Pelvic Sidewall Research Articles

Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review

The use of imprecise and inaccurate terms leads to confusion amongst anatomists and medical professionals. We sought to create recommended standardized terminology to describe anatomic structures of the anterior female pelvis based on a structured review of published literature and selected text books. We searched MEDLINE from its inception until May 2, 2016, using 11 medical subject heading terms to identify studies reporting on anterior female pelvic anatomy; any study type published in English was accepted. Nine textbooks were also included. We screened 12,264 abstracts, identifying 200 eligible studies along with 13 textbook chapters from which we extracted all pertinent anatomic terms. In all, 67 unique structures in the anterior female pelvis were identified. A total of 59 of these have been previously recognized with accepted terms in Terminologia Anatomica, the international standard on anatomical terminology. We also identified and propose the adoption of 4 anatomic regional terms (lateral vaginal wall, pelvic sidewall, pelvic bones, and anterior compartment), and 2 structural terms not included in Terminologia Anatomica (vaginal sulcus and levator hiatus). In addition, we identified 2 controversial terms (pubourethral ligament and Grafenberg spot) that require additional research and consensus from the greater medical and scientific community prior to adoption or rejection of these terms. We propose standardized terminology that should be used when discussing anatomic structures in the anterior female pelvis to help improve communication among researchers, clinicians, and surgeons.

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.

PD38-02 FOUR-POINT PERITONEAL FLAP FIXATION IN PREVENTING LYMPHOCELE FORMATION FOLLOWING RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V1 Apr 2018PD38-02 FOUR-POINT PERITONEAL FLAP FIXATION IN PREVENTING LYMPHOCELE FORMATION FOLLOWING RADICAL PROSTATECTOMY Jens Uwe Stolzenburg, Vinodh Kumar Adithyaa Arthanareeswaran, Anja Dietel, Toni Franz, Evangelos Liatsikos, Iason Kyriazis, Roman Ganzer, Abinaya Ravichandran Chandra, and Hoang Minh Do Jens Uwe StolzenburgJens Uwe Stolzenburg More articles by this author , Vinodh Kumar Adithyaa ArthanareeswaranVinodh Kumar Adithyaa Arthanareeswaran More articles by this author , Anja DietelAnja Dietel More articles by this author , Toni FranzToni Franz More articles by this author , Evangelos LiatsikosEvangelos Liatsikos More articles by this author , Iason KyriazisIason Kyriazis More articles by this author , Roman GanzerRoman Ganzer More articles by this author , Abinaya Ravichandran ChandraAbinaya Ravichandran Chandra More articles by this author , and Hoang Minh DoHoang Minh Do More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2018.02.1749AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Symptomatic lymphocele following laparoscopic/robot assisted radical prostatectomy (RP) and concomitant bilateral extended pelvic lymph node dissection (PLND) procedure has a significant impact on the postoperative recovery and may sometime require surgical intervention. Various strategies have been tested until now to prevent postoperative lymphocele without considerable success. We report the utilization of four-point peritoneal flap fixation (4PPFF) during RP in decreasing the lymphocele formation following PLND. METHODS 4PPFF was performed by suturing the cut end of the ventral parietal peritoneum at four points (to anterior and lateral pelvic side wall on both sides) following PLND such that the peritoneal surface is exposed to the iliac vessels and obturator fossa. Between April 2010 - May 2017, 1358 patients underwent RP with concomitant bilateral extended PLND procedure. From this cohort 193 patients who had undergone PNLD with four-point PF were matched in a 1:1 ratio to patients who underwent PLND without 4PPF with respect to age, body mass index, initial PSA and number of lymph nodes removed. All patients underwent ultrasound on postoperative days 2, 6, 28 and 90 to test for the presence of any lymphoceles. Statistical analysis was performed using Medcalc statistical software (Ver. 17.9, Ostend, Belgium). For univariate analysis, chi-square test and Annova were used appropriately. Statistical significance was set at a p value less than 0.05, and all reported p values were two-sided. RESULTS There was no significant difference between the two groups with respect to intraoperative blood loss, positive surgical margin rate, Gleason score, clinical stage and number of positive cores. Incidence of asymptomatic lymphocele was observed in 4 (2.07%) patients in the 4PPFF group compared to 16 (8.3%) patients without 4PPFF (p=0.0058). Similarly, significant difference was observed in the incidence of symptomatic lymphocele; 2 (1.03%) patients in 4PPFF group vs 9 (4.6%) patients without 4PPF (p=0.0322). There was no difference in other complication rates between the two groups. CONCLUSIONS 4PPFF is a safe and effective procedure in preventing lymphocele formation in patients undergoing RP with PLND. The increased exposure of peritoneal surface to the PLND raw area following this procedure may aid in increased absorption of the accumulating lymph fluid from the PLND raw area. Further prospective randomized multicenter studies are warranted to confirm our observations. © 2018FiguresReferencesRelatedDetails Volume 199Issue 4SApril 2018Page: e736 Advertisement Copyright & Permissions© 2018MetricsAuthor Information Jens Uwe Stolzenburg More articles by this author Vinodh Kumar Adithyaa Arthanareeswaran More articles by this author Anja Dietel More articles by this author Toni Franz More articles by this author Evangelos Liatsikos More articles by this author Iason Kyriazis More articles by this author Roman Ganzer More articles by this author Abinaya Ravichandran Chandra More articles by this author Hoang Minh Do More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

