Laparoscopic Bilateral Salpingo-oophorectomy Research Articles

Transvaginal natural orifice transluminal endoscopic surgery (VNOTES) retroperitoneal sentinel lymph node BIOPSY compared with conventional laparoscopy in patients with endometrial cancer

IntroductionTo explore the possibility of treatment with VNOTES sentinel lymph node dissection concept in patients with endometrial cancer. MethodsPatients who underwent VNOTES sentinel lymph node biopsy with the Comba modification were compared to patients who underwent conventional laparoscopic sentinel lymph node biopsy performed by the same surgical team. A total of 38 patients who underwent sentinel lymph node biopsy + total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (BSO) were compared with 19 patients who underwent VNOTES retroperitoneal sentinel lymph node biopsy + hysterectomy and BSO. Surgical steps were described. ResultsThe average operation time, perioperative blood loss, the number of sentinel lymph nodes, presence of complications, and preoperative-postoperative hemoglobin-hematocrit differences, tumor stages, grades, largest tumor diameter, depths of invasion, and histological subtypes were similar in both the VNOTES and conventional laparoscopy groups. The postoperative pain scores were lower and the hospital stay was shorter in the VNOTES group than in the conventional laparoscopy group. No disease recurrence had been detected in either group at the time of writing. ConclusionCompared to conventional laparoscopy, sentinel lymph node biopsy with the VNOTES technique provides similar surgical results and is more advantageous in terms of postoperative pain and hospital length of stay.

Predicting the Risk of nOdal disease with histological and Molecular features in Endometrial cancer: the prospective PROME trial.

To assess the role of histopathological and molecular features in predicting the risk of nodal metastases in apparent early-stage endometrial cancer patients undergoing sentinel node mapping. This is a prospective trial. Consecutive patients with apparent early-stage endometrial cancer, undergoing laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and sentinel node mapping, were enrolled. Histological and molecular features were used to predict the node positivity. Charts of 223 apparent early-stage endometrial cancer patients were included in this study. Four (1.8%) patients were excluded from this study due to the lack of data about molecular features. Additionally, nine (4%) patients did not meet the inclusion criteria (due to the presence of peritoneal carcinomatosis or bulky nodes (the presence of p53 abnormality correlated with the presence of advanced stage disease (p<0.001)). The study population included 178 (84.8%) and 32 (15.2%) patients with endometrioid and non-endometrioid endometrial cancer, respectively. According to pathological uterine risk factors, 93 (44.3%), 45 (21.4%), 40 (19.1%), and 32 (15.2%) were classified as low, intermediate, intermediate-high, and high-risk, respectively. Using the surrogate molecular classification, 10 (4.8%), 42 (20%), 57 (27.1%), and 101 (48.1%) were included in the POLE mutated, p53 abnormal, MMRd/MSI-H, and NSMP, respectively. Overall, 41 (19.5%) patients were detected with positive nodes. Molecular features were not associated with the risk of having nodal metastases (OR 1.03, 95% CI 0.21 to 5.05, p=0.969 for POLE mutated; OR 0.788, 95% CI 0.32 to 1.98, p=0.602 for p53 abnormal; OR 1.14, 95% CI 0.53 to 2.42, p=0.733 for MMRd/MSI-H). At multivariable analysis, only deep myometrial invasion (OR 3.318, 95% CI 1.357 to 8.150, p=0.009) and lymphovascular space invasion (OR 6.584, 95% CI 2.663 to 16.279, p<0.001) correlated with the increased risk of positive nodes. Our data suggest that molecular classification does not seem useful to tailor the need of nodal dissection in apparent early-stage endometrial cancer. p53 abnormality predicts the risk of having advanced disease at presentation. Further external validation is needed. NCT05793333.

