Left Pelvic Sidewall Research Articles

2647 ¨Uterine Arteries Ligation¨ Previous To Uterine Myomectomy (8-10 CM Myoma)

Video Objective The intention of this video is to show a different technique to ligate the uterine arteries before a large uterine myoma (8-10cm) is dissected. In that way we are decreasing the chances for bleeding. Setting This case is a 26 years old patient with a heavy bleeding y crampy abdominal pains with the periods. An ultrasound shows a large fundic myoma (8-10cm) Interventions Before do the myomectomy, the uterine arteries are ligated, using a 3-0 cromic absorbable suture. The retroperitoneal space is opened, and the anatomical structures are identified. The ureter is followed from the ileac bifurcation, then the vascular retroperitoneal anatomy is identified, the hypogastric artery becomes into the superior vesical artery and uterine artery, this is dissected and sutured with cromic 3-0, the same procedure is done in the left pelvic side wall. The uterine blood supply is decreased by almost 80%. Conclusion Temporary bilateral uterine artery occlusion during laparoscopic myomectomy does not increase mean operative time, offers a possible option to reduce blood loss effectively. This is a very easy technique to occlude temporary the vascular supply to the uterus, with this, there is no bleeding complication from the myomectomy. The main myomectomy complication is bleeding.

1734 Resection of a Retroperitoneal Mature Teratoma Causing Severe Urinary Symptoms

Video Objective The objective of this video is to depict a robotic assisted laparoscopic resection of a retroperitoneal mass, showing a unique case where compression on the pelvic splanchnic nerves produced severe urinary symptoms in a patient which resolved immediately after the procedure. It also shows a rare case of extraogonadal retroperitoneal mature teratoma. Setting The patient is a 28 yo G1P1 who presented to care for worsening left lower quadrant pain and pressure, urinary frequency, urgency and hourly nocturia. History is significant for dysmenorrhea, abdominoplasty and acne taking spironolactone. Imaging revealed a mildly complex mass in the cul-de-sac measuring 10.6 × 8.3 × 7.3 cm, without thickening or nodularity, probably cystic and arising from the left ovary. She underwent laparoscopy for planned excision which was aborted as a retroperitoneal mass was identified involving the cul-de-sac and left pelvic sidewall without involvement of the ovaries, fallopian tubes and uterus. She was then referred to Gynecologic Oncology, Neurosurgery and then by Urogynecology. Interventions She underwent a robotic assisted laparoscopic removal of the left retroperitoneal mass with care to avoid use of excessive cautery, excision of endometriosis, left ureterolysis, enterolysis, peritoneal biopsy and cystoscopy with a intraoperative left ureteral stent placed by Urology, removed at the end of the case. After removal of the mass her urinary symptoms and pelvic pain completely resolved. Her postoperative course was uncomplicated. Pathologic findings of the retroperitoneal mass were consistent with a mature teratoma. Conclusion The retroperitoneal teratoma compressed the inferior hypogastric plexus which led to the patient's symptoms. Careful dissection of the pararectal and paravesical space was performed to cause minimal damage to the inferior hypogastric plexus and surrounding nerves with complete resolution of symptoms. Limited use of electrocautery was employed to avoid thermal damage. Extragonadal teratoma is a rare finding.

