Retroperitoneal Dissection Research Articles

VS 03 - BN Laparoscopic Excision of Aortic Schwannoma

Abstract Background This video presentation describes a laparoscopic approach to the excision of a large retroperitoneal cyst in a 39 year old female presenting with generalised abdominal pain. The patient had a background of Type 2 Diabetes, as well as a laparoscopic hysterectomy. Method The patient presented acutely with the above symptoms. CT and MRI both confirmed a large retroperitoneal cyst measuring 8x9cm. EUS was performed showed a thin walled cyst and a normal pancreas. FNA cytology was benign, hydatid serology was negative Results MDT decision was to go ahead with formal surgical resection. Laparoscopic excision of the cyst was performed, demonstrating that the pancreas was displaced anteriorly, with the coeliac axis displaced to the right. The cyst did not involve the pancreas or adrenal gland. Post operative histology found the cyst to be an aortic schwannoma. Conclusion This video demonstrates the complex retroperitoneal dissection that can be performed laparoscopically. The patient was discharged on post op day 8 with surveillance follow up

Regional Differences in Stage III Nonseminoma Germ Cell Tumor Patients Across SEER Registries

PurposeWe investigated regional differences in patients with stage III nonseminoma germ cell tumor (NSGCT). Specifically, we investigated differences in baseline patient, tumor characteristics and treatment characteristics, as well as cancer-specific mortality (CSM) across different regions of the United States. MethodsUsing the Surveillance, Epidemiology, and End Results (SEER) database (2004-2018), patient (age, race/ethnicity), tumor (International Germ Cell Cancer Collaborative Group [IGCCCG] prognostic groups) and treatment (systemic therapy and retroperitoneal lymph dissection [RPLND] status) characteristics were tabulated for stage III NSGCT patients, according to 12 SEER registries representing different geographic regions. Multinomial regression models and multivariable Cox regression models testing for cancer-specific mortality (CSM) were used. ResultsIn 3,174 stage III NSGCT patients, registry-specific patient counts ranged from 51 (1.5%) to 1630 (51.3%). Differences across registries existed for age (12%-31% for age 40+), race/ethnicity (5%-73% for others than non-Hispanic whites), IGCCCG prognostic groups (24%-43% vs. 14-24% vs. 3%-20%, in respectively poor vs. intermediate vs. good prognosis), systemic therapy (87%-96%) and RPLND status (12%-35%). After adjustment, clinically meaningful inter-registry differences remained for systemic therapy (84%-97%) and RPLND (11%-32%). Unadjusted 5-year CSM rates ranged from 7.1% to 23.3%. Finally in multivariable analyses addressing CSM, 2 registries exhibited more favorable outcomes than SEER registry of reference (SEER Registry 12): SEER Registry 4 (Hazard Ratio (HR): 0.36) and SEER Registry 9 (HR: 0.64; both P = .004). ConclusionWe identified important regional differences in patient, tumor and treatment characteristics, as well as CSM which may be indicative of regional differences in quality of care or expertise in stage III NGSCT management.

VNOTES surgical staging for endometrial carcinoma in overweight patients: a case series.

The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer. Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6kg/m2. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised. The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation. vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.

A case of left testicular artery with high origin passing through a left renal vein fenestration.

Fenestrations of are extremely rare in the venous system, especially renal veins. This paper aims to present a case of left renal vein fenestration where a high origin testicular artery passes through it. Materials and Methods The variation was observed incidentally in a 74-year-old Caucasian male cadaver during routine retroperitoneal dissections for second year medical students. A fenestration in the mid portion of the left renal vein was observed. The length and height of the fenestration was 23 and 3.6 millimeters, respectively. The left testicular artery passed through the fenestration and followed a normal course distal to the fenestration. Posterior to the left renal vein, the testicular artery originated from the lateral aspect of abdominal aorta, just caudal to the left renal artery. On the right side, the testicular artery had a similar high origin, and two renal arteries were present. No venous variations were observed on the right side. The long course of the left renal vein is a factor of preference for donor kidney selection. Uncommon variations of the left renal veins, such as fenestrations, might result in a change in surgical technique and would put the left donor kidney at risk of prolonged anastomosis time and lower survival rates.

