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Objective. There is scarce evidence available about the benefit of combining technetium (Tc-99(m)) and indocyanine green (ICG) for sentinel lymph node (SLN) biopsy in endometrial cancer. The aim of this study was to compare the overall and bilateral pelvic detection rates of SLNs in two retrospective cohorts: ICG exdusive vs. combined ICG+ Tc-99(m). Methods. The COMBITEC study (COMBined ICG and Technetium for SLN detection in Endometrial Cancer) consisted of a multicentre retrospective study (February 2015 June 2020) including patients diagnosed with endometrial atypical hyperplasia or early-stage endometrial carcinoma who underwent SLN biopsy by cervical injection of ICG with or without Tc-99(m) in four different referral centers in Spain. Results. A total of 180 patients were included, 51% (n = 92) in ICG group and 49% (n 88) in ICG+Tc-99(m) group. Eighty-seven percent of the patients presented endometrioid histology, and over 99% of the procedures were performed by a minimally invasive approach. Both groups were comparable regarding their basal characteristics, except for a higher body mass index in ICG+Tc-99(m) group and a bigger proportion of robotic-assisted procedures in ICG group. Overall detection rate was 92.8% without significant differences between groups (ICG: 94.6% vs ICG+Tc-99(m): 90.9%, p = .34). No significant differences were observed neither in bilateral pelvic nor aortic mapping rate. When Tc-99(m) was used, surgical procedures were significantly longer. In 7.3% of mapped patients, at least one positive SLN was found (ICG: 10.3% vs ICG+Tc-99(m): 3.9%, p = .109). Empty node packet rates and number of SLNs retrieved per patient were also similar between cohorts. Conclusion. Combining preoperative Tc-99(m) to intraoperative ICG did not improve SLN detection in endometrial cancer, but resulted in longer procedures. (C) 2021 Elsevier Inc. All rights reserved.

ObjectiveIt has been suggested that the manipulation of neoplastic tissue during hysteroscopy may lead to dissemination of tumor cells into the peritoneal cavity and worsen prognosis and overall survival. The goal of this study was to assess the oncological safety comparing hysteroscopy to Pipelle blind biopsy in the presurgical diagnosis of patients with endometrial cancer.MethodsWe performed a retrospective multicentric study among patients who had received primary surgical treatment for endometrial cancer. A multivariate statistical analysis model was used to compare relapse and survival rates in patients who had been evaluated preoperatively either by hysteroscopy or Pipelle biopsy. The relapse rate, disease-free survival, and overall survival were assessed as the main outcomes. The histological type, tumor size, myometrial invasion, International Federation of Gynecology and Obstetrics (FIGO) stage, surgical approach, use of a uterine manipulator, and adjuvant treatment were also included in the analysis.ResultsA total of 1731 women from 15 centers were included: 1044 in the hysteroscopy group and 687 in the Pipelle sampling group. 225 patients relapsed during the 10 year follow-up period: 139 (13.3%) in the hysteroscopy group and 86 (12.4%) in the Pipelle sampling group. There is no evidence of an association between the use of hysteroscopy as a diagnostic method and relapse rate (HR 1.24, 95% CI 0.92 to 1.66; p=0.16), lower disease-free survival (HR 1.23, 95% CI 0.92 to 1.66; p=0.15), or overall survival (HR 0.95, 95% CI 0.70 to 1.29; p=0.76).ConclusionHysteroscopy is a safe diagnostic method for patients with endometrial cancer with no impact on oncological outcomes when compared with sampling by Pipelle.

The objective of the present study was to define and validate an anastomotic leak prognostic score based on previously described and reported anastomotic leak risk factors (OVA-LEAK: https://n9.cl/ova-leakscore) and to establish if the use of OVA-LEAK score is better than clinical criteria (surgeon's choice) selecting anastomosis to be protected with a diverting ileostomy.This is a retrospective, multicentre cohort study that included patients who underwent cytoreductive surgery for primary advanced or relapsed ovarian cancer with colorectal resection and anastomosis between January 2011 and June 2021. Data from patients already included in the previous predictive model were not considered in the present analysis. To validate the performance of our logistic regression model, we used the OVA-LEAK formula (Annex I: https://n9.cl/ova-leakscore) for estimating leakage probabilities in a new independent cohort. Then, receiver operating characteristic (ROC) analysis was performed and area under the curve (AUC) was used to measure the performance of the model. Additionally, the Brier score was also estimated. 95% confidence intervals (CI) for each of the estimated performance measures were also calculated.848 out of 1159 recruited patients were finally included in the multivariable logistic regression model validation. The AUC of the new cohort was 0.63 for predicting anastomotic leak. Considering a cut-off point of 22.1% to be 'positive' (to get a leak) this would provide a sensitivity of 0.45, specificity of 0.80, positive predictive value of 0.09 and negative predictive value of 0.97 for anastomotic leak. If we consider this cut-off point to select patients at risk of leak for bowel diversion, up to 22.5% of the sampled patients would undergo a diverting ileostomy and 47% (18/40) of the anastomotic leaks would be 'protected' with the stoma. Nevertheless, if we consider only the 'clinical criteria' for performing or not a diverting ileostomy, only 12.5% (5/40) of the leaks would be 'protected' with a stoma, with a rate of diverting ileostomy of up to 24.3%.Compared with subjective clinical criteria, the use of a predictive model for anastomotic leak improves the selection of patients who would benefit from a diverting ileostomy without increasing the rate of stoma use.