Genitofemoral Nerve Sparing Adhesiolysis

Video Objective The objective of this video is to review the anatomical landmarks, innervations and mechanisms of injury of the genitofemoral nerve in order to avoid its injury in cases with significant pelvic adhesions. Setting The patient is a thirty-two-year-old gravida three para three who is known for endometriosis. She previously underwent a caesarean hysterectomy for invasive placentation. She presented with chronic pelvic pain. She tried numerous medical treatments; only GnRH agonist controlled her pain. She was therefore consented for laparoscopic bilateral salpingo-oophorectomy which was performed at a tertiary care center by the minimally invasive gynecology surgery team. She had extensive abdominal and left pelvic side wall adhesions. In fact her left ovary was severely adherent onto the left external iliac artery and genitofemoral nerve. Interventions During the laparoscopic bilateral salpingo-oophorectomy, adhesiolysis and dissection near the genitofemoral nerve and external iliac artery were performed. Conclusion In the case of severe pelvic side wall adhesions and absence of a uterus, recognition of pelvic landmarks is of paramount importance. This facilitates identification of other pelvic structures and in this case, prevented injury to the external iliac artery and the genitofemoral nerve. Furthermore, careful tissue handling and dissection techniques are crucial. These help to maintain minimal blood loss, develop surgical planes and avoid injuries to pelvic structures.

Levator Avulsion: A Review of Surgical Anatomy and Repair Technique for Primary Posterior Perineal Hernias

Video Objective Perineal hernias are exceptionally uncommon gynecologic pathologies that may have a drastic impact on women's health. Hernias that contain pelvic visceral structures present an especially unique challenge that requires immediate attention. Evidence is lacking as to the optimal surgical approach. Our objective is to describe our minimally-invasive technique for the repair of primary posterior perineal hernias with symptomatic bladder prolapse. Setting This patient is a sixty-two year-old female who presented with a large bulge in her left buttock and a chief complaint of difficulty urinating that required reduction in order to void. Her medical history is significant for a prior vaginal delivery without complications, and a prior rectocele repair. Outpatient workup that included cystogram, CT and MRI imaging revealed a left perineal hernia that involved the entire bladder. She was diagnosed with a posterior perineal hernia. Interventions This patient's condition was treated via surgical management. Due to the large defect size and absent levator ani musculature, re-approximation for pelvic support was not feasible and thus a 5 × 4 cm segment of propylene mesh was placed and sutured between the left vaginal sidewall and left pelvic sidewall periosteum. Following, a sacrocolpopexy was performed to repair her perineal descent, and the prolapsed bladder was replaced with a psoas hitch procedure to the contralateral side. Conclusion Primary posterior perineal hernias with concomitant symptomatic bladder prolapse may be repaired with a sacrocolpopexy, paravaginal mesh placement, and a psoas hitch procedure. Using a robotic-assisted, minimally-invasive repair technique has been proven to have favorable short-term outcomes regarding symptomatology as well as anatomic replacement of pelvic viscera. Patients should be counseled about the option for surgical management of perineal hernias, as well as the need for future research to evaluate the long-term outcomes and quality of life markers following transabdominal laparoscopic perineal hernia repairs with use of mesh placement.

1499 Segmental Colitis Associated With Diverticulosis (SCAD): A Rare Cause of Hydroureteronephrosis

INTRODUCTION: Segmental Colitis Associated with Diverticulosis (SCAD) is a rare inflammatory condition affecting segments of bowel with diverticulosis. We present a case of a patient with imaging revealing left colonic wall thickening and left sided hydroureteronephrosis, and work-up confirming a diagnosis of SCAD. CASE DESCRIPTION/METHODS: An 85-year-old female with a history of cognitive impairment, uterine cancer status post hysterectomy, and previous episode of diverticulitis 5 years prior presented to our institution with fevers, chills, and flank pain. Symptoms began 3 days prior to presentation with no associated abdominal pain, nausea, vomiting, hematochezia, or changes to her bowel movements. Upon arrival, her vital signs were within normal limits and physical exam disclosed left flank tenderness. Laboratory data revealed leukocytosis to 17 K/uL with unremarkable hematocrit, basic metabolic panel, and liver chemistries. Urinalysis was positive for pyuria with nitrites and leukocytes. CT abdomen and pelvis revealed short segment of sigmoid colonic, adjacent lymphadenopathy, left psoas abscess, and moderate left hydroureteronephrosis (Figure 1). She was initially treated with antibiotics and left-sided percutaneous nephrostomy tube placement. Colonoscopy was deferred due to concern for high risk of complications in favor of conservative management; however, repeat imaging 4 weeks later revealed unchanged thickening of the mid-sigmoid colon extending into left pelvic sidewall and interval increase in the left psoas collection with concern for fistulizing chronic diverticulitis or potential malignancy. She subsequently underwent exploratory laparotomy with lower anterior resection and ileoclonic resection for tethered and fistulizing small bowel to a left lower quadrant phlegmon. The sigmoid colon was also attached to the phlegmon and pathology revealed diverticulitis with extensive old fibrosis and reactive lymphadenopathy without evidence of malignancy or histology suggestive of IBD. As such, the final diagnosis was SCAD-associated hydroureteronephrosis, and she recovered well without complication. DISCUSSION: Often mistaken for IBD or colorectal cancer, SCAD is an inflammatory condition that should be considered in patients with history of diverticulosis and features suspicious for segmental colonic inflammation. This case reinforces understanding and highlights hydroureteronephrosis as a rare complication seen in a patient with SCAD.