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.

Laparoscopic laterally extended endopelvic resection (LEER) for cervical carcinoma recurring at the pelvic sidewall after concurrent chemoradiotherapy: Our experience in three cases

ObjectivePatients in whom laterally recurrent cervical carcinoma develops in the previously irradiated pelvis are usually abandoned because the resectability rate is low, and the 5-year survival rate is close to zero when complete margin-negative resection is not achieved [1].Höckel described laterally extended endopelvic resection (LEER) as an approach in which the line of resection extends to the pelvic sidewall [2]. Complete margin-negative resection (R0 resection) was achieved in all 100 patients who underwent LEER for laterally recurrent cervical carcinoma, and 5-year survival was very good at 62%. However, two procedure-related deaths occurred, and morbidity was 70% [3]. When cervical carcinoma recurs in the previously irradiated pelvis, fibrosis and adhesion around the recurrent mass increase morbidity and mortality. Because laparoscopy optimizes visualization and thus provides for meticulous dissection, laparoscopic LEER can be advantageous over open LEER for treatment of such recurrent tumors. MethodsWe performed laparoscopic LEER in three cases of previously irradiated laterally recurrent cervical carcinoma under the following criteria: the recurrent tumor was solitary and without distant metastasis; no equally effective alternative treatment existed, preoperative evaluation of the tumor showed R0 resection to be achievable; and the patient provided informed consent for the procedure. ResultsIn all three cases, R0 resection was achieved without the need for blood transfusion and without intraoperative or postoperative complications. There was no associated morbidity or mortality. One patient died from recurrent disease 24months after the operation, but neither of the other two patients has suffered recurrence during the respective 3 and 4months that have passed since the surgery. ConclusionLaparoscopic LEER is a very complicated procedure; the surgeon must possess detailed knowledge of the pelvic anatomy and high-level technical skill. Our experience indicates that laparoscopic LEER is feasible for cervical carcinoma that recurs laterally after irradiation and that low morbidity and mortality can be expected. Oncologic outcomes of the procedure will become clear with an accumulation of cases and long-term follow-up data.

Outcomes and prognostic factors of multimodality treatment for locally recurrent rectal cancer with curative intent.