Modifier 22 Use in Fee-for-Service Medicare

Modifier 22 is a mechanism designed for surgeons to identify cases that are more complex than their Current Procedural Terminology code accounts for. However, empirical studies of the use and efficacy of modifier 22 are lacking. To assess the use of modifier 22 in common surgical procedures and the association of use with compensation. This was a cross-sectional analysis of the 2021 Physician/Supplier Procedure Summary Limited Data Set including all Part B carrier and durable medical equipment fee-for-service claims. Claims for 10 common surgical procedures were evaluated, including mastectomy, total hip arthroplasty, total knee arthroplasty, coronary artery bypass grafting, laparoscopic right colectomy, laparoscopic appendectomy, laparoscopic cholecystectomy, kidney transplant, laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy, and lumbar laminectomy. Data were analyzed from August to November 2023. Rate of modifier 22 use, rate of claim denial, mean charges, mean payment for accepted claims, and mean payment for all claims. The sample included 625 316 surgical procedures performed in calendar year 2021. The proportion of modifier 22 coding for a procedure ranged from 5725 of 251 521 (2.3%) in total knee arthroplasty to 1566 of 18 459 (8.5%) in laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy. Submitted charges were 11.1% (95% CI, 9.1-13.2) to 22.8% (95% CI, 21.3-24.3) higher for claims with modifier 22, depending on the procedure. Among accepted claims, those with modifier 22 had increased payments ranging from 0.8% (95% CI, 0.7-1.0) to 4.8% (95% CI, 4.5-5.1). However, claims with modifier 22 were more likely to be denied (7.4% vs 4.0%; P < .001). As a result, overall mean payments were mixed, with 4 procedures having lower payments when modifier 22 was appended, 4 procedures having higher payments with modifier 22, and 2 procedures with no difference. The largest increase in mean payment for modifier 22 claims was for kidney transplant with an increased payment of $71.46 (95% CI, 55.32-87.60), which translates to a relative increase of 3.4% (95% CI, 2.9-4.6). The findings in this study suggest that modifier 22 had little to no financial benefit when appended to claims for a diverse panel of surgical procedures. In the current system, surgeons have little reason to request modifier 22, and no mechanisms currently exist for surgeons to recoup payment for difficult operations.

Case report: prolonged durable clinical benefit and low toxicity from combination endocrine therapy in a patient with recurrent endometrial carcinoma

BackgroundEndometrial carcinoma is the most common gynecologic cancer, with increasing incidence and mortality. Combination endocrine therapy comprised of tamoxifen and progestational agents has demonstrated promising results in treating recurrent disease. This case report describes the prolonged clinical benefit of treatment with tamoxifen and megestrol acetate in a woman with recurrent, metastatic endometrial endometrioid carcinoma positive for estrogen (ER) and progesterone receptors (PR).CaseA 71-year-old gravida 1 para 1 woman presented with postmenopausal bleeding and vaginal discharge. Pelvic ultrasound and magnetic resonance imaging confirmed a 4.7 cm endometrial mass. The patient underwent a total laparoscopic hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and cystoscopy; pathology revealed a FIGO stage IA grade 1 ER/PR-positive endometroid endometrial adenocarcinoma. She continued under active surveillance for approximately 42 months until she experienced bone metastases in her pelvis, for which she received radiation therapy. Five months later, pulmonary metastases were detected, and she received six cycles of carboplatin and paclitaxel. She then started megestrol acetate and tamoxifen and has remained clinically stable with minimal side effects and reasonable quality of life for approximately 57 months.ConclusionOur case suggests that combination endocrine therapy has the potential to provide substantial long-term clinical benefit in women with recurrent endometrial cancer and bone metastases, despite multiple prior treatments, allowing patients to experience stable disease and quality of life. In patients with recurrent endometrioid, ER/PR-positive disease, endocrine therapy alone or in combination with other targeted therapies are regimens that may be considered due to their low overall toxicity.

