node dissection because of increased morbidity of this case. The final pathology showed ovarian serous adenocarcinoma with clear cell features, without involvement of endometrium, negative lymph nodes and peritoneal washings. We believe that the intrauterine pathological finding during the first surgery was "drop lesion" from the ovary to the uterine cavity. Thus, the final stage assigned was IC1, secondary to ovarian cyst rupture at the initial surgery. She received six cycles of intravenous Carboplatin and Taxol. There is no evidence of recurrence in nine-month follow up. CONCLUSION/CONCLUSIONS:The incidence of malignancies is increasing in cases of renal transplant secondary to the age of patients and the immunosuppressive therapy [2,3]. Laparoscopic surgical treatment for gynecologic malignancies can be challenging due to location of transplanted kidney in the pelvis [4]. We present a rare case of laparoscopic ovarian cancer staging with intraperitoneal renal transplant, which can be safely performed in hands of a skilled laparoscopic surgeon.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The relationship between leiomyoma and endometriosis is poorly understood. Both contribute to considerable pain and may cause subfertility or infertility in women. We conducted this retrospective study to assess the rate of coexistence of endometriosis in women with symptomatic leiomyoma. The primary outcome measured was the coexistence of histology-proven endometriosis in women with symptomatic leiomyoma. METHODS:This is a retrospective review of a data-based collection of medical records of 244 patients treated at a tertiary medical center, who were evaluated for symptomatic leiomyoma from March 2011 through December 2015. Of those, 208 patients underwent laparoscopic or laparoscopic-assisted myomectomy or hysterectomy. All patients provided consent for possible concomitant diagnosis and treatment of endometriosis. The remaining 36 patients underwent medical therapy and were excluded from the study. All patients who had myomectomy or supracervical hysterectomy underwent minilaparotomy for extracorporeal morcellation and specimen removal beginning in April 2012. RESULTS:Of the 208 patients with the presenting chief concern of symptomatic leiomyoma and who underwent surgical therapy, 181 had concomitant diagnoses of leiomyoma and endometriosis, whereas 27 had leiomyoma. Of the 27 patients, 9 also had adenomyosis. Patients with only fibroid tumors were, on average, 4.0 years older than those with endometriosis and fibroids (mean age, 44 vs 40 ± SD). Patients with both pathologies were also more likely to present with pelvic pain and nulliparity than those with fibroid tumors alone. CONCLUSIONS:In our patient population, 87.1% of patients with a chief concern of symptomatic fibroids also had a diagnosis of histology-proven endometriosis, which affirms the need for concomitant diagnosis and intraoperative treatment of both conditions. Overlooking the coexistence of endometriosis in women with symptomatic leiomyoma may lead to suboptimal treatment of fertility and persistent pelvic pain. It is important for physicians to be aware of the possibility of this association and to thoroughly evaluate the abdomen and pelvis for endometriosis at the time of myomectomy or hysterectomy in an effort to avoid the need for reoperation.

STUDY OBJECTIVE/OBJECTIVE:To describe our technique for the repair of a cesarean section uterine scar defect after removal of an ectopic pregnancy from the scar in a patient desiring future pregnancies. DESIGN/METHODS:Step-by-step explanation of the procedure using video (Canadian Task Force classification III). SETTING/METHODS:Uterine scar dehiscence/defect is a known complications of multiple cesarean deliveries that can result in abnormal bleeding, infertility, and cesarean scar ectopic pregnancy. With the increasing number of cesarean sections performed in the United States, the prevalence of this complication is rising. Nonetheless, there currently are no standardized surgical treatment guidelines available to manage this pathology through a minimally invasive approach. INTERVENTIONS/METHODS:In this video, we describe our technique for the surgical management of a symptomatic cesarean section scar defect. We performed a robotic-assisted laparoscopic repair of this defect in a 40-year-old G4P3013 with a recent cesarean section scar ectopic pregnancy managed by endometrial curettage, with subsequent persistent abnormal vaginal bleeding. A repeat ultrasound revealed a low uterine segment defect consistent with dehiscence. She was referred to us because she desired a conservative treatment given her desire for future pregnancies. The defect was localized by hysteroscopy and laparoscopy after developing the bladder flap. The scar tissue around the defect was resected, and the freshened edges of the defect were closed using delayed absorbable suture. Chromopertubation confirmed the watertightness of the repair. Postoperatively, the patient had regular normal periods, and her hysterosalpingogram didn't show any uterine defect. CONCLUSION/CONCLUSIONS:Robotic-assisted laparoscopic repair of cesarean section scar defect is a feasible and safe procedure when done with respect to anatomy and following sound surgical technique. With the increasing number of cesarean sections, gynecologists will be dealing with this pathology more frequently, and need to become more familiar with different techniques that can be helpful in performing such a repair.

Despite advances in medicine, ovarian cancer remains the deadliest of the gynecological malignancies. Herein we present the latest information on the pathophysiology of ovarian cancer and its significance for ovarian cancer screening and prevention. A new paradigm for ovarian cancer pathogenesis presupposes 2 distinct types of ovarian epithelial carcinoma with distinct molecular profiles: type I and type II carcinomas. Type I tumors include endometrioid, clear-cell carcinoma, and low-grade serous carcinoma and mostly arise via defined sequence either from endometriosis or from borderline serous tumors, mostly presenting in an early stage. More frequent type II carcinomas are usually high-grade serous tumors, and recent evidence suggests that the majority arise from the fimbriated end of the fallopian tube. Subsequently, high-grade serous carcinomas usually present at advanced stages, likely as a consequence of the rapid peritoneal seeding from the open ends of the fallopian tubes. On the other hand, careful clinical evaluation should be performed along with risk stratification and targeted treatment of women with premalignant conditions leading to type I cancers, most notably endometriosis and endometriomas. Although the chance of malignant transformation is low, an understanding of this link offers a possibility of prevention and early intervention. This new evidence explains difficulties in ovarian cancer screening and helps in forming new recommendations for ovarian cancer risk evaluation and prophylactic treatments.