Radical management of locally recurrent rectal cancer (LRRC) can lead to prolonged survival. This study aims to assess outcomes and identify prognostic factors for patients with LRRC treated using a multimodality treatment protocol. An analysis of a prospectively maintained institutional database of consecutive patients who underwent radical surgical resection for LRRC was performed. Potential prognostic factors were investigated using a Cox proportional hazards model. Ninety-eight patients were included in this study. A multimodality approach was taken in the majority, including preoperative chemoradiation (78%), intraoperative radiation therapy (47%) and adjuvant chemotherapy (41%). Extended resection was performed where required: bone resection (34%) and lateral pelvic sidewall dissection (31%). The rate of R0 resection was 66%. Estimated rates of 5-year overall survival (OS) and progression-free survival (PFS) were 41.8% (95% CI 32.5-53.7) and 22.5% (95% CI 15.3-33.1). On multivariate analysis, stage III disease at initial primary surgery, a positive margin at initial primary surgery, synchronous or previously resected oligometastases, a lateral or sacral invasive-type pelvic recurrence and the requirement for IORT all predicted for inferior PFS (p < 0.05). Eleven percent of patients subsequently underwent further pelvic surgery for pelvic re-recurrence and had an estimated 5-year OS rate of 54.5% (95% CI 29.0-100.0) from repeat surgery. Radical multimodality management of LRRC leads to prolonged survival in approximately 40% of patients. Those with sacral or lateral invasive-type recurrence or oligometastatic disease have inferior outcomes and further research is needed to optimise treatment for these groups.

Laparoscopic Sacrohysteropexy in a Woman at 12 Weeks' Gestation

Study ObjectiveTo demonstrate laparoscopic sacrohysteropexy for a case of uterine prolapse in a 12 weeks, 3 days pregnant woman. To our knowledge this is the first case of laparoscopic sacrohysteropexy performed at 12 weeks of gestation to be reported in literature. DesignA step-by-step explanation of the surgical procedure (Canadian Task Force classification III). SettingMaltepe University Hospital. PatientA 37-year-old pregnant woman. InterventionLaparoscopic sacrohysteropexy. Institutional Review Board ruled that approval was not required for this study. Measurements and Main ResultsUterine prolapse is very rare condition, manifesting in an estimated 10 000 to 15 000 pregnancies [1]. The management plan must be individualized, and the obstetrician should aware of possible complications, such as preterm labor, high incidence of abortion, cervical ulceration, and cervical dystocia. In general, bedrest, good genital hygiene, and pessary use is recommended. Alternatively, in cases where conservative solutions have failed, laparoscopic surgery in the pregnant patient may be considered. To date, only 1 case of laparoscopic promontohysteropexy at 10th weeks of gestation was reported by Pirtea et al [2]. A 37-year-old woman, at 12 weeks and 3 days of gestation, with stage III pelvic organ prolapse was referred to our clinic. Conservative management with pessary failed. The patient underwent laparoscopic sacrohysteropexy after written informed consent form was obtained. In exploration, uterine manipulation was difficult because of softness and large size of the uterus. First, the sigmoid colon was suspended at the abdominal wall to gain an adequate surgical field. The promontorium was dissected and the parietal peritoneum incised on the right pelvic side wall after ureter visualization. A polypropylene mesh was fixed to the cervix at the level of the uterosacral ligaments. The other edge of the mesh was fixed at the level of the promontory using the Uplift device (Neomedic International, Barcelona, Spain). Then, the peritoneum was sutured to cover the mesh. The patient was discharged 2 days after surgery. At the examination the pelvic floor was detected to be normal. The patient delivered a healthy baby weighing 3030 g by cesarean section at 38 weeks of gestation. The position of the mesh was controlled during surgery. There was no peritoneal fold detected on the cervical part of mesh; however, no adhesion was observed. ConclusionLaparoscopic sacrohysteropexy may be an alternative and safe approach, if conservative treatment fails, for pelvic organ prolapse during pregnancy.

A collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: A randomized clinical trial

ObjectiveTo evaluate the efficacy of a collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies. MethodsIn a multicenter, randomized, clinical trial, 164 women with pelvic lymphadenectomy were allocated either to bilateral pelvic application of two collagen-fibrin patches or no intervention. Main outcome was efficacy, defined as reduction of symptomatic lymphocele rate diagnosed within four weeks after surgery. Secondary outcomes were asymptomatic lymphoceles and subsequent interventions. Sample size was based on the assumption that application of a collagen-fibrin patch reduces the prevalence of symptomatic lymphoceles by at least 66%. The study was single-blinded, i.e., patients and primary outcome assessors, but not surgeons, were blinded to the treatment allocation. ResultsA total of 75 women were randomized to the intervention and 89 to the control group. All women received the allocated intervention. In total, 42 (27.4%) lymphoceles and 8 (5.2%) symptomatic lymphoceles were observed. Symptomatic lymphoceles were observed in 5/68 (7.4%) women in the intervention group and 3/85 (3.5%) women in the control group (p = 0.47). Asymptomatic lymphoceles were observed in 16 (23.5%) women in the intervention group compared to 18 (21.2%) in the control group (p = 0.85). In a multivariate logistic regression model, no independent risk factor for the development of a symptomatic lymphocele was ascertained. DiscussionIntraoperative application of collagen-fibrin patches to the pelvic side walls does not reduce the incidence of symptomatic lymphoceles in women with gynecologic malignancies undergoing pelvic lymphadenectomy.