Splenic sarcoid reaction mimicking metastases in patients after uterine cancer surgery: a report of two cases

BackgroundTumor-associated sarcoid reactions have been observed with various tumors; however, they have not been reported with uterine cancer. We present two cases of splenic sarcoid reactions that mimicked metastases a few years after uterine cancer surgery.Case presentationCase 1 involved a 67-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent open total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Three years after the initial surgery, computed tomography (CT) and positron emission tomography CT showed multiple splenic masses with increasing numbers and sizes. Splenic metastases were diagnosed, and laparoscopic splenectomy was performed. The histopathological analysis revealed sarcoid reactions in the spleen. Case 2 involved a 47-year-old female patient diagnosed with endometrial cancer (pT1aN0M0, pStage Ia, grade 1). The patient underwent laparoscopic total abdominal hysterectomy and bilateral salpingo-oophorectomy with pelvic lymphadenectomy. Two years after the initial surgery, multiple splenic masses were observed. We performed laparoscopic splenectomy for the splenic metastases. Granuloma formations were identified in the splenic specimen and perisplenic lymph nodes that were removed simultaneously, resulting in a final diagnosis of sarcoid reaction. A review of the lymph nodes at the time of the previous uterine surgery revealed granuloma formation. Other than the presence of splenic masses, no findings suggestive of recurrence were observed in these cases. Uterine cancer and sarcoid reactions progressed without recurrence after splenectomy.ConclusionsTo the best of our knowledge, this is the first report of the late development of splenic sarcoid reactions after uterine cancer surgery. Sarcoid reactions and metastases are difficult to diagnose based on preoperative imaging results. However, reviewing the specimen at the time of the initial resection, the number of lesions, and the clinical findings (other than imaging findings) may aid in the determination of the correct diagnosis.

“Evolution” of intravascular leiomyomatosis

BackgroundIntravenous leiomyomatosis (IVL) is a rare and specific type of smooth muscle tumor that is histologically benign but has a malignant biological behavior. It is commonly associated with a history of uterine leiomyomas.Case presentationA 36-year-old woman, G1P1, presented to the hospital with left lower abdominal pain for 2 months and she has accepted hysteroscopic myomectomy about 1 year ago. Ultrasound venography, echocardiography and computed tomography venography (CTV) of inferior vena cava were performed, which revealed IVL located in left intramural myometrium walls growing along the left ovarian vein reaching the level of the lumbar 5-sacral 1 disc. Laparoscopic bilateral salpingo-oophorectomy and hysterectomyis were scheduled. The IVL in the left ovarian vein and parauterine venous plexus were detected and excised completely during surgery. IVL was diagnosed by postoperative pathology and immunohistochemistry. The patient recovered well after surgery. No surgical-related or anesthesia-related complications occurred.The 3-month follow-up CTV of inferior vena cava and echocardiography examination revealed normal.ConclusionsThe cause of IVL is unknown, this observation demonstrates that hysteroscopic myomectomy might lead to the occurrence of IVL.

Which combination cause less inflammatory response during laparoscopic hysterectomy? Ligasure plus monopolar cautery or harmonic plus bipolar cautery?

We aimed to compare the inflammatory response with alterations in hemogram parameters, in patients who underwent laparoscopic hysterectomy and bilateral salpingo-oophorectomy for benign gynecologic conditions with ligasure plus monopolar cautery or harmonic plus conventional bipolar cautery. Patients who underwent Laparoscopic hysterectomy with bilateral salpingo-oophorectomy between January 2017 and January 2022 for benign gynecologic pathology were identified. Patients were divided into two group, according to instruments used during surgery. Instruments were used according to surgeons preference. Preoperative and postoperative in the first 24 hours hematocrit (HCT), WBC, trombocyt, neutrophil- lymphocyte (NLR), platelet-lymphocyte (PLR) ratio, mean platelet volume- lymphocyte ratio (MPVLR) and red cell distribution width- platelet ratio (RPR) values were compared. During study period, a total of 462 patients underwent hysterectomy for benign gynecologic pathology. After exclusion, 212 patients were included in the study. İn the study group, 147 patients were operated with ligasure plus monopolar electrocauter and 65 with harmonic scalpel plus bipolar electrocautery. İn the postoperative period, regardless of the procedure, WBC and RPR count increase, hematocrit and trombocyt decrease in both group but the inflammatory markers lymphocyte count, neutrophyl, NLR, PLR and MPVLR count changed less in the harmonic plus bipolar cautery group which shows less inflamatuar response in this group. Ligasure plus monopolar cautery group compared with harmonic plus bipolar cautery group cause more inflammatory changes in complete blood count values. However, further studies are needed to show whether these changes in laboratory findings affect clinical situations.