Increase in robot assisted operating room efficiency: A quality improvement study

Pyeloplasties are time-sensitive, and the most common robot assisted intervention performed in pediatric urology. Early intervention is intended to avoid permanent loss of renal function with negative long-term effects if surgery is delayed when indicated. A need to increase capacity has become a premium value in patient care. Our aim was to reduce operative time, providing value by reducing total robotic console time in robot assisted pyeloplasty (RP) cases. We hypothesized that process improvement and supply management during RP leads to a significant reduction in operative time. Intraoperative surgical workflow was reviewed and routine tasks performed during the various sections were selected with the goal of reducing Operating room inactivity. We focused on robotic arm activity, and total operative time to assess our outcomes. Our intervention was to standardize an OR staff task list, a priori supply inventory procurement for each anticipated major step in the case, confirmed prior to each major step. Baseline RP duration data for a single Pediatric Urologist were identified and recorded before any interventions. A clinical standard work (CSW) was developed based on optimization of equipment/supplies for the RP procedure, compartmentalized into the 8 key steps for RP. These major steps included: patient positioning, docking, retroperitoneal and ureteral dissection, hitch stitch, pyelotomy, stent placement, and anastomosis. Balancing measures included percentage trainee console use, preparatory time, and OR block start/end time. Baseline data for RP cases performed between 11/2020 and 2/2022 were automatically extracted from charts and analyzed using AdaptX (Seattle, WA). Post-intervention was between 3/2022 to 3/2023. Mann-WhitneyU was used for continuous variables for non-parametric distribution. 37 patients underwent RP during the study period. 15 cases were performed prior to intervention and 22 post intervention Total console time prior to intervention was 152 vs 109min after intervention (p=0.0002). Dual instrument inactivity was reduced from 13.1% to 7.1% (p<0.0001). Dual consoles were used in 40% vs ∼69% pre-vs post-intervention, respectively (p=0.5000). No difference in patient age distribution between groups was seen (p=0.1498). Trainee operative time did not differ statistically pre- and post-intervention (63.0 vs 48.6%, p=0.0871). Decreasing surgical lapses and standardizing intraoperative tasks can result in more efficient case completion, potentially increasing OR capacity.

Oncological outcomes of retroperitoneal node dissection for residual masses after chemotherapy in germ cell tumor. Retrospective analysis of 15 years

Oncological outcomes of retroperitoneal node dissection for residual masses after chemotherapy in germ cell tumor. Retrospective analysis of 15 years

Treatment results of Para-Testicular Rhabdomyosarcoma (PT-RMS) using radiation as an alternative to retro-peritoneal nodal dissection: A single Institution experience.

Para-testicular Rhabdomyosarcoma (PT-RMS) has a favorable treatment outcome adopting multidisciplinary management; resection, namely high inguinal orchiectomy ± retro-peritoneal lymph node dissection (RPLND) followed by standard or intensive chemotherapy ± adjuvant radiation therapy. This is a retrospective study including all patients with pathologically proven PT-RMS, presented to the National Cancer Institute, Cairo University, during the period from 2005 to 2020. Endpoints included overall survival, disease free survival and patterns of failure of different treatment modalities. Forty one patients were identified. Median age in our cohort was 15 years (range: 2-54 years). After a median follow up of 26 months (range, 3-75 months) ,two and five years OS were 100% and 91.7% respectively and median survival was not reached. Patients who underwent retro-peritoneal nodal dissection had a 5-year DFS rate of 100% versus 73% for those who received radiation to para-aortic nodes (p = 0.185). Limitations include retrospective nature and deviation from COG protocol. This study shows promising results suggesting that less aggressive local treatment modalities including radiation to para-aortic chain could be an option in PT-RMS, given the excellent results of this subtype. However further validation in a prospective study is warranted.