20: Laparoscopic management of ovarian remnant syndrome

The purpose of this video is to review the diagnosis and risk factors of ovarian remnant syndrome and to demonstrate the laparoscopic excision of an ovarian remnant through two case presentations. Ovarian remnant syndrome is defined as the presence of a pelvic mass with residual ovarian tissue after previous oophorectomy. Predisposing factors that contribute to incomplete removal of ovarian tissue increase the risk of ovarian remnant syndrome and these include dense pelvic adhesions from multiple prior surgeries or endometriosis, anatomic variations, intraoperative bleeding, pelvic inflammatory disease, and poor surgical technique. Ovarian remnants are frequently located on the pelvic sidewall near the vaginal vault and may be encased in dense and fibrotic scar tissue, which makes surgical excision challenging. This video demonstrates advanced laparoscopic techniques for excision of an ovarian remnant through two case presentations. Ovarian remnant syndrome can be a diagnostic dilemma and surgical challenge. A high index of suspicion is essential for the diagnosis of ovarian remnant syndrome in patients with increased risk factors. Regardless of surgical approach, excision of an ovarian remnant is inherently associated with significant risks and intimate knowledge of pelvic and retroperitoneal anatomy is essential. Laparoscopic resection is considered safe and feasible, and can be a challenge even in the best of hands.

Extended pelvic side wall excision for locally advanced rectal cancers.

Extended pelvic side wall excision is a useful technique for treatment of recurrent or advanced rectal cancer involving sciatic notch and does not compromise the dissection of major pelvic vessels and vascular control.

Laparoscopic Complete Excision of a Recurrent Uterine Primitive Neuroectodermal Tumor Appearing as a Huge Metastatic Lymph Node

Introduction: Primitive neuroectodermal tumor (PNET) is a rare malignant neoplasm that can occur in the female genital tract.1 To date, only 64 cases of primary uterine PNET have been reported, but no conclusions have been reached concerning therapeutic management.2 Complete debulking surgery is generally recommended as the first step in the treatment of primary uterine PNET,3 and no recommendations exist for treatment of recurrent PNET. This video illustrates a case of recurrent uterine PNET for which laparoscopic complete resection was performed. Materials and Methods: A 51-year-old woman underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy, and omentectomy for a presumed stage IA endometrial carcinoma, which was determined upon postoperative histochemical examination to be a PNET of the uterine corpus. Adjuvant chemotherapy (three courses of etoposide and cisplatin) was performed. Two months later, multiple lymph node metastases were detected, and severe right leg edema and pain were identified secondary to an 8-cm metastatic lymph node at the right pelvic sidewall. A laparoscopic lymph node excision was recommended to improve the patient's quality of life (QOL). The video shows the operative procedure used to perform the lymphadenectomy with removal of the huge metastatic lymph node that was compressing the external iliac vein. Results: Complete lymph node excision was achieved. The operation took 517 min with an estimated blood loss of 830 mL. Blood transfusion was not required. The right leg edema and pain resolved completely, and no complication ensued. Two months later, there has been no adjuvant chemotherapy or radiotherapy, and there has been no sign of recurrence. Conclusion: Laparoscopic complete excision of recurrent uterine PNET is technically feasible and can improve the patient's QOL. No competing financial interests exist. Runtime of video: 6 mins 3 secs

Evaluation of a Spray-type, Novel Dextrin Hydrogel Adhesion Barrier Under Laparoscopic Conditions in a Porcine Uterine Horn Adhesion Model

