Gonadal Vessels Research Articles

ADVANCES IN UPPER URINARY TRACT ANATOMY THROUGH IMAGING TECHNIQUES

This scoping review was conducted based on the Joanna Briggs Institute's theoretical framework and registered with the Open Science Framework (https://osf.io/b27wc). The study analyzed 29 manuscripts published between 2013 and 2023, focusing on imaging exams to synthesize evidence on the anatomy and clinical correlations of the upper urinary tract. The results revealed significant findings, highlighting the intrarenal pelvis as a possible predictive indicator of urinary loss after partial nephrectomy. This emphasizes the importance of anatomical assessment of the renal pelvis. Brödel's avascular plane has been categorized into three types relevant to pre-surgical patient planning. Multiple renal arteries and venous variations have also been reported, including retro-aortic and circum-aortic renal veins. A movable section related to the ureter was described in the perirenal space, delimited by the point of intersection with the gonadal vessels. The ureteropelvic and ureterovesical junctions were found to be anatomical points susceptible to ureteral constriction. On the other hand, the point at which the ureter crosses the iliac vessels is no longer considered a site prone to ureteral obstruction. The authors emphasize the need to adopt a standardized terminology to describe the anatomical variations of the blood vessels related to the kidney. Using diverse and unclear terms can hinder teaching and research in this area and lead to inaccuracies. From the authors' perspective, imaging exams have enhanced anatomical accuracy, benefiting the teaching of human anatomy and significantly contributing to continuous medical breakthroughs.

Retroperitoneal Approach to D3-Lymph Node Dissection With Left Colic Artery Preservation in the Treatment of Sigmoid Cancer.

Laparoscopic approaches and robot-assisted operations are used for colorectal cancer surgery because of their minimal invasiveness.1 However, changes in intra-abdominal pressure during laparoscopy can lead to cardiovascular complications in compromised patients;2 obesity and intraabdominal adhesions may further interfere with laparoscopic procedures. The retroperitoneal approach may facilitate minimally invasive surgery, even in patients with comorbidities. The technique for high ligation of the inferior mesenteric artery has been described in left colonic surgeries.3 However, complete termination of the blood supply through this artery may lead to a higher frequency of anastomotic leakage.4. We present a novel retroperitoneal approach for D3-lymph node dissection with low ligation of the inferior mesenteric artery and preservation of the left colic artery. This method can reduce the duration of laparoscopic procedures for compromised patients and meet the standards for extended lymph node dissection with tumor-specific mesocolic excision.5,6. The procedure started with the installation of a paraumbilical optical trocar to introduce a 30-degree optical system. The SILS™ Port (Covidien, Medtronic) was inserted into the retroperitoneal space via a 4-cm incision, made 2 cm below and parallel to the anterior superior iliac spine in the left flank under the control of the optical system. The horizontal aspect of the duodenum served as the cranial landmark during interfascial dissection, with the dissection proceeding in a cranial and medial direction. During the dissection, the left ureter was the primary landmark, passing medial to the gonadal vessels and Gerota's fascia.The aorta was exposed medially and the inferior mesenteric artery was identified. The inferior mesenteric artery was skeletonized from its origin until the branching of the left colic artery and the sigmoid artery. The left colic artery was skeletonized until the passage of the inferior mesenteric vein, and the apical lymphatic nodes with mesocolic tissue were mobilized and excised. The inferior mesenteric artery was cut below the left colic artery.The final step was performed laparoscopically. The parietal fascia along Toldt's line was cut laterally to complete the mesocolon excision. The parietal fascia was cut along the right side of the aorta to free the mesocolonic medial border. The sigmoid mesocolon was dissected at the proximal and distal resection margins.Following mobilization, the colon was cut 10 cm distal to the tumor margin using a linear stapler. The specimen was then extracted using an SILS incision. The sigmorectal anastomosis was made. Atypical hepatic resection was performed using two additional trocars. The incidence of pain syndrome in the early postoperative period was low. Blood loss reached 100 mL. The duration of the surgery was 300 min. The retroperitoneal step took 63 min. Metastases were observed in 7 of the 41 harvested lymph nodes. The patient was discharged on the 8th postoperative day. The retroperitoneal technique can be safely performed. Anatomical structures are readily accessible and easily visualized with this approach after special training, enabling extended lymph node dissection.

