Left Parametrium Research Articles

Transvaginal Sonography for the Preoperative Assessment of Parametrial Deep Infiltrating Endometriosis: A Diagnostic Accuracy Study

Objective: The aim of the study was to evaluate the diagnostic accuracy for parametria endometriosis (PE) of transvaginal sonography (TVS) performed following a systematic approach for the assessment of the lateral parametria. Design: A diagnostic accuracy study was employed based on a prospective observational design. Participants: All consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020 were considered. Setting: The study was conducted at endometriosis referral hospitals. Methods: We prospectively collected clinical, imaging, and surgical data of all consecutive patients who underwent laparoscopic surgery for endometriosis between January 2016 and December 2020. A standardized technique with a systematic approach for the assessment of the lateral parametria following specific anatomic landmarks was used for the TVS. The diagnostic accuracy for PE in TVS was assessed using the intraoperative and pathologic diagnosis of PE as the gold standard. Results: In 476 patients who underwent surgery, PE was identified in 114 out of 476 patients (23.95%): 91 left and 54 right PE out of 476 surgical procedures were identified (19.12% vs. 11.34%; p = 0.001); bilateral involvement in 27.19% (31/114 patients) cases. The sensitivity of TVS for PE was 90.74% (79.70–96.92%, 95% CI) for the right side and 87.91% (79.40–93.81%, 95% CI) for the left side. The specificity was almost identical for both sides (98.58% vs. 98.18%). For the right parametrium, the positive likelihood ratio (PLR) and negative likelihood ratio (NLR) were 63.82 (28.70–141.90, 95% CI) and 0.09 (0.04–0.22, 95% CI), respectively. On the left parametrium, the PLR and NLR were 48.35 (23.12–101.4, 95% CI) and 0.12 (0.07–0.21, 95% CI), respectively. The diagnostic accuracy for right and left PE was 97.69% (95.90–98.84%, 95% CI) and 96.22% (94.04–97.74%, 95% CI), respectively. Limitations: The principal limit is the high dependence of TVS on the operator experience. Therefore, although a standardized approach following precise definitions of anatomical landmarks was used, we cannot conclude that the observed accuracy of TVS for PE is the same for all sonographers. In this regard, the learning curve was not assessed. In the case of negative TVS for parametrial involvement with an absent intraoperative suspect, a complete dissection of the parametrium was not performed to avoid surgical complications; therefore, cases of minor PE may be missed, underestimating false negatives. Conclusions: TVS performed following a systematic approach for assessing the lateral parametria seems to have good diagnostic accuracy for PE with large changes in the posttest probability of parametrial involvement based on the TVS evaluation. Considering the clinical and surgical implications of PE, further studies implementing a standardized approach for assessing the parametrium by TVS are recommended to confirm our observations and implement a standardized protocol in clinical practice.

Robotic Management of Recurrent Rectal Endometriosis After Previous Segmental Bowel Resection

To describe the management of recurrent bowel endometriosis after previous colorectal resection. Surgical video article. The local institutional board review was omitted due to the narration of surgical management. Patient consent was obtained. A tertiary referral center. The patient first underwent segmental bowel resection for deep infiltrating endometriosis of the rectum in the ENDORE randomized controlled trial in 2012 and then received a total hysterectomy in 2018. Five years later, she presented with recurrent nodules in the rectovaginal, left parametrium, and abdominal wall after discontinuing medical suppressive treatment. Laparoscopic management using robotic assistance was employed to complete excision of the rectovaginal nodule. Disc excision was performed to remove rectal infiltration. The procedure started with rectal shaving and excision of vaginal infiltration . A traction stitch was placed over the limits of the rectal shaving area. The general surgeon placed a 28 mm circular anal stapler transanally and performed complete excision of the shaved rectal area. Anastomotic perfusion was checked with indocyanine green. A methylene blue enema test was conducted to rule out anastomotic leakage. Outcomes were favorable, with systematic self-catheterization during 5 postoperative weeks. No specific symptoms were related to the other 2 nodules, which were not removed. Rectal recurrences may occur long after colorectal resection and outside the limits of the previous surgery site. To accurately assess this risk, long-term follow-up of patients is mandatory.. Postoperative medical amenorrhea may play a role in recurrence prevention. Surgical management of recurrences may be challenging and focus on only those nodules responsible for symptoms so as to best preserve the organ's function and reduce postoperative morbidity.