Serous tubal intraepithelial carcinoma detected during benign gynecologic surgery: a case report

High-grade serous carcinoma (HGSC) is the most common type of pelvic cancer among women. Serous tubal intraepithelial carcinoma (STIC) is a precursor lesion of HGSC. Herein, we report a rare occurrence of STIC in patients undergoing surgery for benign indications without a family history of ovarian cancer. A 77-year-old woman underwent total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for uterine prolapse. Pathological examination revealed bilateral STIC without ovarian abnormalities, and no other abnormal findings were noted. Another patient, a 49-year-old woman, underwent laparoscopic total hysterectomy and bilateral salpingectomy for uterine fibroids. STIC lesions were observed in both fallopian tubes. Subsequently, a staging was performed. No additional lesions were found, and the patient was followedup through imaging and blood tests. As reports of STIC lesions are rare, data on their clinical outcomes and management strategies are limited. In this report, we present cases of incidental STIC in benign surgery and discuss its proper interpretation and management. Through the early detection of STIC lesions, patients with risk factors can be identified in advance, which will allow prevention and early detection of ovarian cancer. Opportunistic salpingectomy was also actively discussed in this regard.

A carcinoid arising within an ovarian teratoma: a case report

Benign teratoma is the most common germ cell tumour found in the ovary. One to three percent of these are found to harbour somatic neoplasms,1 of which squamous cell carcinoma, adenocarcinoma and sarcoma account for 95%.2 The first report of a carcinoid presenting in bronchial mucosa, within a teratoma was made in 20183 and we present a similar rare case in a 54 year old female. The patient underwent a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Macroscopically the left ovary measured 45 mm, with a smooth external surface and contained two cysts.

Case report: intraperitoneal tattoo ink pigmentation associated with endometriosis

A 50-year-old female with a history of ulcerative colitis and autoimmune pancreatitis on monoclonal antibody therapy was found to have dispersed, small ‘black spots’ or pigment on uterine, peritoneal and bowel surfaces during a routine total laparoscopic hysterectomy and bilateral salpingo-oophorectomy for treatment of endometriosis. Histological examination of the ‘black spots’ revealed pigment-laden macrophages. These were frequently seen adjacent to and directly associated with endometriosis.

Improved Progression-Free Survival Associated with Tumor-Infiltrating Lymphocytes in High-Grade Endometrial Cancer.

Tumor-infiltrating lymphocytes (TILs) have emerged as a prognostic marker in endometrial cancer (EC). However, the role of TILs in EC with distinct histology grades and molecular types (such as mismatch repair [MMR] deficiency) has not yet been made clear. We retrospectively included 237 patients with primary EC who underwent a standard staging operation of laparoscopic or laparotomy total hysterectomy and bilateral salpingo-oophorectomy for analyses. An independent pathologist who was blind to the study patients' information reviewed the pathologic slides to assess TILs according to the method introduced by the International Immuno-Oncology Biomarkers Working Group in 2017. The outcomes of interest included both progression-free survival (PFS) and overall survival (OS). The Kaplan-Meier method was used to determine the curves of PFS and OS according to TILs, and also in the relevant subgroups (low-grade vs. high-grade, MMR-proficient vs. MMR-deficient). After a median follow-up duration of 1.82 years, 18 patients had experienced either disease progression or death. Overall, TILs (+) were not associated with PFS or OS. We did observe, however, that TILs (+) were associated with a better PFS (p = 0.045) in patients with high-grade EC, but not in those with low-grade tumors (p = 0.733). The effect of TILs on PFS was not observed in patients with MMR-proficient (p = 0.347) or MMR-deficient (p = 0.168) EC. TILs were associated with a better PFS in patients with high-grade EC. Our results suggest that TILs may be a potential prognostic marker in these patients.