AI-powered real-time annotations during urologic surgery: The future of training and quality metrics

Introduction and objectiveReal-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time. Summary background dataWhile AI models possess the capability to generate automated annotations based on a collection of video images, the real-time implementation of such technology in urological robotic surgery to aid surgeon and training staff it is still pending to be studied. MethodsWe conducted an educational symposium, which broadcasted 2 live procedures, a robotic-assisted radical prostatectomy (RARP) and a robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones. This was achieved through trained algorithms, conventional video recognition, and novel Video Transfer Network technology which captures clips in full context, enabling automatic recognition and surgical mapping in real-time. ResultsReal-time AI annotations for procedure #1, RARP, are found in Table 1. The safety milestone annotations included the apical safety maneuver and deliberate views of structures such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound, temporary clip application and removal, hemostatic powder application, and notable hemorrhage. ConclusionsFor the first time, surgical intelligence successfully showcased real-time AI annotations of 2 separate urologic robotic procedures during a live telecast. These annotations may provide the technological framework for send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support, leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes, and support training and education.

Scaphoid megalourethra associated with congenital urethrocutaneous fistula: a case report of a rare association

BackgroundCongenital megalourethra is a rare male genital malformation, with less than 100 cases reported in literature. Urethrocutaneous fistula, in turn, has only 65 cases described, which what makes the association between these two anomalies an even rarer condition.Case presentationThe patient was male and born at 37 weeks of gestational age. At birth, the testicles were impalpable, and he had a penile malformation compatible with scaphoid megalourethra associated with congenital urethrocutaneous fistula, with urine output exclusively through a small orifice in the ventral region of the penis. When the child completed 7 months and 22 days, underwent the first surgery, laparoscopically. The first Fowler-Stephens was performed, and the gonadal vessels were ligated, with reconstruction of the penis. Nine months later, the second Fowler-Stephens procedure was performed, with bilateral orchidopexy and penoplasty to improve penis aesthetics. The urethra region was not approached. The postoperative period of the second surgery progressed uneventfully. Nowadays, the patient presents adequate urinary stream.ConclusionThe scaphoid megalourethra associated with congenital urethrocutaneous fistula is an extremely rare pathology, with very few cases reported in the literature to date. The obstetric USG is important to increasing the chances of early diagnosis and treatment.

Surgical tricks of handling a needle and grasping forceps during laparoscopic percutaneous extraperitoneal closure (LPEC) for pediatric inguinal hernia.

Laparoscopic percutaneous extraperitoneal closure (LPEC) is an alternative to open repair for pediatric inguinal hernias; however, its application for boys remains controversial. In this study, we developed a technique to enhance the safety and feasibility of LPEC. In our technique, forceps are used to pull up the peritoneum ahead on the route, creating a space between the peritoneum and structures, including gonadal vessels and vas deferens. This potentially decreases the risk of perioperative injury of these structures. This technique also allows the needle to pass on the shortest course around the inguinal ring without crossing the vas deferens, possibly lowering the likelihood of injury and preventing excessively high ligation of the vaginalis process. Our technique diversifies the LPEC methods, thereby augmenting the feasibility and safety of the procedure.

Evaluating the perceptions of Canadian urology residents and program directors regarding the current training in genitourinary imaging.

Competency in interpreting genitourinary (GU) imaging is an important skill for urologists; however, no nationally accredited GU imaging curriculum exists for Canadian urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self-perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions. From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point-of-care ultrasound within urology was distributed to all Canadian urology PDs and residents. All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non-contrast computed tomography (CT) scans (9.5/10), CT urogram (9.3/10), and retrograde pyelography (9.3/10). All but one PD favored increasing imaging training in their program. PDs highlighted the lack of time in the curriculum (n=3) and lack of educators (n=3) as the primary barriers to increasing imaging training in their program. Most PDs and residents believe there needs to be more imaging training offered at their institution; however, addressing this is challenging due to the limited time in the curriculum and the need for available educators.

Multivisceral transplantation of pelvic organs in rats.