Letter to the Editor : Classifying the Anatomical Location of the Ureter after Retroperitoneal Dissection.

Letter to the Editor : Classifying the Anatomical Location of the Ureter after Retroperitoneal Dissection.

Risk of Injury to Retroperitoneal Structures in Prone and Lateral Decubitus Transpsoas Approaches to Lumbar Interbody Fusion: A Pilot Cadaveric Anatomical Study.

Introduction The retroperitoneal approach for lateral lumbar interbody fusion (LLIF) originally described an initial posterolateral fascial incision enabling finger dissection from behind the peritoneum and guidance of instruments through a second direct-lateral fascial incision. It has since become common for single direct-lateral incisional access to the retroperitoneum. This study attempted to quantify the distance of the peritoneum from posterior landmarks in the space, assess the risk of peritoneal violation in each access trajectory (i.e., posterolateral versus direct lateral retroperitoneal dissection), and determine whether there are differences based on patient position (prone versus lateral decubitus). Methods In three prone cadaveric torsos, Steinman pins were percutaneously placed mid-disc at each level L2-5 bilaterally (for a total of 18 prone approaches). Open dissections exposed the retroperitoneum including the quadratus lumborum and psoas muscles, maintaining the natural reflection of the peritoneum. Visual assessment qualified whether any pin violated any retroperitoneal structure. Distance from the anterior border of the quadratus lumborum to the posterior-most reflection of the peritoneum was measured. For comparison, three additional torsos were positioned in lateral decubitus, and the above steps were repeated, only unilaterally (for a total of nine lateral decubitus approaches). Results In prone, no pin violated the peritoneum; three (3/18 total approaches) violated the kidney, all at L2-3 (3/6 approaches at L2-3). In lateral decubitus, all three L2-3 pins violated the kidney (3/3 approaches at L2-3); five of the six remaining pins from L3-5 violated the peritoneum (totaling eight violations in the nine total approaches). The incidence of any violation was significantly greater in lateral decubitus vs. prone (8/9 vs. 3/18, p=0.0006). The structure at risk (kidney vs. peritoneum) was significantly associated with disc level (p=0.0041): all kidney violations occurred at L2-3 and all peritoneal violations occurred at L3-4 or L4-5. Distance from the quadratus lumborum to the posterior-most reflection of the peritoneum averaged 8.7 cm (range: 6-10) in prone, and 2.9 cm (range: 2.5-3.2) in lateral decubitus (p=0.0129). Conclusion A cadaveric study of retroperitoneal anatomy demonstrates that there is an increased distance from the quadratus lumborum to the peritoneum in prone versus lateral decubitus and that the trajectory of approach to the lumbar discs risks violation of the peritoneum more frequently when accessing directly laterally versus posterolaterally. In either approach, care should be taken to identify and release the peritoneal reflection to create a safe passage to the lumbar discs.

Retroperitoneal-first dissection approach at the dorsal space for a huge serous cystic neoplasm of the pancreatic tail: a case report

BackgroundLarge tumors of serous cystic adenomas in the pancreatic body-to-tail severely compress the surrounding organs and retroperitoneal space.Case presentationWe present a unique surgical challenge for distal pancreatectomy (DP). We present the case of a patient who had a massive mass lesion measuring more than 20 cm in size that had been misdiagnosed as a retroperitoneal tumor by the previous hospital. However, an expert radiologist at our institute diagnosed serous cystadenoma of the pancreas based on imaging characteristics. We decided to perform retroperitoneal space first dissection using a small incision because we were concerned about tumor infiltration or compressive adhesions in important retroperitoneal vessels. We safely attempted distal pancreatectomy by limiting the laparotomy incision step-by-step while securing the main vascular injury of the retroperitoneum. In addition to the ordinary cooperation with urological surgeons, this technique is referred to by the concept of retroperitoneal procedures for minimally invasive surgery in urology.ConclusionsThis approach is useful for lifting resected specimens by prior and wide retroperitoneal dissection, which may lead to safety and the prevention of unexpected vascular injury.

Primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in left colonic and rectal cancer resections - the first Russian experience

To develop and describe a technique of primary retroperitoneal approach for vessel-sparing D3-lymph node dissection in the left colon and rectal cancer surgery; to evaluate the short-term results of the first series of patients treated with a new minimally invasive method. The first 10 patients with adenocarcinoma of the left colon and rectum, who underwent surgical treatment using the retroperitoneal approach with vessel-sparing D3 lymph node dissection, were included in the study. The primary retroperitoneal approach involved mobilization of the left side of the colon, D3 lymph node dissection with skeletonization of inferior mesenteric artery (IMA) and selective ligation of afferent vessels from retroperitoneal space using SILS access system at the first steps of surgery. Intersection of visceral and parietal peritoneum, as well as intersection of mesentery within the bowel resection borders was performed laparoscopically. Surgical specimen was removed through retroperitoneal access incision. Duration of retroperitoneal stage with lymph node dissection was 100 min (70.0-115.0). There were 28.5 (22-37) regional lymph nodes removed during vessel-sparing D3 lymph node dissection with IMA skeletalization, 3 (1-4) metastatic regional lymph nodes and 3.5 (2-5) apical nodes. In 4 out of 10 patients, we damaged visceral peritoneum during retroperitoneal dissection. Two patients developed Clavien-Dindo grade 1-2 complications. Mean postoperative hospital stay was 8 days (5-12). We developed retroperitoneal vessel-sparing D3 lymph node dissection for the treatment of left colon and rectal cancer. Initial results demonstrated safety and feasibility of this approach.

Laparoscopic retroperitoneal lymph-node dissection in metastatic nonseminomatous germ-cell tumors.

To support laparoscopic post-chemotherapy retroperitoneal lymph-node dissection (L-PC-RPLND) as a potential new standard, we report on a large dataset of patients systematically undergoing L-PC-RPLND. Patients with unilateral residual mass (≥1cm), normalized markers, limited encasement (<30%) of gross retroperitoneal vessels underwent unilateral L-PC-RPLND with no adjuvant chemotherapy. Surgical performances, histology, hospital stay, complications within 30 days and follow-up visits were recorded. Multivariable linear and logistic regression models were used. Between February 2011 and January 2021, 151 consecutive patients underwent L-PC-RPLND. Median size of the residual mass was 25mm (interquartile range [IQR] 20-35mm). Overall median operative time was 208min (IQR 177-241) and was 51min longer (p-value <0.001) for right L-PC-RPLNDs. Eleven procedures were converted to open surgery. Median number of removed and positive nodes was 11 (IQR 8-16) and 1 (IQR 1-2), respectively. Mean hospital stay was 2 days (IQR 2-3). Nine complications (6%) occurred: two were Clavien-Dindo grade III. Definitive pathology revealed post-pubertal teratoma in 65.6%, fibro-necrotic tissue in 23.8%, teratoma with malignant somatic component in 6.6% and viable tumour in 4.0% patients. In multivariable linear regression models, fibro-necrotic tissue (32min, CI 8.5-55.5; p<0.01) and residual volume (1.05min, CI 0.24-1.85; p<0.01) achieved independent predictor status for longer operative time. All patients, but one, are alive and disease-free after a median follow-up of 22 months (IQR 10, 48). L-PC-RPLND, when adequately planned, is safe and effective for most patients with low to medium volume residual masses.

Isthmic retroperitoneal cerclage via vNOTES as a potential alternative to an abdominal cerclage: First technique description.