Laparoscopic Excision of Parametrium Endometriosis

<h3>Study Objective</h3> To present a case of parametrium and bladder endometriosis. <h3>Design</h3> Case report illustrated with video. <h3>Setting</h3> Patient placed in semi-gynecological position, legs in stirrups and Trendelenburg tilt. A minimally invasive laparoscopic surgery was performed helped by a uterine manipulator. <h3>Patients or Participants</h3> We present the case of a 29-year-old woman complaining of chronic pelvic pain, severe dysmenorrhea radiating to lumbar region and coccyx, and intense deep dyspareunia. At the pelvic examination, she had a 4 cm painful nodule affecting the left parametrium, extending to the paravaginal aspect and ipsilateral uterosacral ligament. The complementary investigation with pelvic ultrasound evidenced a uterus with 83cc volume, a 1.5cm leiomyoma, a 1cm infiltrating vesical nodule, a 2 cm nodule in the right round ligament, and a 4 cm retrocervical nodule affecting left parametrium and vaginal wall. <h3>Interventions</h3> Laparoscopic surgical removal of all endometriotic lesions. <h3>Measurements and Main Results</h3> Patient was discharged in the 1^st post-operative day and maintained the use of foley catheter up to the 14th day. She had a negative post-void residual test, no urinary impairment and complete remission of symptoms. The final pathological report confirmed endometriosis and leiomyoma. <h3>Conclusion</h3> Parametrium endometriosis can affect around 17% of women with deep endometriosis, and the surgical treatment can cause voiding disfunctions due to inferior hypogastric nerve and plexus proximity. We should always perform a nerve-sparing surgery when possible.

A rare case of extrauterine schwannoma-ike leiomyoma after transvaginal hysterectomy: laparoscopic management.

Schwannomas (neurilemomas) are encapsulated tumours made entirely of benign neoplastic Schwann cells. They are the most common tumour of peripheral nerves, but very uncommon in gynaecologic practice. The objective is to demonstrate unusual histology mimicking schwannoma in a case of leiomyoma in a woman who had a history of vaginal hysterectomy. We report a case of a 50-year-old hysterectomised patient who was referred with complaints of dull pain in the left inguinal region of the abdominal cavity during the last 3 months. The narrated surgical video article demonstrates the dissection of the left parametrium, tumour removal, colpotomy, specimen extraction, and vagina laparoscopic suturing. Pre-operative CT-scan images of the pelvis with retroperitoneal tumour and macroscopic and histological views of the schwannoma are also provided. Full recovery of the patient after laparoscopic removal of the tumour. As a result of the surgical treatment, the patient has fully recovered. Schwannoma-like leiomyomas are rare tumours. They can be extra peritoneally located, without any connection to the uterus and adnexa. They are difficult to diagnose before surgery. The laparoscopic approach is the best option for the treatment of such rare extra organic tumours.

Laparoscopic treatment of a complex adnexal mass of the retroperitoneal space: A case report

Complex adnexal cystic masses in women of reproductive age should be carefully evaluated before the final diagnosis is set. Adnexal cystic masses are not necessary malignant. On the contrary, they usually refer to a benign and not cancerous pathology. A certain benign pathology behind adnexal masses is endometriosis. Endometriosis occurs in 10-15% of women of reproductive age and presents great diversity both in the way it manifests and in its location. We report a case of a multiparous woman of reproductive age that was referred to our clinic due to abdominal and back pain. The imaging examinations revealed a cystic mass of the left parametrium that was laparoscopically removed. The histopathology set the diagnosis of endometrioma. The aim of our work is to highlight the endometrioma of the retroperitoneal space as part of the differential diagnosis of the cystic masses of the parametrium.