Primary Laparoscopic Repair of Iatrogenic Rectal Perforation during Total Laparoscopic Hysterectomy Using an Endoscopic Automatic Anastomotic Device: A Case Report and Literature Review

Background: Rectal injuries are the most severe complications of gynecologic surgeries, especially total laparoscopic hysterectomy. In several cases, an ileostomy is performed as a lifesaving procedure. Recently, studies have suggested that primary repair should be attempted for all cases of intraperitoneal rectal injuries. To the best of our knowledge, previous case reports have not discussed the specific repair of a rectal injury involving all layers. Case: We report a case of rectal perforation during total laparoscopic hysterectomy and bilateral salpingo-oophorectomy that was laparoscopically repaired using an automatic anastomosis device. Conclusions: A rectal injury may be repaired laparoscopically if the bowel is adequately prepared preoperatively and a skilled surgeon is present.

ODP493 Malignant Struma Ovarii with Papillary Thyroid Carcinoma and concomitant High Risk Thyroid Nodule

Abstract Introduction Struma ovarii is a rare teratoma consisting of &amp;gt;50% thyroid tissue. Malignant transformation very seldomly occurs; most pathology shows papillary thyroid carcinoma. The risk and prevalence of concurrent thyroid gland neoplasm is unclear. Thyroid cancer surveillance post-oophorectomy in these patients may be pertinent but has not yet been established. Case Report A nulliparous 54 year-old woman with one year of menopause without HRT had pelvic and back pain. Imaging detected bilateral ovarian teratomas. Pathology from laparoscopic bilateral salpingo-oophorectomy revealed a 10.7×9.9×10.9cm noninvasive struma ovarii with focal papillary thyroid carcinoma of the left ovary and a benign teratoma of the right ovary. Importantly, the patient had a known thyroid nodule. Two years prior, a FNA of the 1.4cm hypoechoic, hypervascular nodule in the left lower pole yielded benign (Bethesda 2) cytology. After struma ovarii resection, thyroid ultrasound showed highly suspicious TIRAD5. She denied symptoms of hyper- or hypothyroidism and had a normal TSH. She consequently underwent two FNA biopsies, both of which were non-diagnostic. The patient deferred further attempts. History of an initial benign biopsy and stability of the nodule size provide some reassurance. With the patient's reluctance for surgery, serial thyroglobulin (Tg) and ultrasounds will be followed. Post-operative Tg was normal with negative Tg antibody. If Tg becomes markedly elevated, a thyroidectomy will be indicated. Discussion Given the TIRAD5 nodule, this patient's risk of thyroid malignancy is 60-70%. This is compounded with her setting of malignant struma ovarii, which may imply genetic predisposition for thyroid carcinogenesis. Since cytology could not be obtained on the two recent biopsies, definitive pathology by diagnostic lobectomy or thyroidectomy may be considered. A total thyroidectomy would provide the advantage of following Tg for cancer surveillance of both thyroid and ovarian malignancies. There is scant evidence on the treatment of malignant struma ovarii. A few small case series and a pooled review of 57 cases of low-risk (confined to the ovary) malignant struma ovarii in which 50 patients did not undergo thyroidectomy/I-131 ablation showed only a 7.5% recurrence rate at 25 years (Marti et al Thyroid 2012 Apr; 22 (4): 400-406). Hence, this study recommends reserving prophylactic thyroidectomy for patients with extra-ovarian extension or metastases. Treatment of malignant struma ovarii may be extrapolated from those used in differentiated thyroid cancer; high-risk lesions would be those measuring &amp;gt;4cm, have local or distant invasion, or have a BRAF mutation (indicating an aggressive tumor). In conclusion, conservative measures of the thyroid gland with a suspicious nodule may be acceptable in patients with noninvasive malignant struma ovarii, provided strict adherence to cancer surveillance of Tg with both thyroid and pelvic sonography. Presentation: No date and time listed

Robot-assisted laparoscopic hysterectomy for early-stage endometrial cancer with massive uterine leiomyomas: A case report