34. An unusual presentation of a cervical mass

34. An unusual presentation of a cervical mass

Multivisceral, vascular and nodal resection for recurrent rectal cancer involving the left renal tract, left pelvic side wall and abdominal aorta.

Multivisceral, vascular and nodal resection for recurrent rectal cancer involving the left renal tract, left pelvic side wall and abdominal aorta.

The association between ultrasound-based ‘soft markers’ and endometriosis type/location: A prospective observational study

ObjectiveEvaluate whether symptoms and/or transvaginal ultrasound (TVS) ‘soft markers’ (ovarian immobility and/or site-specific tenderness (SST)) are associated with endometriosis type/location. Study designMulticenter prospective observational study (January 2009 to February 2013) in tertiary centers for women with chronic pelvic pain who underwent detailed history, specialized TVS, and laparoscopy. Chart findings were collated into a study database. Outcome measures included correlation between symptoms, ovarian immobility or SST on TVS and endometriosis type and/or location. The performance of ovarian immobility to predict ipsilateral SE was evaluated in terms of accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). ResultsA total of 189 participants were included. Ovarian immobility on TVS was significantly associated with: ipsilateral pelvic pain, uterosacral ligament (USL) and pelvic sidewall superficial endometriosis (SE), endometrioma, posterior compartment deep endometriosis (DE), pouch of Douglas (POD) obliteration, and need for bowel surgery (all p < 0.05). For women with isolated SE (i.e.no endometrioma, DE, or POD obliteration), left ovarian immobility was significantly associated with left USL SE (p = 0.01) and left adnexal SST corresponded to left pelvic sidewall SE (p = 0.03). The accuracy, sensitivity, specificity, PPV and NPV for ovarian immobility at TVS and the presence of ipsilateral pelvic sidewall SE for the left ovary was: 71%, 16%, 87%, 27% and 78%, respectively; and for the right ovary was: 82%, 7.0%, 94%, 14% and 87%, respectively. ConclusionOvarian immobility on TVS was significantly associated with ipsilateral pelvic pain, USL/pelvic sidewall SE, endometrioma, posterior compartment DE, and POD obliteration. The diagnostic accuracy of ovarian immobility for disease location in women with isolated SE showed a high specificity and NPV, but poor sensitivity and PPV, suggesting that ipsilateral pelvic sidewall SE is less likely to be present in women with a mobile ovary (in the absence of endometrioma or DE). Larger studies are required to further evaluate the usefulness of soft markers for the localization of isolated SE.