The Relationship Between Parametrial Involvement and Parametrial Tissue Removed in Radical Surgery in Early-Stage Cervical Cancer.

BackgroundThe study aims to evaluate the effect of parametrial dimensions on the prognosis of cases who underwent type 3 radical hysterectomy or radical trachelectomy in early-stage cervical cancer (stage I - IIa).MethodsMedical reports of patients with early-stage cervical cancer who have undergone surgery between 1998 and 2020 in Akdeniz University Faculty of Medicine Gynecological Oncology Clinic were reviewed retrospectively. A total of 292 cases were identified and included in the study. Demographic characteristics, preoperative examination findings, operation records, and pathology results of the cases were reviewed.ResultsParametrial involvement was found histopathologically negative in 244 out of 292 patients included in our study, the remaining 48 (16.4%) patients were found to be positive. The mean length of the right and left parametrium in the group with negative parametrium invasion, who had an average follow-up of 131.2 (0.57 - 268.2) months, was 3 cm, while the mean volume of the right and left parametrium was 7.2 (0.52 - 32) cm3 and 6 (0.48 - 34) cm3, respectively. On the other hand, the mean length of the right and left parametrium was 3 (1.5 - 5.5) cm and 3 (1.4 - 7) cm, respectively, while the mean volume of the right parametrium was 5.55 (1.37 - 22) cm3, and the mean volume of the left parametrium was 7.5 (1.35 - 24) cm3 in 48 patients with positive parametrial invasion. No statistically significant difference was detected between the two groups when compared in terms of parametrial sizes and volumes (P values of 0.061, 0.262, 0.391, and 0.468, respectively).ConclusionsRadical surgical approach is necessary to obtain a tumor-free surgical margin in the surgical treatment of early cervical cancer, but the complications leading to morbidity and mortality are also increasing with this radicality. For this reason, we consider that it is important to adapt the dimensions of the removed parametrium according to the factors affecting recurrence in cervical cancer to obtain more appropriate surgical margins with the least complications.

Рецидивирующий глубокий инфильтративный эндометриоз с поражением мочевыводящих путей

This article presents a clinical follow-up of a 41-year-old patient with the recurrence of deep infiltrating endometriosis affecting the urinary tract. A multidisciplinary approach to examination and treatment contributed to the successful outcome of laparoscopic surgery, which included adhesiolysis, resection of the left ovary, excision of endometrioid infiltrates in the left parametrium, rectovaginal septum and vagina, posterior wall of the urinary bladder, left ureterocystostomy. The dynamic 6-month follow-up revealed no signs of recurrence of the disease and upper urinary tract dilatation, which made it possible to start preparing for next pregnancy. Key words: recurrence of deep infiltrating endometriosis, multidisciplinary approach, laparoscopy, excision of multifocal endometrioid infiltrates, ureterocystostomy

A proof-of-concept randomized phase 2 non-inferiority trial on simple versus modified radical hysterectomy in IA2-IB1 cervical cancer ≤2cm (LESSER)