Introduction and importanceCompared to conventional laparoscopic surgery, robot-assisted surgery enables precise operation, with the aid of high-resolution 3D images and articulated forceps, even in cases where the uterus is very large.Case presentationA 48-year-old woman with severe obesity was referred to our hospital with atypical genital bleeding for half a year. She was diagnosed with multiple uterine leiomyomas and early endometrial cancer with presumed advanced stage classification (stage IA). Robot-assisted laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymph node biopsy were performed. Due to the difficulty of removing the uterus transvaginally, the umbilical incision was extended by 7 cm, which allowed the uterine tissue removal without shredding or leakage into the pelvic cavity. The patient was discharged 5 days postoperatively, with no postoperative complications.Clinical discussionRobot-assisted surgery has often been used for the management of early-stage endometrial cancer. Robot-assisted laparoscopic hysterectomy has significantly fewer intraoperative and postoperative complications than laparoscopic and abdominal hysterectomy.ConclusionImproving this surgical procedure allows for safe and easy robot-assisted uterine malignant tumor removal even in cases where the patient presents with severe obesity and huge uterine leiomyomas.

Transvaginal small bowel evisceration: Case report and review of literature.

IntroductionTransvaginal evisceration is a rare life-threatening condition that is usually seen in postmenopausal women with past history of gynaecological surgery.Presentation of caseA 54-year-old woman presented with sudden-onset abdominal pain and protrusion of a mass through the vagina after her grandson jumped on her abdomen while at play. She had undergone laparoscopic total hysterectomy and bilateral salpingo-oophorectomy 9 months earlier. Physical examination revealed an intestinal loop in the vagina. She was immediately taken to the operating room. Laparotomy was performed and the prolapsed intestine was reduced. The bowel from the duodenojejunal junction to the ileocecal valve looked healthy, with no areas of ischemia. The rupture in the vaginal vault was repaired with Vicryl. The postoperative course was uneventful, and the patient was discharged on day 5 after the surgery.DiscussionLess than 100 cases of transvaginal evisceration have been reported. The condition, which is more common in postmenopausal women, usually presents with sudden-onset abdominal pain. Some patients may be asymptomatic and only complain of swelling at the introitus. Diagnosis can usually be made by visual examination. Immediate surgery is necessary to reduce the risk of intestinal ischemia and necrosis.ConclusionTransvaginal evisceration must be suspected in any woman presenting with sudden-onset abdominal/pelvic pain. Awareness of this rare condition is necessary to minimize mortality.

Metastatic gastric adenocarcinoma to the uterine cervix—a case report and review of the literature

BackgroundPoorly differentiated diffuse-type gastric adenocarcinoma often presents at an advanced stage. While gastric cancer typically metastasizes to the liver, lung and bone, metastasis to the uterine cervix is extremely rare. To our knowledge, less than forty cases have been described in the medical literature.Case presentationWe report a case of a 47-year-old woman who presented to us with symptomatic uterine leiomyomas and subsequently underwent a successful total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The diagnosis of metastatic cancer involving the cervix was established incidentally on histopathology, which demonstrated atypical signet ring cells in the lymphovascular spaces of the cervix. Further investigations for a primary malignancy revealed a poorly differentiated diffuse-type gastric adenocarcinoma.ConclusionGastric cancer involving the uterine cervix is rare and associated with a poor prognosis. When presented with isolated cervical metastases, the gastrointestinal tract should be considered as a possible primary source. Due to the limited publications on this clinical entity, we expect to raise awareness and study this unique manifestation of gastric cancer by presenting our case.