The primary objective was to evaluate the response rate of conservative treatment for endometrial cancer, and the secondary objective was to assess oncological, fertility and obstetric outcomes in patients who underwent fertility preservation treatment.This multicentre, observational, retrospective study evaluated endometrial cancer patients who underwent fertility-sparing treatment in Spanish centres between January 2010 and January 2020. Seventy-three patients with stage IA endometrioid adenocarcinoma of the uterus were included in the study.The levonorgestrel intrauterine device (LNG-IUD) was the most common fertility-sparing treatment (53.4%), followed by megestrol acetate (20.5%) and medroxyprogesterone acetate (16.4%). During the 24-month follow-up period, the rate of complete response to fertility-sparing management was 74% (n = 54), and 8.2% (n = 6) of patients presented a partial response. Additionally, 13 (17.8%) patients presented with persistent disease and six (8.2%) relapsed after response. The LNG-IUD was associated with a higher complete response rate than the other methods (87.2 vs. 58.8%; p = 0.01). Surgical treatment (at least hysterectomy) was performed in 44 (60.3%) patients as the end of fertility-sparing treatment. Four (5.5%) patients presented relapse after surgery, associated with final FIGO stage III (p = 0.036), myometrial invasion 50% (p = 0.018) and final tumour grade 2-3 (p = 0.018). The mean follow-up period was 57.8 (range 6-159) months. The 5-year relapse-free survival and overall survival rates were 92.6% [95% CI (81.3, 97.2)] and 93.5% [95% CI (80.7, 97.9)], respectively. During follow-up, three patients (4.1%) died of the disease after completion of surgical treatment. Up to 50.7% of patients included in the study attempted to get pregnant. Of these, the rate of pregnancy was 81.1% (n = 30/37), and reproductive techniques were used for this purpose in 78.4% of cases.Fertility-sparing management presented a high response rate in patients with endometrial cancer. LNG-IUD was associated with a better response rate compared to the other treatment options. Moreover, in patients using this management method, pregnancy could be achieved using reproductive techniques.

Objective. Despite radical surgery and chemotherapy, most patients with ovarian cancer die due to disease progression. M-Trap is an implantable medical device designed to capture peritoneal disseminated tumor cells with the aim to focalize the disease. This trial analyzed the safety and performance of the device. Methods. This first-in-human prospective, multi-center, non-blinded, single-arm study enrolled 23 women with high-grade serous advanced ovarian cancer. After primary or interval debulking surgery, 3 M-Trap devices were placed in the peritoneum of the abdominal cavity. 18-months post-implantation or at disease progression, devices were initially removed by laparoscopy. The primary safety endpoint was freedom from device and procedure-related major adverse events (MAEs) through 6-months post-implantation compared to an historical control. The primary performance endpoint was histopathologic evidence of tumor cells capture. Results. Only one major adverse event was attributable to the device. 18 women were free of device and pro-cedure related MAEs (78.3%). However, the primary safety endpoint was not achieved (p = 0.131), primarily at-tributable to the greater surgical complexity of the M-Trap patient population. 62% of recurrent patients demonstrated tumor cell capture in at least one device with a minimal tumor cell infiltration. No other long-term device-related adverse events were reported. The secondary performance endpoint demonstrated a lack of disease focalization. Conclusions. The M-Trap technology failed to meet its primary safety objective, although when adjusted for surgical complexity, the study approved it. Likewise, the devices did not demonstrate the anticipated benefits in terms of tumor cell capture and disease focalization in recurrent ovarian cancer. (c) 2021 Elsevier Inc. All rights reserved.