Objectives: To evaluate the safety and efficacy of simple hysterectomy in early stage cervical cancer. Methods: The LESSER (LESs Surgical radicality for EaRly stage cervical cancer) study was a proof of concept randomized phase 2 non-inferiority trial evaluating the safety and efficacy of simple hysterectomy compared to modified radical hysterectomy in patients with stages IA2-IB1 cervical cancer and tumors of ≤2cm in size. Primary end-point was 3y-DFS rates and secondary endpoints were 3y-OS (3-year overall survival), surgical morbidity, indication of adjuvant therapy, and QoL (EORTC QLQ-C30). The study was registered at ClinicalTrials. gov (NCT02613286). Results: A total of 40 patients were randomized 1:1 from May 2015 to April 2018 in 3 oncological centers from Northeast Brazil. All cases had pelvic systematic lymph node dissection. Overall, 10% of patients underwent MIS procedures, 80% of tumors were SCC and 7.5% had lymph node metastasis, whereas inaccuracies for clinical tumor size estimation, LVSI and stromal invasion > 1 cm were found in 20%, 22.5% and 30% of cases, respectively. Clinical and pathological characteristics were well balanced between treatment arms, but the length of surgery and the time for bladder catheterization removal were higher after radical hysterectomy (p=0.003 and p=0.043, respectively). There was no postoperative mortality and rates of any grade postoperative complication were not statistically different between arms (15% and 20%; p=1.00). No major differences in the QoL over time were also observed. A quarter of patients received adjuvant therapy, with no significant difference between groups (30% vs. 20%, p=0.48). There was one death at 25 months of follow-up due to pelvic recurrence in the simple hysterectomy arm. A pathological review of this case found tumor embolus in the lymphovascular space of left parametrium that was missed at the time of former anatomopathological analysis. Another patient died of lung metastasis from a second primary thyroid cancer at 54.4 months of follow-up in the radical hysterectomy arm. A major late complication was also recorded after 3 months from radical surgery in a patient with distal urethral stenosis that was treated with segmental resection and psoas-hitch ureteroneocystostomy. Survival outcomes with a minimum of 3y follow-up will be mature for presentation during the SGO 2021 Annual Meeting on Women's Cancer. Conclusions: Simple hysterectomy is a promising substitute for modified radical hysterectomy in stage IA2-IB1 cervical cancer ≤2cm. To evaluate the safety and efficacy of simple hysterectomy in early stage cervical cancer. The LESSER (LESs Surgical radicality for EaRly stage cervical cancer) study was a proof of concept randomized phase 2 non-inferiority trial evaluating the safety and efficacy of simple hysterectomy compared to modified radical hysterectomy in patients with stages IA2-IB1 cervical cancer and tumors of ≤2cm in size. Primary end-point was 3y-DFS rates and secondary endpoints were 3y-OS (3-year overall survival), surgical morbidity, indication of adjuvant therapy, and QoL (EORTC QLQ-C30). The study was registered at ClinicalTrials. gov (NCT02613286). A total of 40 patients were randomized 1:1 from May 2015 to April 2018 in 3 oncological centers from Northeast Brazil. All cases had pelvic systematic lymph node dissection. Overall, 10% of patients underwent MIS procedures, 80% of tumors were SCC and 7.5% had lymph node metastasis, whereas inaccuracies for clinical tumor size estimation, LVSI and stromal invasion > 1 cm were found in 20%, 22.5% and 30% of cases, respectively. Clinical and pathological characteristics were well balanced between treatment arms, but the length of surgery and the time for bladder catheterization removal were higher after radical hysterectomy (p=0.003 and p=0.043, respectively). There was no postoperative mortality and rates of any grade postoperative complication were not statistically different between arms (15% and 20%; p=1.00). No major differences in the QoL over time were also observed. A quarter of patients received adjuvant therapy, with no significant difference between groups (30% vs. 20%, p=0.48). There was one death at 25 months of follow-up due to pelvic recurrence in the simple hysterectomy arm. A pathological review of this case found tumor embolus in the lymphovascular space of left parametrium that was missed at the time of former anatomopathological analysis. Another patient died of lung metastasis from a second primary thyroid cancer at 54.4 months of follow-up in the radical hysterectomy arm. A major late complication was also recorded after 3 months from radical surgery in a patient with distal urethral stenosis that was treated with segmental resection and psoas-hitch ureteroneocystostomy. Survival outcomes with a minimum of 3y follow-up will be mature for presentation during the SGO 2021 Annual Meeting on Women's Cancer. Simple hysterectomy is a promising substitute for modified radical hysterectomy in stage IA2-IB1 cervical cancer ≤2cm.