Long‐term survival of a patient with malignant transformation of extragonadal endometriosis treated solely with chemotherapy: A case report

A 52-year-old woman presented to our hospital complaining of genital bleeding and was found to have a 50-mm vaginal tumor that involved the bladder, rectum, and small bowel and extended to the left pelvic side wall. Her history included a bilateral salpingo-oophorectomy and a total abdominal hysterectomy for fibroids and endometriosis. She had been prescribed estrogen replacement therapy (1.25 mg/day) following the second surgery and continued it for 8 years. The pathology of the vaginal biopsy showed endometrioid adenocarcinoma. Total pelvic exenteration was recommended for complete resection, but she chose chemotherapy (paclitaxel 175 mg/m2 and carboplatin AUC:6). Clinical complete remission was obtained for 11 years. She had a recurrence 11 years later. She was again found to have a 5-cm vaginal tumor. Surgical excision with upper vaginectomy was performed. The tumor was resected without invasion of the bladder, rectum and small bowel. Histologic examination of the specimen confirmed clear cell carcinoma with endometriosis. Chemotherapy may be the first-line treatment that can preclude aggressive surgery for malignant transformation of extragonadal endometriosis. However, combined chemotherapy and surgery is necessary for this disease.

Laparoscopic Anterior Pelvic Exenteration with Super Radical Parametrectomy for a Recurrent Low-Grade Endometrial Sarcoma That is Resistant to Hormone Therapy and Chemotherapy

Study ObjectiveTo show total laparoscopic complete resection of a recurrent low-grade endometrial sarcoma. DesignStep-by-step demonstration of the technique of laparoscopic anterior pelvic exenteration with super radical parametrectomy, including the explanation of detailed pelvic anatomy (Canadian Task Force classification III). SettingLow-grade endometrial stromal sarcoma (LGESS) is a rare malignancy that makes up around 0.2% of all uterine malignancies [1]. Total abdominal hysterectomy and bilateral salpingo-oophorectomy is a standard treatment; however, the recurrence risk is quite high [2]. For a recurrent LGESS that is resistant to hormone therapy and chemotherapy, complete resection with negative surgical margins (R0 resection) can be the most promising method [3]. PatientThe patient had undergone total abdominal hysterectomy and bilateral salpingo-oophorectomy because of a LGESS. Almost 20 years later, a recurrent LGESS was detected at the vaginal stump, and the patient underwent several rounds of chemotherapy and hormonal therapy. These treatments were inefficacious, and the recurrent tumor progressed. An abdominal computed tomographic scan revealed that the recurrent tumor occupied the vaginal stump, involved the bladder and the left ureter, and extended to the left pelvic sidewall. InterventionsAnterior pelvic exenteration with super radical parametrectomy was performed laparoscopically with no blood transfusion. R0 resection could be achieved without any intraoperative and postoperative complications. Without any adjuvant treatment, there has been no sign of recurrence during the 12 months that have passed since the surgery. This video obtained institutional review board approval through our local ethics committee in the Cancer Institutional Hospital (institutional review board number 2016-1007). ConclusionThe good visualization and meticulous dissection provided during laparoscopic surgery can make the approach advantageous and may contribute to R0 achievement.

Laparoscopic Ligation of Uterine Vasculature for Fertility-Sparing Management of Postabortal Hemorrhage