Study ObjectiveTo establish a porcine uterine horn adhesion model that mimicked laparoscopic procedures and use it to investigate the effect of a spray-type, novel dextrin hydrogel adhesion barrier (AdSpray; Terumo Corporation, Tokyo, Japan) on postsurgical adhesions. DesignA single-blind randomized controlled trial (Canadian Task Force Classification I). SettingA Certified animal research facility. SubjectsSixteen female pigs. InterventionsAll animals underwent laparoscopically assisted adhesion-inducing surgery. The uterine horns and the peritoneum of the pelvic sidewall were injured. In the experimental group, AdSpray was applied to the injured site, and the handling of the sprayer was assessed. At 28 ± 1 days after surgery, animals were sacrificed, and adhesions at the injured site were evaluated. Uterine horn suture sites were examined under a light microscope to assess healing of the incised wound, the inflammatory reaction, abscess, and the foreign body reaction to the surgical suture. Measurements and Main ResultsThe control group showed severe adhesions over the entire surface interface at the uterine horn suture sites and peritoneal resection site. Compared with the control treatment, AdSpray exhibited a higher percentage of adhesion-free sites (p < .001) and reduced the total adhesion score (p < .001). In the AdSpray group, no inflammation or abscess formation was observed on histopathological examination, and ideal healing of the suture sites was confirmed in all cases. ConclusionBased on the results of the present study, the novel dextrin hydrogel shows excellent adhesion prevention and can be easily applied during laparoscopy using a dedicated sprayer.

508 - A Refined Method for Laparoscopic Pelvic Lymphadenectomy in Gynecologic Cancers Using the “Lateral Approach Technique”

The following video clip demonstrates a refined method for laparoscopic pelvic lymphadenectomy in gynecologic malignancies using the “lateral approach technique”. Laparoscopic staging surgery in gynecologic malignancies is safe and feasible. Pelvic lymphadenectomy is a crucial procedure for the surgical staging. This video introduces a novel procedure for safe and simple laparoscopic pelvic lymphadenectomy using the “lateral approach technique”. The procedure was initiated incising the peritoneum over the proximal left common iliac artery. The key to this technique is lateral approach along the pelvic side wall. Lymphatic tissue was dissected from pelvic floor muscles. This method makes it possible to minimizing bleeding from microvessels of the lymph node. Perform the dissection on the external iliac vessels the same way on the pelvic wall. The nodal tissue is retrieved in an impermeable sac. The described refined procedure would be sufficient and convenient for laparoscopic pelvic lymphadenectomy in gynecologic malignancies.

276 - Complete Endometriosis Excision Surgery: Goals and Basic Principles

We are presenting the surgical procedures involved in an endometriosis excision surgery. We prefer the use of conventional laparoscopy while performing endometriosis excision. This video will teach the dissection techniques utilized while excising endometriosis from pelvic side wall, posterior cut-de sac, right diaphragm and other basic procedures involved like appendectomy, chromopertubation and oophoropexy. We routinely perform these procedures with every endometriosis excision surgery, in order to provide symptom relief to the patient and prevent recurrence.The principles of traction, countertraction, alternate use of energy application and blunt dissection are highlighted.

214 - Laparoscopic Hysterectomy with Extended Peritonectomy for Endometriosis

This video demonstrates technique for performing a bilateral pelvic sidewall peritonectomy as part of a total laparoscopic hysterectomy, in the setting of extensive stage 1 endometriosis. The patient is a 42 year old G2P1 with a history of multiple ablative surgeries for endometriosis and pelvic pain. She has persistent dysmennoreah and is seeking definitive treatment.

Ovarialkarzinom: Komplettresektion trotz Beckenwandinfiltration möglich

Nishikimi K et al. Complete resection of locally advanced ovarian carcinoma fixed to the pelvic sidewall and involving external and internal iliac vessels. Gynecol Oncol 2017; 146: 436 – 437

Re-irradiation of cervical and endometrial cancer.