Introduction/Background Despite its extended use, there is scarce evidence about the combined use of 99mTc-albumin nanocolloid (99mTc) and indocyanine green (ICG) for the detection of sentinel lymph node (SLN) in endometrial cancer, when compared to ICG alone. The aim of this study is to compare the detection parameters of both methods. Methodology Multicentric retrospective study (November 2015-June 2020) including patients diagnosed with endometrial atypical hyperplasia or initial preoperative stage endometrial carcinoma (FIGO I-II) who underwent SLN biopsy by cervical injection of: a) ICG intraoperatively, or b) 99mTc preoperatively, and ICG intraoperatively (ICG+99mTc). Results A total of 180 patients were included, 51% (n=92) in the ICG group and 49% (n=88) in the ICG+99mTc group. 86.7% of the patients presented endometrioid histology, and 58.7% were preoperatively classified as low risk, according to the ESMO/ESGO/ESTRO criteria. The vast majority of the procedures (99.4%) were performed by a minimally invasive approach. Both groups were comparable regarding their basal characteristics, except for a higher body mass index (27.6 vs. 30.3 kg/m2, p=0.014) in the ICG+99mTc group and a bigger proportion of robotic-assisted procedures (54.4 vs 29.6%, p=0.001) in the ICG group. Global detection rate was 92.8% (IC 95%: 88.0–95.7), without statistically significant differences among groups (ICG:94.6% vs ICG+99mTc:90.9%, p=0.344). No significant differences were observed in the pelvic bilateral mapping rate (71.6%, ICG:70.7% vs ICG+99mTc:71.6%, p=0.890) or the aortic mapping rate (5.6%, ICG:8.7% vs ICG+99mTc:2.3%, p=0.058). When ICG+99mTc was used, surgical procedures were 30 minutes longer when compared to ICG (150 vs 180 min, p=0.003). In 12 patients (6.7%) at least one positive SLN was found (ICG:9.8% vs ICG+99mTc:3.4%, p=0.164). No significant differences were observed regarding the empty node packets rate or the number of SLNs retrieved per patient. There were no patients with a positive lymphadenectomy specimen and a negative SLN, thus sensitivity was 100%. Conclusion Combining preoperative 99mTc to intraoperative ICG did not improve SLN detection in endometrial cancer, but resulted in longer procedures. Disclosures Nothing to disclose.

The uterine manipulator is a device commonly used in minimally invasive hysterectomy procedures for benign disease to facilitate uterus mobilization during surgery, generate tension on the main supporting elements of the uterus (broad ligament, uterine vessels, and uterosacral ligaments) to improve

Objective To demonstrate the feasibility of a protective maneuver to avoid tumor exposure during laparoscopic radical hysterectomy. Design This video illustrates the vaginal cuff closure technique in cervical cancer surgery. Setting The Oncologic Gynecology Department at the University Hospital La Fe. Interventions After the Laparoscopic Approach to Cervical Cancer trial [1] , the laparoscopic approach to the surgical treatment of cervical cancer has been questioned: laparotomic surgery has been associated with a better cancer outcome. This publication has changed the current approach recommendation for performing radical hysterectomy from minimally invasive surgery to open surgery. There are some theories that might justify these findings. In minimally invasive surgery, the use of a uterine manipulator can condition the spread owing to erosion and friction caused on the tumor, even leading to the perforation of the tumor. In addition, intraperitoneal colpotomy can lead to pelvic peritoneum contamination by the tumor. To close the gap between laparoscopy and laparotomy, some protective maneuvers, such as vaginal cuff closure, have been proposed [ 2 , 3 ]. These strategies aim to reduce the possibility of manipulation or exposure of the tumor to the pelvis during colpotomy in laparoscopic radical hysterectomy. These protective maneuvers have been shown to decrease the relapse rate in retrospective studies [4] . However, prospective trials are needed to elucidate and confirm these findings. In this video, we explain step-by-step the technique of vaginal cuff closure before a radical hysterectomy performance for uterine cervical cancer. First, the nodal status is established by laparoscopic sentinel lymph node dissection and frozen section study. Bilateral pelvic lymphadenectomy is completed according to the size of the tumor. In the case of negative nodal status, the vaginal cuff is closed: Approximately 2 to 3 cm from the tumor (depending on its size), a circumferential incision of the vaginal mucosa is performed, followed by the dissection of the vaginal wall, which should be sufficient to allow a tension-free vaginal closure. The vaginal cuff is then closed with a running suture. A laparoscopic radical hysterectomy is then completed, and the surgical specimen is removed without any manipulation of the tumor. Conclusion Avoiding manipulation of the tumor during cancer surgery is crucial. A vaginal cuff closure technique appears to be an easy protective maneuver that prevents tumor exposure and manipulation during laparoscopic radical hysterectomy.