Vnotes: a vaginal approach to laparoscopic hysterectomy and prolapse repair

The objective of this video is to describe the set-up, execution, and advantages of laparoscopy via a vaginal approach for hysterectomy and pelvic organ prolapse repair. This video details the case of a 63-year-old patient with stage II symptomatic pelvic organ prolapse and mixed urinary incontinence. She had a history of prior pelvic surgery including a sigmoid colectomy and reanastomosis and strongly desired hysterectomy and bilateral salpingo-oophorectomy at the time of her prolapse repair. Laparoscopic assisted vaginal hysterectomy, bilateral salpingo-oophorectomy (BSO), and uterosacral ligament vaginal vault suspension were performed via the vNOTES procedure. Technique, equipment, set-up, and strategies for success are described throughout the video. Pelvic anatomy from a vaginal vantage point is highlighted and a direct view during crucial points of each procedure is provided. Laparoscopic techniques including lysis of adhesions and retroperitoneal exploration are detailed in the video as a result of her prior surgery. This video demonstrates the equipment and feasibility of vaginal laparoscopy and highlights the advantages of increased visualization during difficult vaginal surgery.

Ovarian Hilus Cell Hyperplasia and Sertoli-Leydig Cell Tumor in a Patient with Postmenopausal Virilization: a Rare Case Report

Objective; We present a case report regarding a 71-year-old woman with postmenopausal virilization caused by ovarian hilus cell hyperplasia and Sertoli-Leydig cell tumor who was suffered from hair loss, clitoromegaly and hirsutism. Case Report; The patient’s plasma testosterone levels were high. In the MRI examination, a nodular formation of 20x26mm in size was observed in the right ovary. At the transvaginal ultrasound, a cystic mass of 28x28mm was seen in the right ovary. Then we performed a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy. The final pathology showed a poorly differentiated Sertoli Leydig cell tumor at the right ovary and hilus cell hyperplasia at the left ovary. Sertoli-Leydig cell tumors, which are relatively less common, are extremely rare to be seen in the postmenopausal period. Conclusion; What distinguishes this case from others is that Sertoli-Leydig cell tumor and hilus cell hyperplasia may cause virilization symptoms together, in addition to its prevalence in advanced age.

A phase III randomized clinical trial comparing sentinel node biopsy with no retroperitoneal node dissection in apparent early-stage endometrial cancer – ENDO-3: ANZGOG trial 1911/2020

BackgroundSentinel node biopsy is a surgical technique to explore lymph nodes for surgical staging of endometrial cancer, which has replaced full retroperitoneal lymph node dissection. However, the effectiveness of sentinel...

Total Laparoscopic Hysterectomy without Mini-Laparotomy for a 7060g Myomatous Uterus with Cystic Degeneration.

<h3>Study Objective</h3> Uterine leiomyomas are the most common benign gynecological soft tissue tumors in women. Although the laparoscopic approach is a standard treatment option, it is more difficult to achieve minimally invasive hysterectomy in cases with giant myomatous uteri. The laparoscopic removal of a myomatous uterus over 7000g without mini-laparotomy has not been reported in literature. Here we report the surgical challenges in the case of a patient with a 7060g myomatous uterus with cystic degeneration. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> An urban general hospital. <h3>Patients or Participants</h3> A 54-year-old woman was referred to our department for treatment for a huge fibromatous uterus. She suffered pelvic pressure and abdominal distension for several months. A magnetic resonance imaging scan showed a cystic-degenerated fibromatous uterus measuring 27.5cm × 21.3cm × 29.5cm with no suggestion of malignancy. <h3>Interventions</h3> We performed a laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Intraoperatively, we aspirated the contents of the degenerative cyst of the uterus for mass reduction, and then closed the cyst hole by suturing to prevent leakage of the contents. This was followed by our usual surgical steps. We removed the specimen transvaginally. The total weight of the uterus removed was 7060g, including 5300g of cyst contents. The operation lasted for 79 minutes, and the intraoperative blood loss was 50g. No intraoperative complications occurred. <h3>Measurements and Main Results</h3> The histology confirmed the diagnosis of leiomyoma. The patient's postoperative course was unremarkable with no complications. <h3>Conclusion</h3> Uterus size has been considered a barrier to the use of laparoscopy for hysterectomy. We believe this is the first reported laparoscopic hysterectomy without mini-laparotomy in a patient with a giant uterus, over 7000g. Though appropriate case selection is necessary, this case demonstrates the efficiency and safety of laparoscopic hysterectomy for giant myomatous uterus cases.