Search

Objective: To evaluate the safety and feasibility of the new surgical robot HUGO robotic assisted surgery (RAS) in a series of gynecologic surgical procedures. Methods: Between March and October 2022, 138 patients treated at Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy were enrolled in the study. All patients suitable for a minimally‐invasive approach were prospectively included and divided into two groups: Group 1 (78 patients) made up of patients operated on for uterine and/or adnexal pathologies, and Group 2 (60 patients) made up of patients treated for pelvic organ prolapse. Results: In Group 1, median docking time (DT) was 5 min and median console time (CT) was 90 min. In two patients (2.6%) redocking was necessary. In two patients (2.6%), the surgeon continued the surgery laparoscopically. Intraoperative complications occurred in two surgeries (2.6%). In Group 2, median DT was 4 min and median CT was 134.5 min. In three patients (5%), redocking was necessary. In all patients, the surgery was successfully completed robotically without intraoperative complications. Conclusions: The present study demonstrates that the new HUGO RAS system for gynecologic surgery is safe with good results in terms of surgical efficacy and perioperative outcomes. Further studies are needed to investigate its use in other technical and surgical aspects. Synopsis: The new robotic system HUGO RAS is safe with good results in terms of surgical efficacy and perioperative outcomes. [ABSTRACT FROM AUTHOR]

Background: Premature ovarian failure may be a consequence of radiotherapy administered for the treatment of various female oncologic diseases. Before radiotherapy, fertility may be preserved through ovarian transposition (OT), which consists of moving the ovaries away from the radiation field. Objective: To ascertain all types of surgical techniques employed for OT, outline the endocrine and reproductive outcomes of each one, and discover if one works better than the others. Search strategy: The authors performed a systematic search of the English literature looking for all studies related to OT before radiotherapy published up to June 2023. Nine studies were included. Selection criteria: The eligible studies were assessed based on the presence of a description of the surgical technique employed for OT before pelvic radiotherapy and a report of the endocrine and reproductive outcomes. Data collection and analysis: Odds ratios (OR) with 95% confidence intervals were used to compare endocrine and reproductive outcomes The χ2 test was employed for the statistical analysis and a P value less than 0.05 was considered significant. Main results: A total of 323 female patients aged between 7 and 51 years—198 (61.3%) with non‐gynecologic cancer and 125 (38.7%) with gynecologic cancer—underwent OT, either bilateral (221, 68.4%) or unilateral (102, 31.6%), before radiotherapy. Essentially, two types of OT were employed: lateral and medial. A total of 71 (22%) patients underwent medial OT and 252 (78%) patients (127 with non‐gynecologic tumors and 125 with gynecologic tumors) had a lateral OT. The latter was used in a similar percentage of cases for gynecologic (50.4%) and non‐gynecologic (49.6%) tumors, whereas the medial approach was performed only for non‐gynecologic cancers (Hodgkin's lymphoma). The difference between medial OT and lateral OT was not significant regarding the preservation of endocrine function (OR 0.65, P = 0.120). However, midline OT worked better in terms of reproductive outcomes. In fact, the percentage of patients with pregnancy (49.2%) and live births (45%) associated with medial OT was significantly higher than that associated with lateral OT, 6.5% and 13.4%, respectively, and the difference between such data was statistically significant (OR 7.04, P = 0.001 and OR 5.29, P = 0.003, respectively). Conclusions: Ovarian transposition is an important method to preserve fertility before radiotherapy, considering the worldwide ongoing use of this treatment for various cancers arising in young women. The surgical method depends on the type of disease, but OT—especially medial OT when feasible—is effective in terms of ovarian function preservation and reproductive outcomes. Synopsis: The difference in endocrine function preservation between medial and lateral ovarian transposition was not significant, but midline ovarian transposition yielded better reproductive outcomes. [ABSTRACT FROM AUTHOR]

Uterus didelphys is a rare Müllerian anomaly, often diagnosed during menarche or in women with a personal history of infertility and/or recurrent pregnancy loss. Its association with other genitourinary anomalies is frequent and may determine the existence of established syndromes. This case report refers to a 13‐year‐old female patient diagnosed with OHVIRA syndrome (Obstructed Hemivagina with Ipsilateral Renal Agenesis), a condition wherein the presence of a didelphic uterus is associated with hemivagina obstruction and ipsilateral renal agenesis. The patient presented with cyclic pelvic pain, related to the presence of hematocolpos and hematometra, which persisted despite several surgical approaches, including vaginal septum excision and correction of cervical stenosis. The recurrence of the condition indicated exploratory laparotomy, revealing two hemi‐uteri and two uterine cervixes, with hematometra on the right. A subtotal hemihysterectomy was performed on the right. Post‐procedure, the patient developed with regular menstrual cycles and improvement of pelvic pain complaints. Given the limited prevalence and low index of suspicion, the potential requirement for surgical intervention and its potential impact on reproductive future, diagnosing and treating OHVIRA syndrome and other Müllerian anomalies poses notable challenges in clinical practice. Hence, sharing different therapeutic approaches of a rare diagnosis with the scientific community is of paramount importance to aid in early diagnosis and effective management of similar clinical cases. Synopsis: A case report of a patient with obstructed hemivagina with ipsilateral renal agenesis syndrome supports hemihysterectomy as a potential therapeutic approach in refractory cases. [ABSTRACT FROM AUTHOR]