Objective. To determine the factors related with diverting ileostomy performance after colorectal resection and anastomosis, in advanced ovarian cancer cytoreductive surgery. Methods. We have previously demonstrated the risk factors associated with anastomotic leak after colorectal anastomosis: Advanced age at surgery, low serum albumin level, additional bowel resections, manual anastomosis and distance of the anastomosis from the anal verge. However, use of diverting ileostomy is strongly variable and depends on individual surgeon preferences and training. Eight hospitals participated in this retrospective study. Data of 695 patients operated for ovarian cancer with primary colorectal anastomosis were included (January 2010-June 2018). Fourteen pre-/intraoperatively defined variables were identified and analysed as justification factors for use of diverting ileostomy. Results. The rate of diverting ileostomy in the entire cohort was 19.13% (133/695; range within individual centers 4.6-24.32%). Previous treatment with bevacizumab [OR 2.8 (1.3-6.1); p=0.01]; additional bowel resections [OR 3.0 (1.8-5.1); p

ObjectiveThe purpose of this study is to asses the impact of lymphovascular space invasion (LVSI) present in early-stage endometrial cancer, regarding its therapeutic management and prognosis knowledge, based on a survey among Spanish oncologic gynecologist.Methods/MaterialsBetween October and November 2014, the Young Spanish Onco-gynecologist Group carried out a survey to perform a cross-sectional study about the management of LVSI. All active members in the oncology field of the Spanish Society of Gynecology and Obstetrics were invited to participate in the survey.ResultsMost respondents consider LVSI a bad prognosis factor for endometrial cancer (66%) and also consider that it should be included in the International Federation of Gynecology and Obstetrics classification (56%). Seventy-five percent of all gynecologists did not modify their surgical treatment. Regarding follow-up, 38% of the respondents do not change their surveillance, 28% modify it, and 31% reported any change only with additional factors. Forty-seven percent of respondents advise systemic treatment with chemotherapy.Data were dichotomized between less than or equal to 20 versus greater than 20 years of OB-GYN specialist and less than or equal to 5 versus greater than 5 years of main dedication to gynecology oncology, but it was not possible to show any significant differences among the groups. The response rate (34 individuals) was too low to expect any significant differences.ConclusionsResults suggest that LVSI remains a controversial issue in the management of patients with endometrial cancer. Acquiring a deeper knowledge and uniform criteria could avoid the risk of undertreatment and overtreatment in this group of patients with early-stage endometrial cancer. The identification of vascular pseudoinvasion is recommended, although the clinical and prognostic implications still need to be determined.

ObjectiveEarly-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and safety concerns of sentinel lymph node biopsy in patients with clinical stage I–II ovarian cancer.MethodsWe conducted a prospective cohort study of 20 patients with histologically confirmed ovarian cancer. 99mTc and indocyanine green were injected into both the utero-ovarian and infundibulopelvic ligament stump, if they were present, during surgical staging. An intraoperative gamma probe and near-infrared fluorescence imaging were used to detect the sentinel lymph nodes. Inclusion criteria included: >18 years of age, suspicious adnexal mass (unilateral or bilateral) at ultrasound and CT imaging or confirmed ovarian tumor after previous surgery (unilateral or bilateral salpingo-oophorectomy with or without hysterectomy). Adverse events were recorded through postoperative day 30. The primary trial end point was to report adverse events related to the technique, including the use of 99mTc and ICG intraperitoneally, as well as the feasibility of the technique.ResultsA total of 20 patients were included in the analysis. Sentinel lymph nodes were detected in 14/15 (93%) pelvic and all 20 (100%) para-aortic regions. Five patients did not have utero-ovarian injection because of prior hysterectomy. The mean time from injection to sentinel lymph node resection was 53±15 min (range; 30–80). The mean number of harvested sentinel lymph nodes was 2.2±1.5 (range; 0–5) lymph nodes in the pelvis and 3.3±1.8 (range; 1–7) lymph nodes in the para-aortic region. There were no adverse intraoperative events, nor any within the 30 days of follow-up related with the technique.ConclusionSentinel lymph node mapping in early-stage ovarian cancer is feasible without major intraoperative or < 30 days safety concerns. (NCT03452982).Trial registration numberClinicalTrials.gov, NCT03452982.