ObjectiveTo describe a new technique for performing an isthmic retroperitoneal cerclage via vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES). DesignStepwise explanation of the surgical technique using original video footage. This study was exempted from requiring hospital IRB. SettingDepartment of Obstetrics and Gynaecology, Imelda Hospital, Belgium. InterventionA circumferential vaginal incision is made around the cervix after infiltration of the tissue with local anaesthetic and adrenaline. The bladder is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. The rectum is deflected from the cervix up to the level of the isthmus but the peritoneum is not opened. A Gelpoint vPath (9.5 cm) (Applied Medical, Rancho Santa Margarita) is used as a vNOTES port. The inner ring of the Alexis is inserted into the retroperitoneal dissection space around the cervix, covering the bladder anteriorly and the rectum posteriorly. An insufflation stabilization bag (ISB) is connected to the Gelseal cap to minimize pressure fluctuations within the confines of the retroperitoneal operative space. The paracervical space is opened just inferior to the uterine artery. A paracervical tunnel is made from the anterior to the posterior retroperitoneal space just lateral to the cervix and just inferior to the uterine artery. This procedure is performed bilaterally. A vessel loop is inserted from anterior to posterior through the paracervical tunnel on each side of the cervix. The Gelseal cap is removed and an Ethibond-2 suture is tied to the vessel loop. The Gelseal cap is placed again. By pulling on the vessel loop, it is replaced by the Ethibond suture. The Ethibond suture is now tied endoscopically to complete the cerclage; alternatively the suture could be tied vaginally without endoscopic instruments to the surgeon's preference. The vNOTES port is removed and the vaginal mucosa is sutured to the cervix again using a resorbable suture. DiscussionAbdominal cerclage is the preferred approach to treat patients with refractory cervical insufficiency [1]. Over the last 20 years this technique increasingly gets performed laparoscopically with similar success rates [2]. The new transvaginal approach demonstrated in this video article may help reduce the invasivess even more by avoiding abdominal incisions and opening the peritoneum, while still benefiting from the vNOTES endoscopic visualization and minimally invasive instruments [3]. The cerclage is placed permanently at the level of the isthmus, similar to an abdominal cerclage. It is placed more cranially than a McDonald or Shirodkar cerclage and leaves no non-resorbable sutures in the vagina [4]. It can be an alternative to a conventional transvaginal cervicoisthmic cerclage [5,6] in patients with a narrow vagina and without uterine descensus. Following the guidelines of the IDEAL collaboration we present this technique to be peer reviewed in its early developmental phase before starting further studies [7]. ConclusionThis is a first feasibility and technique description report on performing a retroperitoneal isthmic cervical via vNOTES. This technique should be considered new, not to be performed on pregnant patients or outside of clinical trials, and only in carefully counselled patients.

Endoscopic full-thickness resection with retroperitoneal dissection for duodenal myogenic cyst with adjustable traction from an independently controlled snare

Video 1Endoscopic full thickness resection with retroperitoneal dissection for duodenal myogenic cyst with adjustable traction from an independently controlled snare.