“Nerve-sparing” laparoscopic treatment of parametrial ectopic pregnancy

To demonstrate laparoscopic surgical management of parametrial ectopic pregnancy. Video presentation of laparoscopic nerve-sparing treatment of parametrial pregnancy. Tertiary university center. A 33-year-old patient, nullipara at 8 weeks of gestation, with no comorbidity and no previous surgery, was admitted to a spoke hospital for acute abdominal pain. During hospitalization, a transvaginal gynecologic ultrasound revealed pregnancy with ectopic localization. Free pelvic fluid was detected, and a subsequent diagnostic laparoscopy was performed because of worsening symptoms. During the procedure, hemoperitoneum drainage was instituted and American Society of Reproductive Medicine stage III pelvic endometriosis was diagnosed. A round formation approximately 3 cm in diameter was found at the left posterior parametrium (Fig.1). Due to the pregnancy position and β-human chorionic gonadotropic (β-hCG; 820 mUI /mL) values, conservative treatment was chosen. Thus, methotrexate at 50 mg/m2 body surface area was administered. A second dose of methotrexate was administered seven days after the first one, and the β-hCG increased to 1068 mUI. On day 14 after treatment, the β-hCG was 1053 mUI/mL. Therefore, surgical treatment was chosen, and the patient was transferred to our center. An ultrasound assessment confirmed the ectopic pregnancy with a live fetus in the left posterior parametrium. The patient underwent operative laparoscopy to remove the ectopic pregnancy. Surgery was performed using a 3-dimensional optical system (TIPCAM 1, S D3-LINK; Karl Storz SE & Co., Tuttlingen, Germany). After drainage of the hemoperitoneum, the gestational sac was identified in the left posterior parametrium. The uterus, tubes, and ovaries showed normal morphology. Pelvic endometriosis was confirmed. After accessing the left pelvic retroperitoneum with the medial and lateral pararectal spaces' opening and development, ipsilateral ureterolysis was necessary to isolate the parametrial pregnancy in close contact with it. Coagulation and sectioning of the deep uterine veins were essential to control hemostasis. Identification of the left hypogastric nerve, which was partially infiltrated by the chorionic villi, and the pelvic splanchnic nerves, was required to safeguard them (Fig.2). Subsequently, the surgeon decided to place a ureteral stent to prevent urologic complications. The laparoscopic approach proved to be safe and feasible to manage parametrial pregnancy. The pregnancy was removed entirely. The patient was discharged 72 hours after the procedure with an uneventful postoperative course. The histologic report confirmed the diagnosis of parametrial pregnancy on decidualized endometriotic tissue. The β-hCG serum level became negative in 20 days. Extrauterine pregnancies represent one of the leading causes of maternal death in the first trimester and constitute approximately 1%-2% of total pregnancies. Of these percentages, only 5%-8.3% are nontubal. Cases of abdominal pregnancy are even rarer, estimated at <1%, and among these, according to a recent review, only 20 cases of retroperitoneal pregnancy were described in the literature. The intraoperative finding of multiple endometriotic implants on the parietal peritoneum above the retroperitoneal pregnancy, together with the decidualized endometriosis result of the histologic examination have been considered to explain the pathogenesis of the condition. It is plausible to suppose that endometriosis has represented the access route for the fertilized ovum, which implanted on endometriotic superficial tissue and then moved toward the retroperitoneal vascularized structures. The diagnosis and treatment are challenging for the gynecologist. Medical treatment is a valid approach to uninterrupted early ectopic pregnancies; however, symptomatic patients' medical therapy failure is one indication for a surgical procedure. The laparoscopic method is optimal, especially in cases like the reported one, in which minimally-invasive techniques allowed complete removal of the pregnancy, respecting the anatomic structures of the retroperitoneum using nerve-sparing techniques. Furthermore, it ensured a safe ureteral stent placement without imaging. The laparoscopic surgical approach can be a safe and feasible option. It allows an early discharge, with a minimum risk of dysfunctional complications, and improves life quality compared to more destructive interventions. In conclusion, to control vascular, nervous, and urinary tract structures, surgical treatment should be based on anatomic knowledge of retroperitoneal anatomy to guarantee the best surgical outcome.