Study ObjectiveTo present a surgical video in which bilateral uterine vasculature was ligated laparoscopically in order to preserve the uterus in a patient with postabortal hemorrhage. DesignA case report (Canadian Task Force classification III). SettingA tertiary referral center in New Haven, CT. InterventionsThis is a step-by-step demonstration of laparoscopic ligation of the uterine vasculature in a patient with postabortal hemorrhage. The patient was a 33-year-old Para 4014 woman who presented with postabortal hemorrhage after she underwent an urgent dilation and evacuation for the management of symptomatic placenta accreta at 19 weeks of pregnancy. The patient underwent a physical examination when she presented to the emergency department with postabortal hemorrhage. She was hemodynamically stable, and the examination was negative for cervical or vaginal lacerations. Coagulation studies were negative for any coagulopathy. A pelvic ultrasound did not show any retained products of conception. As per the Society of Family Planning guidelines, uterine massage was performed, and uterotonics (i.e., methylergonovine maleate 0.2 mg intramuscularly and misoprostol 1000 mg per rectum) were given [1]. The postabortal hemorrhage persisted despite medical therapy with an approximate blood loss of 600 mL over 2 hours. An intrauterine tamponade balloon was placed, and the patient then underwent a uterine angiogram and bilateral uterine artery embolization secondary to continued vaginal bleeding despite medical management. She was closely monitored and noted to have another 500 mL of blood loss over 2 hours after completion of uterine artery embolization. At this point, she was resuscitated with 2 U red blood cells because she developed symptoms of hemodynamic instability. Her hematocrit was increased suboptimally after transfusion with stabilization of her vitals. The patient was then counseled on her surgical options because she had failed medical management, intrauterine balloon tamponade, and uterine artery embolization. She stated a strong desire to preserve her uterus. Given her overall hemodynamic stability, laparoscopic ligation of the uterine vessels was proposed, which she agreed on [2]. Risks of the laparoscopic approach were explained to the patient, which included injury to the uterus, ureters, blood vessels, and nerves as well as the possibility of conversion to laparotomy. The surgery started with exploration of the peritoneal cavity. Her uterus was noted to be significantly enlarged with many engorged vessels. In order to decrease the risk of uterine perforation in this bulky and highly vascular uterus, the surgeon decided not to place a uterine manipulator. The retroperitoneum was entered at the right pelvic sidewall. Pararectal and paravesical spaces were then developed. Ureterolysis was performed in order to free its peritoneal and uterine artery attachments. The uterine artery was skeletonized cephalad to the hypogastric bifurcation and was ligated with 5-mm vascular clips. The attention was then turned to the ovarian vessels at the cornu of the uterus. Peritoneal avascular windows were created inferior and superior to the vessels. The blood supply was then ligated with an absorbable suture, and the ligature was secured using the extracorporeal knot tying technique. The same steps were repeated on the left pelvic sidewall. The procedure was completed once excellent hemostasis was assured. Besides the technical steps of the procedure, pelvic anatomic landmarks have also been emphasized in this video for educational purposes. Measurements and Main ResultsLaparoscopic ligation of the uterine vasculature was performed without any complications. The operative time was 65 minutes, and blood loss was minimal. The patient had an uneventful postoperative course and was discharged home the day after her laparoscopic surgery. ConclusionThe uterus was preserved with this minimally invasive approach for the management of postabortal hemorrhage. Laparoscopic ligation of the uterine vessels should be considered in hemodynamically stable patients who desire future fertility when managing postabortal hemorrhage.

Total Laparoscopic Resection Surgery for a Cervical Carcinoma that Recurred in the Pelvic Sidewall After Radical Hysterectomy and Adjuvant Concurrent Chemoradiotherapy

Study ObjectiveTo show total laparoscopic resection of a cervical carcinoma that recurred at the left pelvic sidewall after radical hysterectomy and concurrent chemoradiotherapy (CCRT). DesignA step-by-step demonstration of the technique in a surgical video, including the strategy for achieving complete surgical resection with negative margins (R0 resection) (Canadian Task Force Classification III). SettingFor high-risk cervical carcinoma, radical hysterectomy and adjuvant CCRT is the standard treatment, but even this multimodal therapy cannot prevent recurrence. When the recurrent mass is localized in the pelvic cavity, R0 resection offers the most promise; however, for laterally recurring cervical carcinoma, the resectability rate is low, owing mainly to severe adhesion and fibrosis, and thus the morbidity and mortality rates are high. Because laparoscopy optimizes visualization and provides for meticulous dissection, laparoscopic surgery can be advantageous over open surgery for resection of cervical carcinoma recurring at the pelvic sidewall after radical hysterectomy and adjuvant CCRT. InterventionsA 48-year-old woman with stage IB2 cervical adenocarcinoma had undergone radical hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy, and, because lymph node metastasis was found in the removed lymph nodes, adjuvant CCRT. At 6 months after completion of this multimodal therapy, a recurrent mass was detected at the left pelvic sidewall. The mass involved the left ureter, bladder, left internal iliac vessels, and endopelvic fascia, and left renal function was unrecoverable. Tumor excision and left nephroureterectomy were performed laparoscopically. The total operating time was 608 minutes, blood loss volume was 250 mL, and blood transfusion was not required. Complete tumor clearance (R0 resection) was achieved by resection of the left internal iliac vessels, left internal obturator muscle, left pubococcygeal muscle, left ureter, and bladder. There were no postoperative complications. Institutional Review Board approval was obtained through our local Ethics Committee in Cancer Institute hospital. ConclusionComplete laparoscopic resection surgery for recurrent cervical carcinoma at the pelvic sidewall after radical hysterectomy and adjuvant CCRT is technically feasible. The good visualization and meticulous dissection provided during laparoscopic surgery make the approach advantageous for the management of laterally recurrent cervical carcinoma.