Surgical Management of Ovarian Remnant Syndrome

Study Objective To provide a basic overview of the management of ovarian remnant syndrome by discussing evidence from case series and demonstrating advanced dissection techniques commonly required to surgically treat ovarian remnant syndrome. Design Surgical video with highlighted anatomy and narration. Setting Academic Tertiary Care Hospital. Patients or Participants Patients with a history of bilateral salpingo-oophorectomy found to have a pelvic mass and premenopausal hormone levels consistent with ovarian remnant syndrome. Interventions In this video, we provide an overview of surgical treatment for ovarian remnant syndrome. Ovarian remnant syndrome occurs when ovarian tissue is inadvertently left behind during salpingo-oophorectomy and can result in pain. We review the diagnostic workup for these patients using information from large case series. We then demonstrate advanced surgical dissection techniques required to successfully remove an ovarian remnant using two surgical cases. These techniques focus on safe ureterolysis, retroperitoneal dissection with identification of avascular spaces and their borders, as well as enterolysis. We highlight relevant anatomy to aid visualization of surgical planes. Measurements and Main Results N/A. Conclusion Ovarian remnant syndrome presents a surgical challenge. In order to successfully remove an ovarian remnant, surgeons must have a good understanding of surgical anatomy and advanced dissection techniques. To provide a basic overview of the management of ovarian remnant syndrome by discussing evidence from case series and demonstrating advanced dissection techniques commonly required to surgically treat ovarian remnant syndrome. Surgical video with highlighted anatomy and narration. Academic Tertiary Care Hospital. Patients with a history of bilateral salpingo-oophorectomy found to have a pelvic mass and premenopausal hormone levels consistent with ovarian remnant syndrome. In this video, we provide an overview of surgical treatment for ovarian remnant syndrome. Ovarian remnant syndrome occurs when ovarian tissue is inadvertently left behind during salpingo-oophorectomy and can result in pain. We review the diagnostic workup for these patients using information from large case series. We then demonstrate advanced surgical dissection techniques required to successfully remove an ovarian remnant using two surgical cases. These techniques focus on safe ureterolysis, retroperitoneal dissection with identification of avascular spaces and their borders, as well as enterolysis. We highlight relevant anatomy to aid visualization of surgical planes. N/A. Ovarian remnant syndrome presents a surgical challenge. In order to successfully remove an ovarian remnant, surgeons must have a good understanding of surgical anatomy and advanced dissection techniques.

8356 Robotic Surgery: Pelvic Mass Excision, Resection of Non-Communicating Uterine Horn, and Fulguration of Endometriosis

<h3>Study Objective</h3> To demonstrate surgical techniques for approaching an advanced case of endometriosis in a patient with a congenital uterine anomaly, large pelvic mass, and severe adhesive disease. <h3>Design</h3> A step-by-step explanation of the surgery. <h3>Setting</h3> Community Based Teaching Hospital, Operating Room. <h3>Patients or Participants</h3> 33-yo G0 with known unicornuate uterus with non-communicating uterine horn, dysmenorrhea, suspected endometriosis, infertility, congenital absence of right kidney. <h3>Interventions</h3> Chromotubation was first performed to evaluate if the patient had patent fallopian tubes. The pelvic mass was then decompressed and drained revealing multiple right ovarian cysts. Anatomical landmarks were identified with a retroperitoneal dissection and extensive lysis of adhesions. The bladder was backfilled intermittently to help identify surgical planes. A Keith needle was temporarily placed in the abdomen to elevate the pelvic mass and aid in visualization. The pelvic mass and non-communicating uterine horn were resected. Hemostasis was achieved with electrocautery and suturing. Endometriotic implants in the pelvis and diaphragm were fulgurated and an appendectomy was performed due to extensive damage from endometriosis. All specimens were placed in a bag and removed through the umbilical port site. Post-operatively, the patient was started on progesterone therapy. <h3>Measurements and Main Results</h3> Successful completion of surgery, no complications, the patient reported improvement in her symptoms. <h3>Conclusion</h3> When dealing with severe adhesive disease, abnormal anatomy, and limited space due to a pelvic mass it is key to approach these cases in a stepwise fashion. Visualization can be optimized via temporary measures such as using a Keith needle. If irregular anatomy is noted, landmarks can be identified via the retroperitoneal dissection.

Robotic-Assisted Laparoscopic Excision of Deep Infiltrating Endometriosis with Concomitant Left Ureteroneocystostomy