Robotic Nerve Sparing Radical Hysterectomy with Cerclage Evolving Technique Post LACC Trial Era

Study Objective To evaluate the feasibility of the novel technique of robotic assisted radical hysterectomy with cerclage. Design Prospective patients who underwent robotic assisted radical hysterectomy with cerclage (RARHC) were evaluated for intraoperative outcomes such as operative time, blood loss, conversion, and complications. The pathological specimen outcomes such as parametria length, vaginal cuff margin, number of lymph nodes retrieved, grade, histology, LVSI and cytology was assessed. Length of hospital stay, readmissions, and postoperative complications were determined. Setting A tertiary academic affiliation hospital. Patients or Participants Clinical Stage I cervical cancers were enrolled after appropriate consent forms were obtained. Interventions Robotic Xi platform was utilized to perform all the procedures. Measurements and Main Results 10 patients underwent RARHC from 10/2018 to 04/2020. The demographics characteristics are: Age 46.9, BMI 30, clinical tumor size 1.6 cm. The pathological outcomes: 7/10 had squamous cell carcinoma, 2/10 adenocarcinoma, 1/10 adenosqaumous carcinoma histology. The grade of the tumor 5/10 grade 1, 4/10 grade 2, 1/10 grade 3. The average parametria obtained were 4.5 × 1.3 × 0.65 cm and 4.53 × 1.45 × 0.63 cm on the right and left parametrium respectively, the number of lymph nodes obtained 19.9 and vagina length margin was 2.2 cm. The average operative time was 214 minutes with estimated blood loss of 112 cc. The average length of hospitalizations was 21 hours. There was no conversion, complications and readmission. Conclusion Robotic assisted radical hysterectomy with Cerclage is feasible and safe. Long term outcomes compared to other surgical modalities will be reported in the future.

One-stage, radical laparoscopic endometriosis excision involving three different organ systems: A case report from tertiary referral center

Introduction: We present a case of an extensive endometriosis involving left paracolpium and left parametrium, rectovaginal septum, urinary bladder, left interiliac region between artery and vein, left ureter and rectum, presenting as dysmenorrhoea, alternating bouts of diarrhea and constipation and hydronephrosis. Methods: Laparoscopic surgery made by a multidisciplinary team consist of gynecologic, abdominal surgeon and urologist. Results: Successfully managed deep infiltrated endometriosis. Conclusion: The aim of this report is to demonstrate benefit of one-stage, minimally invasive radical surgical procedure performed in a tertiary referral center. To the best of our knowledge, this report presents an extremely complex case because we successfully managed deep infiltrating endometriosis in three different organ systems at the same time, using minimally invasive nerve-sparing technique. A case with the same constellation has not been published yet since reported cases of extrapelvic endometriosis chiefly address one organ system involvement.

Fusion imaging of ultrasound and MRI in the assessment of locally advanced cervical cancer: a prospective study

BackgroundFusion imaging is a new diagnostic method that integrates MRI and ultrasound. It may improve the detection and staging of locally advanced cervical cancer.ObjectiveTo evaluate the feasibility and accuracy of...

Perivascular epithelioid cell tumor arising in the left parametrium: a case report

The perivascular epithelioid cell tumors (PEComas) mimic rare epithelial mesenchymal tumors with epithelioid features and perivascular clear cells that co-express the muscle and melanocytic markers. The PEComas include lymphangioleiomyomatosis, clear cell sugar tumor, angiomyolipoma, and myomelanocytic tumors. We report a case involving 37-year-old woman with a PEComa in the left parametrium. The patient was referred to our hospital with an adnexal tumor detected during medical examination. Therefore, she underwent laparoscopic mass excision surgery. Immunohistochemical staining of the tumor cells indicated positivity for Melan A, HMB45, and desmin. Finally, the tumor was diagnosed as a PEComa. The patient is undergoing regular follow-up, and no recurrence has been noted at 2 years after the surgery.