Laparoscopic Total Pelvic Exenteration After Neoadjuvant Imatinib Therapy for Gastrointestinal Stromal Tumor of the Rectum: A Case Report

Total pelvic exenteration (TPE) may be the only curative procedure for locally advanced rectal gastrointestinal stromal tumor (GIST) that is contiguous with the adjacent organs and pelvic wall. There is no previous report of laparoscopic TPE for advanced rectal GIST. Here, we describe our experience of performing laparoscopic TPE on a locally advanced rectal GIST after neoadjuvant imatinib chemotherapy. A 62-year-old Japanese man was diagnosed with locally advanced rectal GIST that was contiguous with the seminal vesicles, prostate, and left pelvic sidewall. He received imatinib mesylate for 5 months, after which the mass had shrunk but was still contiguous with adjacent organs. We therefore needed to perform TPE, and we accomplished the operation laparoscopically. The total operative time was 540 minutes and estimated blood loss was 280 mL. There were no intraoperative complications and not required conversion to open surgery. The patient had his first stool on the first postoperative day and discharged on the 21st postoperative day with no major complication. Pathologic examination of the resected specimen revealed negative margins. The patient had further adjuvant imatinib chemotherapy and had no recurrence for 20 months postoperatively. Laparoscopic TPE appears to be minimally invasive surgery and safe in the present case of rectal GIST. This is the first report of a case in the world that underwent laparoscopic TPE for advanced rectal GIST.

A Case of a Gastrointestinal Stromal Tumor Diagnosed at the Postpartum Period.

Introduction. We discuss a rare gastrointestinal stromal tumor (GIST) case detected at the 10th postpartum week and we want to pay attention to the challenges and improvements in the diagnosis, surgery, chemotherapy, and follow-up of this rare tumor accompanied with the review of the current literature. Case Presentation. A 32-year-old multiparous woman presented with abdominal swelling 10 weeks after her second vaginal birth. Abdominal examination revealed a mass starting from the pelvic level and extending to the right upper quadrant. Radiological examinations showed a solid, multiloculated, and hypervascular mass starting from the pelvis and extending to the transverse colon. En bloc mass with a 20 cm jejunal segment resection and a left pelvic side wall peritonectomy with omentectomy was performed. The pathologic examination revealed a high-risk GIST which originated from the jejunum and disseminated to the peritoneum. The patient has been given imatinib 400 mg/day since then. She did not reveal any progression during the 15-month follow-up postoperatively. Conclusion. GIST tumors are rare and there is not sufficient information in the literature regarding its management. In this patient having high risk GIST and GIST sarcomatosis we successfully treated the patient by surgery and adjuvant imatinib chemotherapy.