Chronic, severe Crohn's disease in a young female patient can result in surgical complexity. The rarity of the presentation of intractable pelvic abscesses within this etiology with additional considerations given to fertility concerns and hence requirement for input from a multi‐disciplinary team makes this a vital case in building a consensus for evidence‐based surgical management. A 29‐year‐old nulliparous woman was referred to our tertiary centre for surgical management of Crohn's disease with known tubo‐ovarian abscess and abdominoperineal and abdominal wall sinuses. Her previous surgical history included 4 midline laparotomies, subtotal colectomy and proctectomy with stoma formation. The patient underwent egg collection to preserve fertility. This was followed by midline laparotomy and abdominoperineal resection, which involved a retrograde radical modified hysterectomy using the Hudson technique, alongside excision of the perineal sinus, with reconstruction of the perineal defect using an internal pudendal artery perforator gluteal fold flap, and in addition to excision and drainage of the abdominal wall abscess. Involvement was sought from gynecological oncology, colorectal, urology, plastics, stoma, fertility, microbiology, and gastroenterology teams, which enabled successful preservation of end organ function and improvement in patient psychological well‐being. This case is a paradigm of surgical challenge, requiring expert gynecological oncology techniques including a retroperitoneal approach, nerve and vessel sparing considerations alongside colorectal and urological procedures. Moreover, we believe that our blueprint for effective multi‐disciplinary practice will inform the future management of gynecological surgery. Therefore this report aims to contribute towards the optimum management of the gynecological sequelae of Crohn's disease. Synopsis: We detail the surgical management of a young female with tubo‐ovarian abscess complications of Crohn's disease and the evidence‐based management undertaken by our tertiary center. [ABSTRACT FROM AUTHOR]

Despite their general good health, an increasing proportion of elderly individuals require surgery due to an increase in average lifespan. However, because of their increased vulnerability, these patients need to be handled carefully to make sure that surgery does not cause more harm than good. Age‐related postoperative cognitive disorders (POCD) and postoperative delirium (POD), two serious consequences that are marked by adverse neuropsychologic alterations after surgery, are particularly dangerous for the elderly. In the context of gynecologic procedures, POCD and POD are examined in this narrative review. The main question is how to limit the rates of POCD and POD in older women undergoing gynecologic procedures by maximizing the risk–benefit balance. Three crucial endpoints are considered: (1) surgical procedures to lower the rates of POCD and POD, (2) anesthetic techniques to lessen the occurrence and (3) the identification of individuals at high risk for post‐surgery cognitive impairments. Risks associated with laparoscopic gynecologic procedures include the Trendelenburg posture and CO2 exposure during pneumoperitoneum, despite statistical similarities in POD and POCD frequency between laparoscopic and laparotomy techniques. Numerous risk factors are associated with surgical interventions, such as blood loss, length of operation, and position holding, all of which reduce the chance of complications when they are minimized. In order to emphasize the essential role that anesthesia and surgery play in patient care, anesthesiologists are vital in making sure that anesthesia is given as sparingly and quickly as feasible. In addition, people who are genetically predisposed to POCD may be more susceptible to the disorder. The significance of a thorough strategy combining surgical and anesthetic concerns is highlighted in this article, in order to maximize results for senior patients having gynecologic surgery. [ABSTRACT FROM AUTHOR]

Objective: To evaluate whether abdominal hot water pack application improves gastrointestinal motility following gynecological oncology surgery. Methods: The study was registered at ClinicalTrials.gov (NCT04833699). (https://clinicaltrials.gov/ct2/show/NCT04833699?cond=NCT04833699&draw=2&rank=1). In this randomized controlled trial, participants were randomly assigned (1:1) to the hot water pack group (standardized enhanced recovery protocols plus rubber water bag with a fluffy cover filled with boiled tap water [80°C] and placed on the abdomen at 3, 6, 9, and 12 h postoperatively for 30 min each time) or the control group (standardized enhanced recovery protocols). A subumbilical or supraumbilical vertical midline incision was made to perform staging surgery procedures, including hysterectomy, salpingo‐oophorectomy with retroperitoneal lymphadenectomy. The primary outcome was the time to first passage of flatus from the end of the staging procedure. Results: In total, 121 women were randomized to the control (n = 62) or hot water pack (n = 59) group. The use of an abdominal hot water pack significantly reduced the mean time to passing first flatus (25.2 ± 3.6 vs. 30.6 ± 3.9 h; hazard ratio [HR] = 4.4; 95% confidence interval [CI]: 2.8–7.1; P < 0.0001), mean time to first bowel movements (28.4 ± 4.0 vs. 34.4 ± 4.5 h; HR = 4.9; 95% CI: 3.0–7.9; P < 0.0001), mean time to first defecation (33.4 ± 4.9 vs. 41.0 ± 7.6 h; HR = 4.3; 95% CI: 2.1–6.8; P < 0.0001), and mean time to tolerating solid diet (2.1 ± 0.6 vs. 2.8 ± 1.0 days; HR = 4.4; 95% CI: 2.2–8.7; P < 0.0001) compared to the control group. The postoperative ileus incidence was significantly lower in the hot water pack group (3.4%) than the control group (16.1%) (P = 0.01). Conclusion: Abdominal hot water pack application improved gastrointestinal function recovery in women following surgical staging procedures for gynecological malignancy. Synopsis: An abdominal hot water pack significantly reduced postoperative ileus and corresponding medical costs; early hospital discharge was feasible. [ABSTRACT FROM AUTHOR]