Multivisceral transplantation of pelvic organs would be a potential treatment for severe pelvic floor dysfunction with fecal and urinary incontinence, extensive perineal trauma, or congenital disorders. Here, we describe the microsurgical technique of multivisceral transplantation of pelvic organs, including the pelvic floor, in rats. We performed a perineal (including the genitalia, anus, muscles, and ligaments) and abdominal incision. The dissection progressed near the pelvic ring, dividing ligaments, muscles, external iliac vessels, and pudendal nerves, allowing pelvic floor mobilization. The aorta and vena cava were isolated distally, preserving the internal iliac and gonadal vessels. The graft containing the skin, muscles, ligaments, bladder, ureter, rectum, anus and vagina, uterus and ovarian (female), or penile, testis and its ducts (male) was removed en bloc, flushed, and cold-stored. The infrarenal aorta and vena cava were isolated and donor/recipient aorta-aorta and cava-cava end-to-side microanastomoses were performed. After pelvic floor and viscera removal, we performed microanastomoses between the donor and the recipient ureter, and the rectum and pudenda nerves. The pelvic floor was repositioned in its original position (orthotopic model) or the abdominal wall (heterotopic model). We sacrificed the animals 2 h after surgery. We performed seven orthotopic and four heterotopic transplantations. One animal from the orthotopic model and one from the heterotopic model died because of technical failure. Six orthotopic and three heterotopic recipients survived up to 2 h after transplantation. The microsurgical technique for pelvic floor transplantation in rats is feasible, achieving an early survival rate of 81.82%.

Robot-assisted radical nephrectomy for Wilms’ tumor in children

Surgical removal of the tumor is a key step in the management of nephroblastoma. Less invasive surgical approaches such as robot-assisted radical nephrectomy (RARN) has gained momentum over the past few years. This video presents a comprehensive step-by-step video for two cases: one uncomplicated left RARN and one more challenging right RARN. Following the UMBRELLA/SIOP protocol, both patients received neoadjuvant chemotherapy. Under general anesthesia, in a lateral decubitus position, four robotic and one assistant port are placed. After mobilization of the colon, the ureter and gonadal vessels are subsequently identified. The renal hilum is dissected, and the renal artery and vein are divided. The kidney is dissected with sparing of the adrenal gland. The ureter and gonadal vessels are divided, and the specimen is removed through a Pfannenstiel incision. Lymph node sampling is performed. Patients were 4 and 5 years old. The total surgical time was 95 and 200min, with an estimated blood loss of 5 and 10cc. The hospital stay was limited to 3 and 4 days. Both pathological reports confirmed the diagnosis of nephroblastoma, with tumour-free resection margins. No complications were observed 2 months postoperatively. RARN is feasible in children.

V04-09 ROBOT-ASSISTED RADICAL NEPHRECTOMY FOR WILMS TUMOR IN CHILDREN

You have accessJournal of UrologyCME1 Apr 2023V04-09 ROBOT-ASSISTED RADICAL NEPHRECTOMY FOR WILMS TUMOR IN CHILDREN Jolien van der Jeugt, Camille Berquin, Caroline Jamaer, Karel Decaestecker, Charles van Praet, and Anne-Françoise Spinoit Jolien van der JeugtJolien van der Jeugt More articles by this author , Camille BerquinCamille Berquin More articles by this author , Caroline JamaerCaroline Jamaer More articles by this author , Karel DecaesteckerKarel Decaestecker More articles by this author , Charles van PraetCharles van Praet More articles by this author , and Anne-Françoise SpinoitAnne-Françoise Spinoit More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003252.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical removal of the tumor is a key step in the management of nephroblastoma. Less invasive techniques - such as robot-assisted radical nephrectomy (RARN) - have gained momentum over the past few years, but are still less frequently used in the pediatric population. This video shows our technique in case of left and right RARN in children. METHODS: We present 2 cases of pediatric RARN for Wilms tumor, respectively patients of 3 and 4 years old. Both patients were treated pre-operatively with chemotherapy according to the SIOP guidelines. Repeat imaging is performed after chemotherapy as pre-operative tool to assess the feasibility of a robot-assisted approach. Under general anesthesia, in a lateral decubitus position, four robotic and one assistant port are placed. In case of right RARN an additional assistant port is placed to retract the liver. After mobilization of the colon, the ureter and gonadal vessels are subsequently identified. The renal hilum is dissected, and the renal artery and vein are divided with hem-o-lock clips. The kidney is released with sparing of the adrenal gland. The ureter and gonadal vessels are divided, and the specimen is removed through a Pfannenstiel incision. RESULTS: Total surgical time were respectively 95 and 200 minutes, with an estimated blood loss of 5 cc. The hospital stay was limited to 3 and 4 days. Both pathological reports confirmed the diagnosis of nephroblastoma, with tumor-free surgical margins. No complications were observed 6 months postoperatively. CONCLUSIONS: This video demonstrates the robotic approach for Wilms tumors in children. Although limited series RARN for Wilms tumor is feasible in the pediatrie population. Source of Funding: Non applicable. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e340 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Jolien van der Jeugt More articles by this author Camille Berquin More articles by this author Caroline Jamaer More articles by this author Karel Decaestecker More articles by this author Charles van Praet More articles by this author Anne-Françoise Spinoit More articles by this author Expand All Advertisement PDF downloadLoading ...