Pelvic local recurrence in a patient with muscle-invasive bladder cancer treated with interstitial thermal therapy and interstitial brachytherapy

The patient was a 53-year-old man who developedhematuria in 2007. Cystoscopy revealed a 5- to 6-cm masson the left floor of the bladder near the ureteral orifice. Heunderwent transurethral resection of the tumor, whichrevealed extensive high-grade urothelial carcinoma invad-ing the detrusor muscle. Computed tomography (CT) ofthe abdomen revealed no appreciable evidence of adeno-pathy or metastatic disease. The patient underwent acystoprostatectomywithilealconduitdiversion.Pathologydemonstrated a high-grade urothelial carcinoma thatinvolved the posterior and left lateral wall, as well as thetrigone and dome of the bladder, and that had invaded thedeep muscularis propria. The closest margin was 8 mmposteriorly, with no lymphovascular space invasion. Onerightpelvicand2leftobturatorlymphnodeswerefoundtobe positive. Extracapsular extension was appreciated in aleft obturator node.The tumor was staged as T2bN2Mx (stage IV)urothelial carcinoma of the bladder. The patient completed4 cycles of adjuvant gemcitabine and cisplatin in April2008. In August 2013, CT of the abdomen/pelvis revealedinterval development of a soft tissue mass around thesurgical clips on the left pelvic sidewall, for which he wasinitially observed. He presented in January 2014 with a3-month history of weight loss, nausea, intermittent smallbowel obstruction, worsening pelvic pain, and shootingdiscomfort in the left sciatic distribution. Positronemission tomography/CT in February 2014 revealed a

A prospective study examining the incidence of asymptomatic and symptomatic lymphoceles following lymphadenectomy in patients with gynecological cancer

ObjectiveTo identify the incidence of asymptomatic and symptomatic (i.e., causing pain, hydronephrosis, venous thrombosis, acute lymphedema of the lower or urinary urgency) lymphoceles, as well as risk factors for their development, through a prospective study of patients undergoing sole pelvic or combined pelvic and paraaortic lymphadenectomy for gynecological cancer. MethodsPatients with endometrial, ovarian or cervical cancer scheduled for sole pelvic or combined pelvic and paraaortic lymphadenectomy as a primary surgical treatment or salvage surgery for recurrence were enrolled at single institution from February 2006 to November 2010 and prospectively followed up with ultrasound. ResultsOf 800 patients who underwent sole pelvic or combined pelvic and paraaortic lymphadenectomy for gynecological cancer, the overall incidence of lymphoceles was 20.2%, with symptomatic lymphoceles occurring in 5.8% of all patients. Lymphoceles are predominantly located on the left pelvic side wall. Lymphadenectomy in ovarian cancer, a higher number of lymph nodes obtained (>27), and radical hysterectomy in cervical cancer were found to be independent risk factors for the development of symptomatic lymphoceles. ConclusionsThe overall incidence of lymphocele development after lymphadenectomy for gynecological cancer remains high. However, the majority of lymphoceles are only incidental finding without clinical impact. A symptomatic lymphocele is an uncommon event, occurring in only 5.8% of patients. Symptomatic lymphoceles tend to develop earlier than asymptomatic. Although such risk factors are hard to avoid, patients known to be at an increased risk of developing symptomatic lymphoceles can be counseled appropriately and followed up for specific symptoms relating to lymphocele development.

Laparoscopic Dissection and Anatomy of Sacral Nerve Roots and Pelvic Splanchnic Nerves