<h3>Study Objective</h3> To describe the surgical techniques employed to effectively excise deep infiltrating endometriosis involving the ureters and to highlight the successful re-implantation of the left ureter. <h3>Design</h3> Video presentation. <h3>Setting</h3> Academic tertiary care center. <h3>Patients or Participants</h3> This is the case of a 45-year-old G1P1001 patient with a history of chronic pelvic pain and endometriosis. She underwent previous exploratory laparotomy due to endometriosis. Her symptoms however recurred and worsened to the point where she started experiencing left flank pain. A CT scan revealed moderate left hydroureteronephrosis to the level of the left adnexa. MRI findings confirmed the left ureter to be encased by pelvic endometriosis causing significant extrinsic compression. <h3>Interventions</h3> Intra-operatively, deep infiltrating endometriosis was noted involving the posterior cul-de-sac, bilateral uterosacral ligaments, with retroperitoneal fibrosis involving bilateral ureters. Retroperitoneal dissection was performed using a medial approach thus identifying the ureters bilaterally. Careful and extensive dissection was then carried out, excising the fibrotic endometriotic nodule from the ureters. The left hydroureter was transected at its most distal and narrowed portion by the urology team. The proximal end for re-implantation was then spatulated. The bladder was mobilized, and a tension free re-implantation was successfully completed after placing a double pig-tail stent in a retrograde fashion. A water-tight re-anastomosis was confirmed. <h3>Measurements and Main Results</h3> The patient recovered well from her procedure and had significant improvement in her pain symptoms when she was reviewed at her postoperative visit. <h3>Conclusion</h3> Despite its incessant, recalcitrant nature, endometriosis affecting the ureters can be effectively resected. Laparoscopic ureteroneocystostomy for ureteral endometriosis is safe, feasible, and can achieve good surgical outcomes leading to effective control of patient's symptoms as was noted in this case.

8136 Robotic Interval Debulking with Radical Hysterectomy and Partial Urinary Bladder Resection for Locally Advanced Uterine Carcinosarcoma

<h3>Study Objective</h3> Demonstrate an interval debulking where meticulous retroperitoneal dissection, ureterolysis and intentional cystotomy with ureteral stenting were performed robotically in a patient with large volume uterine carcinosarcoma to avoid pelvic exenteration. <h3>Design</h3> Demonstration of robotic radical hysterectomy, retroperitoneal dissection, ureterolysis, and intentional cystotomy with ureteral stenting. <h3>Setting</h3> Tertiary referral center in New Haven, Connecticut. <h3>Patients or Participants</h3> Surgical video case presentation. <h3>Interventions</h3> 47-year-old with locally advanced uterine carcinosarcoma underwent neoadjuvant chemotherapy with TAP (paclitaxel, doxorubicin, and cisplatin), followed by an interval debulking surgery. The uterus was enlarged with lower uterine segment tumor replacing the majority of the ectocervix. The posterior supratrigonal wall of the urinary bladder was extensively involved with the tumor. Extensive ureterolysis was performed from above the pelvic brim to the ureterovesical junctions in order to safely lateralize bilateral ureters. Tedious bladder dissection was performed to prevent thermal injury. A modified (Type B) radical hysterectomy was performed, sacrificing the bladder pillars, distal ureterosacral ligaments, and 2 cm of upper vagina. The posterior urinary bladder wall had clinically questionable residual tumor, therefore intentional cystotomy was performed to resect the involved segment. Six French, 24 cm double-J stents were placed to decrease the risk of ureteral fistula and stricture, given anticipation of postoperative pelvic radiation. The bladder was repaired in two layers. The patient was discharged home on postoperative day 2, and received adjuvant chemotherapy and vaginal brachytherapy, per tumor board recommendations. <h3>Measurements and Main Results</h3> N/A. <h3>Conclusion</h3> Locally advanced uterine carcinosarcoma can be managed on an individualized basis with neoadjuvant therapy followed by non-exenterative interval laparoscopic/robotic radical surgery, with emphasis on quality-of-life.