Re-irradiation historically has been associated with unacceptable toxicity and limited benefit. Recent advances in radiotherapy can change the treatment paradigm to provide new salvage treatments for recurrences of cervical and endometrial cancer. Image-guided brachytherapy is an effective method for salvaging central pelvic recurrence, although it has resulted in 20-25% severe late toxicity. Pelvic sidewall disease is not accessible to brachytherapy, so a combined modality approach with radical surgery and intraoperative radiotherapy is an alternative approach. Stereotactic body radiotherapy (SBRT) now provides the option of radical re-irradiation with local control rates of 50-80% and a low incidence of severe late complications. Initial outcomes using SBRT and image-guided brachytherapy for re-irradiation of gynaecological cancer are encouraging. There has been good local control and acceptable toxicity. Further, large-scale studies are required to define optimal target doses and OAR limits.

Super-radical hysterectomy for recurrent cervical cancer

BackgroundRecurrent cervical cancer with the pelvic side wall invasion has a deleterious effect on prognosis if there is no alternative method to achieve local tumor control [1, 2]. For the surgical treatment, super-radical hysterectomy has been introduced by Ryukichi Mibayashi in 1941 [3, 4]. However, its feasibility and safety is still on debate because of a lack of reproducibility and high level of surgical techniques. Thus, we showed the surgical procedure of super-radical hysterectomy for recurrent cervical cancer. VideoA 40 year-old woman visited after diagnosis of the pelvic recurrence, who received concurrent chemoradiation before 13 months due to stage IIB cervical cancer. Preoperative examination showed tumor invasion to upper third of the vagina, the right distal ureter and urethra, the posterior bladder wall and the right pelvic wall. Thus, we performed anterior pelvic exenteration with super-radical hysterectomy for removing the right pelvic side wall tumors. First, we ligated the right superior gluteal vessels, and then ligated the right internal iliac vessels. Second, we ligated the right inferior gluteal vessels, and subsequently the right internal pudendal vessels. Third, we resected her genitourinary tract with the right internal iliac vessels around the pelvic floor completely. ResultsThe procedure time was 160 minutes, and she underwent subsequent procedures including ileal conduit and omental J flap. She was discharged after 2 weeks without complications. ConclusionSuper-radical hysterectomy can be considered to be feasible and safe through the step-wise ligation of the internal iliac vessels for recurrent cervical cancer with the pelvic side wall invasion.

Robotic Resection of a Symptomatic Parasitic Leiomyoma From the Obturator Fossa

Study ObjectiveTo demonstrate a technique for robotically resecting a parasitic leiomyoma from the obturator fossa. DesignCase report and a step-by-step video demonstration of resection of a symptomatic parasitic leiomyoma (Canadian Task Force classification III). SettingTertiary referral center in New Haven, Connecticut. InterventionsThis 48-year-old Caucasian female had undergone a previous total abdominal hysterectomy for uterine leiomyomas. She presented to her primary care provider with lower back pain radiating to the right groin and with a burning sensation on the medial aspect of the inner thigh. She denied any decrease in leg muscle strength. Pelvic magnetic resonance imaging revealed a 3.3-cm mass in the obturator fossa compressing the obturator nerve. She was subsequently referred to gynecologic oncology for resection of the mass, and was brought to the operating room for robotic resection. Once retroperitoneum on the right pelvic sidewall was explored, ureterolysis was performed. The external iliac artery and vein were then mobilized medially to access the obturator fossa. The mass was visualized at the sidewall. Safe resection of the obturator fossa mass requires identification of the obturator nerve. The specimen was resected off the right pelvic sidewall with traction-countertraction, gentle wiping, and grasping-tenting techniques. It was then placed in a laparoscopic bag and removed from the peritoneal cavity in a contained manner. The procedure was performed without any complications. The patient had an uneventful postoperative course and was discharged to home on postoperative day 0. Pathology revealed a benign leiomyoma. The patient was symptom-free at her 4-week postoperative visit. ConclusionRobotic resection of a symptomatic retroperitoneal mass in the obturator fossa was successfully performed, with resulting resolution of obturator neuropathy. Parasitic leiomyomas should be considered in the differential diagnosis for a patient presenting with an intraperitoneal or retroperitoneal mass with a history of previous surgery for leiomyomas.

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.