Study ObjectiveTo demonstrate the technique of laparoscopic dissection for identification of sacral nerve roots and pelvic splanchnic nerves. DesignCase report (Canadian Task Force classification III). SettingPrivate practice hospital in São Paulo, Brazil. PatientA 31-year-old woman with suspected iatrogenic and/or compression of sacral nerve roots. She reported debilitating pelvic, gluteal, and perineal unilateral left-sided pain (score 8 on a pain scale of 0–10), and had primary infertility with 1 previous failed attempt at in vitro fertilization. Surgical history included laparoscopic excision of endometriosis 10 months before the procedure and left oophoroplasty during adolescence because of a benign neoplasm. InterventionsStandard 4-puncture laparoscopy was performed. The peritoneum of the left pelvic sidewall was resected to preclude eventual residual endometriosis. This also enabled identification of uterine vessels including the deep uterine vein, which is the limit between the pars vascularis superiorly and the pars nervosa inferiorly in the uterine broad ligament. Surgery was using the laparoscopic neuro-navigation (LANN) technique, previously described by one of us (M. P.). For identification of the sacral roots, dissection was begun medial to the ureter and lateral to the uterosacral ligament. The Okabayashi pararectal space was entered as deep as possible via blunt dissection in avascular spaces. Hemostasis was performed using 5-mm bipolar forceps, and harmonic energy was not used. The hypogastric fascia was entered from medial to lateral, and the piriformis muscle was identified. The sacral nerve root S1 was identified lying over it. Dissection then proceeded caudally, and sacral roots S2 and S3 were sequentially identified. Small and delicate fibers forming the pelvic splanchnic nerves were isolated emerging from sacral roots S2 and S3. Other nerve fibers were identified caudally, probably representing pelvic splanchnic nerves emerging from S4. Measurements and Main ResultsThe surgical operative time was 70 minutes, and bleeding was minimal. No suspected compression or iatrogenic injury was identified. The patient was discharged on the day after the procedure. At 8-month follow-up, she had partial resolution of pain (score 5, pain scale 0–10), and another failed attempt at in vitro fertilization was attributed to unsatisfactory quality of the embryos. There were no symptoms or dysfunctions attributable to manipulation of the nerves. ConclusionLaparoscopy is a useful tool for identification of sacral roots and pelvic splanchnic nerves in suspected diseases. Its application in the field of neuropelveology can be expanded with proper knowledge and training.

Case of a locally advanced carcinoma cervix presenting withprotrusio acetabuli: pre-screening era presentation rarely seen in modern times

Cervical cancer is the third most commonly diagnosed cancer, and the fourth leading cause of cancer deaths in women worldwide. In 2008, there were an estimated 529 000 new cases of cervical cancer, and 275 000 cervical cancer-related deaths. 1 Cancer of the cervix has been the most common cancer in women in India for the past two decades. 2 The lungs, para-aortic lymph nodes and supraclavicular nodes are the most common sites of distant metastases. Bone metastases are not commonly seen, usually only in 0.8-23% of cases, and then mostly in the dorsal or lumbar vertebrae. 3,4 Skeletal deposits were estimated to occur in less than 1% of patients in postmortem reports of large series of cases, such as those compiled by MacCormack. 5 Matsuyama, Tsukamoto, Imachi and Nakano reported rates as high as 4-6.5%. 6 Large fungating or invasive lesions are rarely seen since the advent of the routine use of screening procedures for cervical cancer in the Western world. However, such lesions are still commonly observed in developing countries. We describe a case of locally advanced cervical cancer, which had spread laterally to involve the left pelvic side wall, causing erosion and destruction of the left acetabulum and femoral head.

Pelvic Sidewall Anatomy

Endometriosis can alter pelvic anatomy. Thus, it is important to be aware of key structures during the resection of endometriotic implants. Knowledge of the anatomy may decrease potential injury to these structures. This video highlights the ureter, obliterated umbilical artery, uterine artery, pelvic floor muscles, external iliac vessels and obturator vessels and nerve during a resection of endometriosis of the left pelvic sidewall. Our video aims to show the relationship of these structures to each other as show partial dissection of the pelvic sidewall.

Vaginal Malakoplakia: A Benign Mimic of Pelvic Malignancy in a Postmenopausal Female

Malakoplakia is an uncommon chronic inflammatory condition with distinct histopathologic features. Herein, we report a 64-year-old Caucasian female with anemia and renal failure, who presented with 4 weeks of hematuria, vaginal bleeding, and left hip pain. Magnetic resonance imaging demonstrated a 10-cm soft tissue mass in the pelvis, which involved the left pelvic sidewall, the left external iliac vein …