Evaluation of a New Prognostic Tumor Score in Locally Advanced Cervical Cancer Integrating Clinical Examination and Magnetic Resonance Imaging

The integral results of clinical examination and magnetic resonance imaging (MRI) of patients with locally advanced cervical cancer may provide prognostic information that cannot readily be placed in current staging systems, such as proximal versus distal parametrial invasion, unilateral versus bilateral involvement, or organ infiltration on MRI. The aim was to develop and investigate the performance of a simple but comprehensive tumor score for reporting and prognostication. In the present study, 400 consecutive patients with locally advanced cervical cancer treated 2005 to 2018 with chemoradiation and image guided adaptive brachytherapy (IGABT) were analyzed. The diagnostic workup included clinical examination, positron emission tomography/computed tomography, and MRI. International Federation of Gynecology and Obstetrics 2009 stage distribution was IB to IIA 9%, IIB 61%, and III to IV 30%. Involvement of 8 anatomic locations (cervix, left parametrium, right parametrium, vagina, bladder, ureter, rectum, and uterine corpus) was scored according to a ranked ordinal scale with 0 to 3 points. The total sum of points constituted the tumor score (T-score). The median T-score was 6 (range, 0-20). Based on the frequency distribution of the T-score, 4 equally sized groups were formed: 0 to 4, 5 to 6, 7 to 9, and >9 points. The T-score grouping was highly significant in both univariate and multivariable analysis and outperformed International Federation of Gynecology and Obstetrics stage for both survival and local control enabling also intrastage prognostication. Used as a linear variable, the T-score was correlated with IGABT target volume (high-risk clinical target volume, CTVHR), use of interstitial needles, dose (D90 of CTVHR), and total reference air kerma. The T-score is a simple instrument for combining clinical findings and imaging into a powerful prognostic factor for survival and local control with capabilities surpassing traditional staging. In addition, the T-score may already at diagnosis predict essential IGABT parameters and may be used for audit and comparison of results in multicenter settings.

Non-Metastatic Basaloid Squamous Cell Carcinoma of the Uterine Cervix in a Woman with History of Subtotal Hysterectomy

Introduction: Basaloid squamous cell carcinoma (BSCC) of the cervix is an uncommon tumor in female genital tract. The aggressive clinical behavior makes this entity distinguished from other SCC subtypes. Case Presentation: We described a case of basaloid squamous cell carcinoma in uterine cervix in a 62-year old woman with previous subtotal hysterectomy. Clinical and radiologic examination suggested a 3 cm mass in cervical stump involving left parametrium. She underwent trachelectomy and lymph node dissection followed by adjuvant radiochemotherapy. The light microscopy and immunohistochemistry warranted the basaloid SCC diagnosis that was suspected in pre-operational biopsy. The small, round to oval-shaped cells with scant cytoplasm and hyperchromatic nuclei were positive for cytokeratin AE1/AE3 (CK AE1/AE3) and negative for p63, C-KIT, chromogranin and synaptophysin. Conclusions: Although this tumor has an aggressive behavior, this is not enough to substantiate that BSCC has a poorer medical outcome as compared to conventional SCC of the cervix.

Papillary Squamotransitional Cell Carcinoma of the Uterine Cervix: A Case Report and Review of the Literature.

Introduction. Papillary squamotransitional cell carcinoma (PSTCC) is an uncommon histopathological variant of squamous cell carcinoma (SCC) of the uterine cervix, which occurs in postmenopausal women. Presentation of Case. Herein, we describe a case of a 63-year-old woman who presented with 4-month history of postmenopausal vaginal bleeding. Vaginal examination revealed a fragile lesion of size 1 × 1 cm invading left posterior vaginal fornice and parametrium. Biopsy showed the presence of papillae containing fibrovascular cores lined by multilayered atypical epithelial cells resembling squamous and transitional cell epithelium, confirming the diagnosis of PSTCC of the uterine cervix. After staging work-up she was staged according to the International Federation of Gynecology and Obstetrics (FIGO) staging system 2009 as FIGO IIB, and she was started on extended field concurrent chemoradiation. Discussion. PSTCC of the uterine cervix is an extremely rare and aggressive entity. PSTCC is often characterized by the presence of papillary structures with prominent fibrovascular cores. PSTCC of the uterine cervix should be differentiated from transitional cell carcinoma, squamous papilloma, papillary adenocarcinoma, and cervical intraepithelial neoplasia with papillary features. Conclusion. PSTCC of the uterine cervix is a diagnostic challenge; further studies regarding the mechanism underlying the development of PSCC are warranted.