LBA01-17 AI-POWERED REAL-TIME ANNOTATIONS DURING UROLOGIC SURGERY: THE FUTURE OF TRAINING AND QUALITY METRICS

You have accessJournal of UrologyCME1 Apr 2023LBA01-17 AI-POWERED REAL-TIME ANNOTATIONS DURING UROLOGIC SURGERY: THE FUTURE OF TRAINING AND QUALITY METRICS Laura Zuluaga, Jordan M. Rich, Raghav Gupta, Adriana Pedraza, Burak Ucpinar, Kennedy E. Okhawere, Indu Saini, Mani Menon, Ashutosh Tewari, and Ketan K Badani Laura ZuluagaLaura Zuluaga More articles by this author , Jordan M. RichJordan M. Rich More articles by this author , Raghav GuptaRaghav Gupta More articles by this author , Adriana PedrazaAdriana Pedraza More articles by this author , Burak UcpinarBurak Ucpinar More articles by this author , Kennedy E. OkhawereKennedy E. Okhawere More articles by this author , Indu SainiIndu Saini More articles by this author , Mani MenonMani Menon More articles by this author , Ashutosh TewariAshutosh Tewari More articles by this author , and Ketan K BadaniKetan K Badani More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003360.17AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Real-time artificial intelligence (AI) annotation of the surgical field has the potential to automatically extract information from surgical videos, helping to create a robust surgical atlas. This content can be used for surgical education and qualitative initiatives. We demonstrate the first use of AI in urologic robotic surgery to capture live surgical video and annotate key surgical steps and safety milestones in real-time. METHODS: We conducted an educational symposium, which broadcasted two live procedures, a robotic-assisted radical prostatectomy (RARP) and robotic-assisted partial nephrectomy (RAPN). A surgical AI platform system (Theator, Palo Alto, CA) generated real-time annotations and identified operative safety milestones (Image 1). This was achieved through trained algorithms, conventional video recognition, and novel technology called Video Transfer Network which captures clips in full context, enabling automatic recognition and surgical mapping in real-time. RESULTS: Real-time AI annotations for procedure #1, RARP, are found in Table 1. Safety milestone annotations included the apical safety maneuver and structures identification such as the external iliac vessels and the obturator nerve. Real-time AI annotations for procedure #2, RAPN, are found in Table 1. Safety milestones included deliberate views of structures such as the gonadal vessels and the ureter. AI annotated surgical events included intraoperative ultrasound and notable hemorrhage among others. CONCLUSIONS: Surgical intelligence successfully showcased real-time AI annotations of two separate urologic robotic procedures during live telecast for the first time. These annotations may provide the technological framework to send automatic notifications to clinical or operational stakeholders. This technology is a first step in real-time intraoperative decision support; leveraging big data to improve the quality of surgical care, potentially improve surgical outcomes and, support training and education. Source of Funding: N/A © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1183 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Laura Zuluaga More articles by this author Jordan M. Rich More articles by this author Raghav Gupta More articles by this author Adriana Pedraza More articles by this author Burak Ucpinar More articles by this author Kennedy E. Okhawere More articles by this author Indu Saini More articles by this author Mani Menon More articles by this author Ashutosh Tewari More articles by this author Ketan K Badani More articles by this author Expand All Advertisement PDF downloadLoading ...