Objective: To compare surgical outcomes in patients with benign diseases who underwent laparoscopically assisted vaginal hysterectomy (LAVH) to determine the association between surgical outcomes and resident participation in the gynecologic field. Methods: A single‐center retrospective study was conducted of patients diagnosed with benign gynecologic diseases who underwent LAVH between January 2010 and December 2015. Clinicopathologic characteristics and surgical outcomes were compared between the resident involvement and non‐involvement groups. The primary endpoint was the 30‐day postoperative morbidity. Observers were propensity matched for 17 covariates for resident involvement or non‐involvement. Results: Of the 683 patients involved in the study, 165 underwent LAVH with resident involvement and 518 underwent surgery without resident involvement. After propensity score matching (157 observations), 30‐day postoperative morbidity occurred in 6 (3.8%) and 4 (2.5%) patients in the resident involvement and non‐involvement groups, respectively (P = 0.501). The length of hospital stay differed significantly between the two groups: 5 days in the resident involvement group and 4 days in the non‐involvement group (P < 0.001). On multivariate analysis, Charlson Comorbidity Index >2 (odds ratio [OR] 8.01, 95% confidence interval [CI] 2.68–23.96; P < 0.001), operative time (OR 1.02, 95% CI 1.01–1.03; P < 0.001), and estimated blood loss (OR 1.00, 95% CI 1.00–1.00; P < 0.001) were significantly associated with 30‐day morbidity, but resident involvement was not statistically significant. Conclusion: There was no significant difference in the 30‐day morbidity rate when residents participated in LAVH. These findings suggest that resident participation in LAVH may be a viable approach to ensure both residency education and patient safety. Synopsis: Trainee involvement in hysterectomy. [ABSTRACT FROM AUTHOR]

Objective: To evaluate intraoperative factors predicting appendiceal pathology during gynecologic oncology surgery for suspected mucinous ovarian neoplasms. Methods: We conducted a retrospective study on 225 patients with mucinous ovarian neoplasms who underwent surgery for an adnexal mass with concurrent appendectomy between 2000 and 2018. Regression analyses were used to evaluate intraoperative factors, such as frozen section of the ovarian mass and surgeon's impression of the appendix in predicting appendiceal pathology. Results: Most patients (77.8%) had a normal appendix on final pathology. Abnormal appendix cases (n = 26) included: metastasis from high‐grade adenocarcinoma of the ovary (n = 1), neuroendocrine tumor of the appendix (n = 4), and low‐grade appendiceal mucinous neoplasms (n = 26; 23 associated with a mucinous ovarian adenocarcinoma, 2 with a benign mucinous ovarian cystadenoma, and 1 with a borderline mucinous ovarian tumor). Combining normal intraoperative appearance of the appendix with benign or borderline frozen section yielded a negative predictive value of 85.1%, with 14.9% of patients being misclassified, and 6.0% having a neuroendocrine tumor or low‐grade appendiceal neoplasm. Conclusion: Benign or borderline frozen section of an ovarian mucinous neoplasm and normal appearing appendix have limited predictive value for appendiceal pathology. Appendectomy with removal of the mesoappendix should be considered in all cases of mucinous ovarian neoplasm, regardless of intraoperative findings. Synopsis: The false‐negative rate for normal appearing appendix with benign/borderline ovarian frozen section is 6% and as high as 15% with reassuring intraoperative factors. [ABSTRACT FROM AUTHOR]

Synopsis: Uteroenteric fistulae in the setting of degenerating leiomyomas may present with small bowel obstruction and require multidisciplinary surgical management to perform fertility‐sparing myomectomy. [ABSTRACT FROM AUTHOR]

Synopsis: Reproductive surgery is a distinct form of gynecologic surgery. Instead of eradicating the disease, reproductive surgery is intended to maintain or treat fertility. [ABSTRACT FROM AUTHOR]