Uterine leiomyomas affect 20-30 % of women 35 years and older. Extrauterine leiomyomas are rare and present a greater diagnostic challenge. Those unusual growth patterns occur more often in women of reproductive age with a history of hysterectomy or surgery for uterine leiomyomas. They have been reported in the literature in case reports and small case series and include benign metastasizing leiomyoma (BML), disseminated peritoneal leiomyomatosis, intravenous leiomyomatosis (IVL), parasitic leiomyomas, and retroperitoneal growth. In this case series we present a case of BML with a first report of concomitant endometriosis metastasis to paraaortic lymphnodes, and a case of IVL. The findings and surgical management of those cases, as well as a review of the literature pertinent to those entities, are also presented.

BACKGROUND AND OBJECTIVES/OBJECTIVE:To determine if surgery using ultrasonic energy for dissection results in less adhesion formation than monopolar electrosurgical energy in the late (8 weeks) postoperative period. METHODS:Injuries were induced in rabbits by using ultrasonic energy on one uterine horn and the adjacent pelvic sidewall and using monopolar energy on the opposite side. Eight weeks postoperatively, the rabbits underwent autopsy and clinical and pathologic scoring of adhesions was performed by blinded investigators. RESULTS:There was no significant difference in clinical adhesion scores between the two modalities. The mean clinical score for monopolar cautery was 1.00 versus 0.88 for the Harmonic device (Ethicon Endo-Surgery, Cincinnati, Ohio) (P = .71). Furthermore, there was no significant difference found in the pathologic adhesion scores between the ultrasonic scalpel and monopolar energy. The mean pathologic score for monopolar electrosurgery was 4.35 versus 3.65 for the Harmonic scalpel (P = .30). CONCLUSION/CONCLUSIONS:Neither monopolar electrosurgery nor ultrasonic dissection is superior in the prevention of adhesion formation in the late postoperative period.

STUDY OBJECTIVE: To compare the outcome of robotic-assisted laparoscopy vs conventional laparoscopy in the management of ovarian masses. DESIGN: Retrospective cohort (Canadian Task Force classification II-3). SETTING: Academic medical centre in the northeast United States. PATIENTS: Retrospective medical record review of 71 consecutive patients with presumed benign ovarian masses. INTERVENTION: Robotic-assisted laparoscopy in 30 patients with presumed benign ovarian masses was compared with conventional laparoscopy in 41 patients. MEASUREMENTS AND MAIN RESULTS: Operative outcomes including operative time, estimated blood loss, length of hospital stay, and complications were recorded. Standard statistical analysis was used to compare the outcomes in the 2 groups. Mean (SD) operative time in the robotic group was 1.95 (0.63) hours, which was significantly longer than in the conventional laparoscopic group, 1.28 (0.83) hours (p = .04). Estimated blood loss in the robotic group was 74.52 (56.23) mL, which was not significantly different from that in the conventional laparoscopic group, 55.97 (49.18) mL. There were no significant differences in length of hospital stay between the robotic and conventional laparoscopic groups: 1.20 (0.78) days and 1.48 (0.63). Conversion to laparotomy was not necessary in either group of patients. Intraoperative and postoperative complications were similar between the 2 groups. CONCLUSION: Robotic-assisted laparoscopy is a safe and efficient technique for management of various types of ovarian masses. However, conventional laparoscopy is preferred for management of ovarian masses because of shorter operative time. Prospective studies are needed to evaluate the outcomes of robotic-assisted laparoscopic management of benign and malignant ovarian neoplasms.

Proper development of each component of the reproductive tract is imperative for successful natural reproduction. The aim was to investigate some morphological features of the fetal uterus in early phases of its development. The uteruses of 65 fetuses of different gestational age were included and each of them was measured in three dimensions: uterine length (UL), uterine width (BC) and the antero-posterior (sagittal) thickness of the uterine fundus (FT) using ImageJ computer program. It was observed that the most intense fetal uterus growth occurred between seventh and eighth month of gestational age (between week 25 and 31). The most intense rate of uterine growth had UL and it showed steeper growth curve from the fourth month of gestational age. The values of UL, BC, FT showed statistically highly positive Pearson's linear correlation with values of CRL, and GA, and among themselves. The strongest correlation was between UL and gestational age. Contrary to proved rising linear trends of UL/FT and UL/BC, BC/FT performed linear trend of decline. However, two divergent linear trends, one ascending (UL/FT), and other declining (BC/FT) have similar descent in values during the early gestational age, from week 12 to 15. Fetal uteruses did not grow at the same rate by all three measured dimensions, and each of measured dimensions has noticeable standard deviations during gestational periods, even with a resolution of a week, suggesting individuality of each human development/growth even during prenatal life.

OBJECTIVES/OBJECTIVE:The objectives of this study were to evaluate the current evidence of the association of endometriosis and subsequent carcinoma of the ovary and to contextualize this evidence into daily practice issues. METHODS:This study is a critical review of observational and in vitro studies. RESULTS:Although the lifetime risk for ovarian cancer is low in general population and remains low in the broad spectrum of endometriosis, there may be clusters of individuals at higher risk of oncogenesis, whose identification would allow individualized surveillance and prophylactic interventions. Prevalence studies show that specific subtypes of ovarian cancer predominate in women with endometriosis. This has been validated in pathogenetic, genomic, immunobiologic, and hormonal studies. CONCLUSIONS:Taken together, these data provide a strong rationale for identifying, monitoring, counseling, and treating women with endometriosis who are at highest risk for cancer conversion.