Non-Electrical Ligation of Vessels Using Hem-o-lok Clips Ensures No Electrical Ureteral Injury during Total Laparoscopic Hysterectomy

Background: Ureteral injury is one of the most common anatomical complications during total laparoscopic hysterectomy (TLH). And most ureteral injuries resulted from electrosurgery and were recognized postoperatively. To avoid thermal damage to the ureter during TLH, we evaluated the feasibility and safety of vessel ligation using the Hem-o-lok clip. Methods: A retrospective analysis of 480 patients who underwent TLH. Hem-o-lok clips were used to ligate both uterine vessels. If the patient underwent unilateral or bilateral salpingo-oophorectomy, the gonadal vessels were also ligated by using Hem-o-lok clips. Clinical outcomes including perioperative and postoperative complications were evaluated. Results: Perioperative complications were reported in six patients, with four cases of stump dehiscence and two cases of bladder injury. All bladder injuries were found during the operation and repaired. None of the patients experienced ureter injury or vessel rebleeding. Conclusions: Vessel ligation by Hem-o-lok clips in TLH is a safe method for ligating vessels and avoiding unexpected ureteral injury. Prospective studies are needed to confirm the real clinical benefit of this surgical approach.

The Extraperitoneal Approach to Left-Sided Colorectal Rectal Resections: EXPERTS Procedure.

Current transperitoneal approaches to colorectal resections can be technically challenging, especially in obese patients. The head-down position can lead to rare but serious complications, e.g. compartment syndrome and brachial plexus injuries. The aim of this study was to assess the safety and feasibility of a novel extraperitoneal approach in patients requiring anterior resection. The extraperitoneal left-sided approach was performed in the supine position. A 5cm LIF incision was created into which a Gelpoint port was inserted. The full video of the procedure is embedded in the QR code below. The procedure was performed by three surgeons with experience in minimally invasive surgery. Patients requiring left colonic resections were prospectively selected over a 2-year period. Forty-one patients were prospectively assessed between March 2020 and April 2022; 26 were males, with a median age of 67 (55-88)years. The average body mass index (BMI) was 30 (22-40). 38/41 cases were cancers and three were diverticular diseases; 31 cases had anterior resection and 11 had sigmoid colectomies. Peak airway pressures were significantly less (10 cmH20) in the supine position compared with the head-down position (p<0.0001). Median time to identify the ureter and gonadal vessels was 23 (3-55)min, and median time to return of bowel function and length of stay was 2 (0-13) and 5 (IQR 3-7) days, respectively. No intraoperative complications or postoperative mortality occurred within 90 days of discharge. Three patients had anastomotic complications, and an R0 resection was achieved in all 38 cancer patients. The median lymph node count was 16. Extraperitoneal surgery for left colonic resections is safe and clinically feasible, and allows for early identification of important retroperitoneal structures.

The Extraperitoneal Approach to Left-Sided Colorectal Resections: A Human Cadaveric Study

IntroductionTechnical challenges during laparoscopic and robotic anterior resection include identification of key retroperitoneal structures and obtaining clear views of the inferior mesenteric artery (IMA) pedicle and total mesorectal excision (TME) plane. Steep head-down position improves surgical exposure but is associated with cerebral oedema, high intrapulmonary pressures, and rare neurological complications. In this article we describe the key steps of an anterior resection performed via the extra-peritoneal (XP) space in the supine position. MethodsThe technique of same-side lateral-to-medial XP dissection has been developed and refined in serial cadaveric workshops. A standard periumbilical port is inserted for initial laparoscopic exploration. Dissection is then performed in the left XP space via a 5 cm skin incision (later used as the extraction site) to allow for insertion of four (latterly three) working ports. The colon is mobilized along its lateral attachments, reflecting retroperitoneal structures down and away. The IMA pedicle is taken proximally, next to the duodenum. If required, TME dissection can be continued in the same plane. A short intraperitoneal phase is then required to complete the procedure. ResultsEight cadavers were studied (seven males; median 78 y). Four operations were performed laparoscopically and four robotically. Excellent views of the key retroperitoneal structures were achieved early in the procedure. Anatomical identification was performed sequentially for left-sided structures–psoas tendon, gonadal vessel, ureter, common iliac artery, IMA, and duodenum before ligation of the IMA pedicle. High ligation of IMA on the aorta and splenic flexure mobilization were performed in all eight procedures. ConclusionsThis novel study shows it is feasible to perform the key steps of an anterior resection using the XP space in the supine position. This will reduce the need for steep head-down positioning which may have meaningful clinical benefits. Prospective clinical studies are required to validate the technique within a patient population.