Laparoscopic Resection of Cesarean Scar Pregnancy at 11 Weeks Gestational Age

<h3>Study Objective</h3> To demonstrate a laparoscopic technique for resection of cesarean scar pregnancy (CSP) and revision of cesarean scar defect. <h3>Design</h3> We present a stepwise narrated demonstration of our technique of a resection of a CSP. <h3>Setting</h3> Referral Center in NY. <h3>Patients or Participants</h3> 33-year-old with cesarean scar pregnancy at 11 weeks gestational age, desiring fertility sparing treatment <h3>Interventions</h3> A retroperitoneal dissection is performed, and the uterine blood supply is isolated<b>.</b> Hemostatic control is achieved with the use of intrauterine vasopressin and temporary occlusion of the uterine blood supply. The bladder is carefully dissected from the lower uterine segment and cesarean scar pregnancy. Ultrasound guidance is used to assist in hysterotomy location for resection of the ectopic pregnancy. The myometrium is repaired with a 3-layer closure. Uterine ventrosuspension by plication of the round ligaments bilaterally results in anteversion of the previously sharply retroverted uterus, reducing tension on the repair. Hysteroscopy under laparoscopic visualization confirms repair of the scar defect. <h3>Measurements and Main Results</h3> Successful laparoscopic resection of a cesarean scar ectopic pregnancy and resection of scar defect with EBL of 250 mL. Patient discharged home postoperative day one. Normal appearing uterus on 3-month follow-up MRI with no residual cesarean scar defect and residual myometrial thickness of 1.6 cm. <h3>Conclusion</h3> Laparoscopic resection provides a means of addressing cesarean scar pregnancy at advanced gestational age while repairing the associated cesarean scar defect. Control of the uterine blood supply and mobilization of the bladder are critical aspects of the surgery. Intraoperative ultrasound and laparoscopic guided hysteroscopy can ensure full resection of the defect and achieve optimal repair. For the retroverted uterus, ventrosuspension may avoid tension on the repair to promote healing. For this patient, our technique resulted in no residual cesarean scar defect on follow-up imaging.

Ovarian Remnant Syndrome Versus Retroperitonealized Ovary: Preoperative Evaluation and Surgical Management

<h3>Study Objective</h3> Our objectives are to compare the definitions of ovarian remnant syndrome and retroperitonealized ovary, present a patient with each condition, describe the preoperative evaluation, and demonstrate the surgical management. <h3>Design</h3> Perioperative evaluation and laparoscopic excision of ovarian remnant syndrome and retroperitonealized ovary. <h3>Setting</h3> Tertiary care center. <h3>Patients or Participants</h3> Reproductive-aged women presenting with pelvic pain and a history of prior pelvic surgery subsequently diagnosed with ovarian remnant syndrome or retroperitonealized ovary. <h3>Interventions</h3> Minimally-invasive retroperitoneal dissection and excision of ovarian remnant or retroperitonealized ovary. <h3>Measurements and Main Results</h3> Ovarian remnant syndrome is the presence of ovarian tissue following an oophorectomy, and retroperitonealized ovary is the presence of ovarian tissue in the retroperitoneum. Patients with a history of pelvic surgery, particularly with extensive retroperitoneal dissection, are at risk for these conditions. Retroperitonealized ovary occurs most frequently following ovarian cystectomy, while ovarian remnant syndrome occurs after oophorectomy. Importantly, ovarian remnant syndrome can usually be anticipated during preoperative evaluation, while retroperitonealized ovary is encountered during the surgery. Patients typically present with chronic pelvic pain. The preoperative workup for patients with suspected retroperitonealized ovary or ovarian remnant syndrome includes a detailed patient history, thorough physical exam, and transvaginal ultrasound evaluation. A follicle-stimulating hormone and estradiol level can evaluate for ovarian function, while a clomiphene provocation test can be used if an ovarian mass is not initially visualized on imaging. Surgical excision is the recommended management option for both conditions. It involves dissection and removal of the ovary from the surrounding structures. In patients with endometriosis, the isolation and removal of the ovarian tissue is typically complicated by dense adhesions to the pelvic sidewall, ureter, and bowel. Complete surgical resection of the ovarian tissue is imperative, as patients are at risk for endometriosis and ovarian cancer. <h3>Conclusion</h3> Both ovarian remnant syndrome and retroperitonealized ovary are potential sequelae of prior pelvic surgery and require surgical resection.