Cerebral oedema following robotic surgery: a rare complication.

We present an unusual complication following robotic assisted radical hysterectomy. A 51-year-old female with stage 1B1 cervical cancer underwent a robotic assisted radical hysterectomy. The procedure was prolonged with difficulties dissecting the left parametrium and vaginal fornix with persistent bleeding from the left vaginal vault. Post-operatively the patient was electively sedated and ventilated. Extubation was difficult due to patient agitation but achieved on day 2. Agitation persisted and a head CT scan was performed and a diagnosis of cerebral oedema was made. Factors contributing to this case include prolonged operating time, prolonged Trendelenburg position with high pressures of CO2 pneumoperitoneum and excessive blood loss. These factors may contribute to poor cerebral venous outflow, increasing intracranial pressure leading to increased risk of cerebral oedema. The mechanics of robotic assistance may be used to reduce these risks by significantly reducing intra-abdominal pressure improving venous return. The use of robotics in surgery has been increasing over the last 10 years, and the benefits have been well documented. We present an unusual complication following robotic assisted radical hysterectomy performed for cervical cancer.

Laparoscopic Treatment of Rectovaginal Fistula with Manual Suture

This is a 38 years-old woman with infertility for 2 years and mild pain in the last year. Pre-operative MRI showed a 3,7 cm lesion of the rectosigmoid infiltrating the muscular layer. The first surgery included extensive ureterolysis, resection of the proximal left parametrium and shaving of the rectal nodule. Five days after surgery she had an acute pain and developed signs of peritonitis. Laparoscopy revealed a 2cm opening of the rectum and a moderate amount of purulent secretion in the abdominal cavity.

Endometrial stromal sarcoma of the uterus with malignant thrombosis of the iliac and femoral veins: Case report and review of literature

A case report of endometrial stromal sarcoma is presented. A 37 year old patient was admitted with a history of excessive bleeding per vaginum during menstruation and lump in abdomen for the past 6-7 months which was found to be about 24 weeks pregnancy size. On opening the abdomen for hysterectomy the uterus showed a growth extending into the left adnexa, sigmoid mesocolon, and left parametrium. During surgery there was accidental transection of the left ureter and external iliac vein which showed extensive thrombus. As total hysterectomy was not possible, subtotal hysterectomy with bilateral salpingo-oophorectomy was performed, with D-J stenting of the ureter and ligation of the external iliac vein. Postoperatively the diagnosis of thrombosis of the internal iliac, external iliac, femoral and popliteal veins was established by CT scan and Doppler imaging. Histopathology showed endometrial stromal sarcoma.

Abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix

Surgical management of deep infiltrating endometriosis can be very challenging even for experienced gynecologists. Radical procedures like bowel resection and nephrectomy have been reported for treatment of the disease. Our aim is to report abdominal radical trachelectomy for treatment of deep infiltrating endometriosis of the cervix causing obstructive uropathy and diminished kidney function. We present a 38-year-old woman who was treated in our department for cervical endometriosis involving the vagina and left parametrium. Abdominal radical trachelectomy, insertion of a pig-tail catheter in the left ureter and end-to-end anastomosis of the uterus with the vagina was performed to remove the endometriotic lesion. Cooperation between gynecologists, urologists and nephrologists enabled fertility preservation as well as improvement of renal function. Deep infiltrating endometriosis is a complex disease that requires a multidisciplinary approach. Abdominal radical trachelectomy for cervical lesions seems feasible in this setting and helps preserve fertility.