8732 Laparoscopic Bilateral Gonadectomy in a Patient with Mosaic 45,X/46,XY Turner Syndrome

<h3>Study Objective</h3> To demonstrate a laparoscopic technique for prophylactic bilateral gonadectomy in a patient with mosaic 45,X/46,XY Turner syndrome. <h3>Design</h3> We present a stepwise, narrated demonstration of our technique for risk reducing bilateral gonadectomy. We highlight key anatomy, and place special attention on techniques to permit excision of at least 2 cm of the gonadal vessels with the specimen. <h3>Setting</h3> Referral center in Upstate New York. <h3>Patients or Participants</h3> 27-yo G1P1 diagnosed with mosaic Turner syndrome (45,X/46,XY) <h3>Interventions</h3> Visual inspection of the pelvis was performed, and pelvic washings were obtained. The course of the ureter was dissected out within the retroperitoneal space, developing a window between the ureter and gonadal vessels. The peritoneum was opened medial and lateral to the streak gonad to ensure removal of all tissue with potential for malignancy. The infundibulopelvic ligament (IP) was skeletonized and gonadectomy was performed transecting the IP 3-4 cm cephalad to the streak gonad. The same procedure was completed on the opposite side. <h3>Measurements and Main Results</h3> Successful laparoscopic bilateral gonadectomy was performed with an estimated blood loss of 5mL. Pathology demonstrated bilateral streak gonads without evidence of germ cell tumor. <h3>Conclusion</h3> Given the inability to reliably diagnose the presence of germ cell tumors in streak gonads preoperatively, the use of wide dissection at the time of laparoscopic bilateral gonadectomy for risk reduction in mosaic Turner Syndrome patients with Y-chromosome material is an important consideration.

Ruptured Spontaneous Heterotopic Pregnancy Presenting with Hemoperitoneum: a case report

Heterotopic pregnancy (HP) is the coexistence of intrauterine (IU) and extrauterine (EU) gestation. It is rare and potentially fatal condition if not correctly treated or diagnosed. In this case report, we present a 33-year-old woman with a 16-week topical pregnancy with spontaneous rupture of an ectopic pregnancy (EP) in the uterine tube. At first, the patient had diffused abdominal pain, specifically in the lower abdominal level and tachycardia. The evaluation of the fetus showed no signs of distress. Abdominal and transvaginal ultrasound (US) show free intraperitoneal fluid, a normal-looking IU gestation with a positive fetal heart rate consistent with a fetal age of approximately 16 weeks, signs of parenchymal vascular hypoflux of the spleen on the color doppler study, associated with a splenic vein with low vascular amplitude flow. General surgery team were requested and to rule out aneurysm of splenic vessels as a source of bleeding she had an abdominal angiotomography that showed a moderate amount of free fluid, ectasia of gonadal and uterine vessels, with no signals of active bleeding and no spleen changes. No signs of EP were identified in this exam. The patient had hemodynamic deterioration with maintenance of abdominal girth. An emergency exploratory laparotomy was performed under general anesthesia through a supra and subumbilical incision, leading to a finding of a ruptured EP. There was a 3 cm right tubal ruptured ectopic pregnancy. A total right salpingectomy was performed with removal of the hemoperitoneum and peritoneal lavage. The patient recovered uneventfully and was discharged from the hospital within 5 days.

376 Ovarian remnant syndrome and recurrent ovarian serous cystadenoma

Introduction and aims: Ovarian remnant syndrome (ORS) is a rare gynecological complication, most often induced by difficult salpingoophorectomy that leave residual ovarian tissue on the pelvic wall. Recurrent serous cystadenoma may arise from ORS. Our objective was to enhance the importance of diagnosis and surgical management in patients with ORS. Methods: We describe the case of a patient with continuous interventions before radical surgery for ORS. She had a right nephrectomy at age 43, a total abdominal hysterectomy at 45, and bilateral adnexectomy for serous cystadenoma at age 47. After thirteen years of continuous transvaginal aspirations for recurrent cystadenoma, and two laparotomies for cystectomies she was referred to our center. She presented with an abdomino-pelvic mass of 22cm, pain, and compression symptoms. Basic surgical principles were followed: high religation and resection of gonadal vessels; bilateral stripping and excision of the pelvic side wall peritoneum; wide excision of tissue surrounding the remnant ovary. Results and discussion: She needed partial bladder and sigma resection, and comprehensive ureterolysis for complete surgical resection, without significant postoperative complications. Histollogically, remnant ovarian tissue was associated with serous cystadenoma. After being heavily pretreated the modest risk of bowel, bladder or ureteral trauma caused definitive sidewall stripping and vaginal excision. Nearly two years later it occurred a low-rate growing cystic colonic perianastomosis recurrence of 3cm, which has reached 6 cm to date, and remains completely asymptomatic. Conclusions: Meticulous surgery is advised to assure the best outcome to patients. Even a benign non-threatening lesion such as ovarian serous cystadenoma may become a locorregional problem, with aggressive behavior similar to low-grade malignant lesions.

Development and Validation of an Objective Scoring Tool for Robot-Assisted Partial Nephrectomy: Scoring for Partial Nephrectomy.

Objective: To develop a structured and objective scoring tool for assessment of robot-assisted partial nephrectomy (RAPN): Scoring for Partial Nephrectomy (SPaN). Materials and Methods:Content development: RAPN was deconstructed into 6 domains by a multi-institutional panel of 10 expert robotic surgeons. Performance on each domain was represented on a Likert scale of 1 to 5, with specific descriptions of anchors 1, 3, and 5. Content validation: The Delphi methodology was utilized to achieve consensus about the description of each anchor for each domain in terms of appropriateness of the skill assessed, objectiveness, clarity, and unambiguous wording. The content validity index (CVI) of ≥0.75 was set as cutoff for consensus. Reliability: 15 de-identified videos of RAPN were utilized to determine the inter-rater reliability using linearly weighted percent agreement, and Construct validation of SPaN was described in terms of median scores and odds ratios. Results: The expert panel reached consensus (CVI ≥0.75) after 2 rounds. Consensus was achieved for 36 (67%) statements in the first round and 18 (33%) after the second round. The final six-domain SPaN included Exposure of the kidney; Identification and dissection of the ureter and gonadal vessels; Dissection of the hilum; Tumor localization and exposure; Clamping and tumor resection; and Renorrhaphy. The linearly weighted percent agreement was >0.75 for all domains. There was no difference between median scores for any domain between attendings and trainees. Conclusion: Despite the lack of significant construct validity, SPaN is a structured, reliable, and procedure-specific tool that can objectively assesses technical proficiency for RAPN.

Fertility-Preserving Surgical Management of a Cesarean Section Scar Ectopic Pregnancy

To demonstrate techniques used for fertility-preserving surgical management of a cesarean scar ectopic pregnancy. A narrated video case report demonstrating techniques and surgical approach. With the increasing number of cesarean deliveries being performed, cesarean scar ectopic pregnancies (CSEP) have an increasing incidence affecting approximately 1 in 2000 pregnancies. CSEP can be associated with serious complications, which include maternal hemorrhage, uterine rupture, and even maternal death. This video highlights a case presentation of a 28-year-old G6P4014 with a history of 4 previous cesarean deliveries who presented with a persistent cesarean scar ectopic pregnancy that had failed previous medical management. This video highlights the techniques that allow for fertility-preservation with restoration of normal anatomy as well as minimizing blood loss with a potentially morbid procedure. Techniques used to allow for fertility preservation with restoration of normal anatomy: 1. Utilization of avascular spaces and identification of critical structures to restore anatomy that is often distorted by the CSEP. 2. Limited use of electrosurgery to allow for adequate postoperative healing. 3. Identification of the endometrial cavity to allow for complete removal of the CSEP and isthmocele repair. Techniques used to minimize blood loss: 1. Intracervical injection of dilute vasopressin. 2. Intrauterine injection of dilute vasopressin (20U in 60 cc of injectable saline). 3. Temporary occlusion of bilateral gonadal vessels using surgical clips. The surgical techniques highlighted in this video allow for the surgical removal of a cesarean scar ectopic pregnancy with concurrent repair of the uterine defect, allowing for restoration of normal anatomy. This is a safe and feasible fertility-preserving option that can be performed using a minimally-invasive approach.

Complicated Laparoscopic Trachelectomy Following Supracervical Hysterectomy

<h3>Study Objective</h3> To review the most common indications and risk factors for trachelectomy after supracervical hysterectomy and demonstrate technique for a complicated laparoscopic trachelectomy. <h3>Design</h3> Narrated video tutorial for a safe and reproducible laparoscopic trachelectomy complicated by extensive adhesive disease after supracervical hysterectomy. <h3>Setting</h3> Although trachelectomy is a relatively uncommon procedure, it may be indicated for a variety of benign pathologies women who have undergone supracervical hysterectomy. The potential complications of this procedure may be elevated from baseline surgical risks due to the presence of adhesive disease from prior surgeries or concurrent pelvic pathologies. This patient underwent her surgery at a tertiary academic center. She was positioned in dorsal lithotomy with arms tucked for surgical ergonomics. <h3>Patients or Participants</h3> This is a 43-year-old para 1 who presented for surgical management of cyclic heavy vaginal bleeding after a supracervical hysterectomy for adenomyosis and fibroids in 2014. <h3>Interventions</h3> This educational video demonstrates a complicated laparoscopic trachelectomy with an opportunistic bilateral salpingectomy, left ureterolysis, excision of endometriosis, and cystoscopy. <h3>Measurements and Main Results</h3> Not applicable. <h3>Conclusion</h3> Laparoscopic trachelectomy after supracervical hysterectomy may be significantly complicated by adhesive disease. The following strategies are key in the approach to a complicated laparoscopic trachelectomy: 1. Restoration of normal pelvic anatomy 2. Retroperitoneal dissection to safely identify the ureters, as well as the gonadal and uterine vessels and 3. Use of a uterine manipulator with a colpotomy ring to delineate target tissues, allow for multidirectional movement and facilitate safe entry into key planes.

Minimally Invasive Approach to Pelvic Arteriovenous Malformation (AVM) Refractory to Embolization

Study Objective To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Design Case report. Setting Single center academic institution. Patients or Participants A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Interventions Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Measurements and Main Results Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. Conclusion In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization. To describe a minimally invasive approach to hysterectomy and excision of a pelvic AVM after embolization failed twice. Case report. Single center academic institution. A 33-year-old female presented with chronic pelvic pain after a cesarean section. Ultrasound and CT angiogram showed a left-sided dilated vessel with turbulent flow adjacent to the uterus consistent with pelvic AVM. The AVM persisted despite two embolizations by vascular surgery. Upon abdominal entry, extensive vascularity was noted in the left gonadal vessels, paravesical space, and pararectal space. A 5cm AVM was noted adjacent to the uterus. Each of the multiple blood vessels leading to the AVM, including those to the bladder serosa, were isolated, fulgurized, and cut. Concomitant left ureterolysis was completed. The paravesical space dissection involved separating dense bladder adhesions, left ovarian fossa, external iliac vein and medial umbilical ligament, from the malformation. Blood vessels from the deep sidewall encircling and feeding the AVM were serially fulgurated and separated from the ureter. The ascending branch of the uterine artery on the underside of the AVM was serially fulgurated. Lateral to the ureter, the uterine artery from origin to insertion was unroofed and excised. The AVM was excised by isolating it from the level of the cervix upwards along the pelvic sidewall and uterus. The remainder of the modified radical hysterectomy was uncomplicated. Estimated blood loss was 50cc. Total surgical time was 4.5 hours. The postoperative course was uncomplicated. Final pathology was consistent with AVM. At her post-operative appointment, the patient experienced a significant reduction of symptoms. In the absence of large series or randomized trials, we suggest that robotic-assisted surgery is a valid treatment option for pelvic AVM in the setting of failed embolization.