Introduction/Background Female sexuality is a complex phenomenon with important repercussions on their overall quality of life. In the case of women who have undergone gynecological interventions, their quality of sexual life may be diminished. Methodology Women survivors of gynecological cancers usually have important sequelae derived from the treatment. The radicality of the surgery and / or adjuvant radiotherapy treatments are sometimes unavoidable and they involve reconstructive surgery to restore the anatomical defect (vaginal stenosis) and, in this way, the woman can recover her sexual life and body self-perception as before. Results The role of reconstructive surgery for the anatomo-functional sequelae and body self-perception of the onco-gynecological patient has already been evaluated in previous studies (Hawighorst-Knapstein 2004, Chen 2015) with promising results since women who underwent reconstructive techniques such as Vaginoplasty with autologous peritoneal tissue (Chen 2015) improved sexual functioning and quality of life. Similar results were obtained in non-oncological patients with vaginal aplasia using the technique of vaginoplasty modified by Creatsas in which up to 95.5% of women reported feeling satisfied in their sexual life (Creatsas 2007). The surgical video is presented. With the goal of visualization this technique in the treatment of vaginal stenosis after pelvic radiotherapy for gynecological cancer. Conclusion Reconstructive surgery such as vaginoplasty modified by Creatsas, can help to restore the anatomical defect and, ultimately, improve the patient´s body perception and quality of sexual life. Disclosure Nothing to disclose

Introduction/Background There is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the video is to show the standardized sentinel lymph node technique in early ovarian cancer Methodology In the case of malignancy, the sentinel lymph node technique was performed. We subperitoneally injected 0.2 mL of saline solution containing 37 mBq of 99mTc nanocolloid (Albu-res, Pharmaceutical Nycomed Amersham, Braunschweig, Germany). At the same time, 0.5 mL of indocyanine green (concentration 1.25 mg/mL) was injected. We used a 27 G needle at each injection point Results The sentinel lymph nodes were checked with an intra-operative mobile gamma camera (Sentinellatm, Oncovision) for descriptive purposes only. Thirty minutes after the injection, the SLN procedure was started regardless of probe migration with the IMGC. Guided by the acoustic signal of a gamma probe (Wprobe wireless gamma probe STD and LAP, Oncovision), we performed a minimum dissection looking for the hottest sentinel lymph node(s) in the pelvic/para-aortic region. We simultaneously used the Imagen1 HUB-OPAL1 (NIR/ICG system) (Karl Storz Endoscopy, GmbH, Mittelstrasse, Tuttlingen, Germany) to detect the sentinel lymph node(s) dyed with indocyanine green. Any lymph node with a remarkably higher count than the background was considered a sentinel lymph node and was harvested separately. Conclusion In light of the findings of SENTOV clinical trial, the sentinel lymph node technique appears to be applicable in early-stage ovarian cancer Disclosure Nothing to disclose

Introduction/Background In advanced ovarian cancer surgery, there is rather limited published evidence, drawn from a small sample, providing information about risk factors for anastomotic leak. Methodology To determine pre-/intraoperative risk factors for anastomotic leak after modified posterior pelvic exenteration (MPE) or colorectal resection in ovarian cancer and to create a practical instrument for predicting anastomotic leak risk. Eight hospitals participated in this retrospective study. Data on 695 patients operated for ovarian cancer with primary anastomosis were included (January 2010-June 2018). Twelve pre-/intraoperative variables were analysed as potential independent risk factors for anastomotic leak. A predictive model was created to stablish the risk of anastomotic leak for a given patient. Results He anastomotic leak rate was 6.6% (46/695; range 1.7%–12.5%). A total of 457 patients were included in the final multivariate analysis. The following variables were found to be independently associated with anastomotic leakage: age at surgery (OR 1.046, 95% CI 1.013–1.080, p = 0.005), serum albumin level (OR 0.621, 95% CI 0.407–0.948, p = 0.027), one or more additional small bowel resections (OR 3.544, 95% CI 1.228–10.23, p = 0.019), manual anastomosis (OR 8.356, 95% CI 1.777–39.301, p = 0.007) and distance of the anastomosis from the anal verge (OR 0.839, 95% CI 0.726–0.971, p = 0.018). Conclusion Due to the low incidence of AL in ovarian cancer patients, a restrictive stoma policy based on the presence of risk factors should be the actual recommendation. Hand-sewn anastomosis should be avoided. Disclosure Nothing to disclose.

Introduction/Background There is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the present pilot study and clinical trial is to determine the feasibility of the sentinel lymph node technique by applying a clinical algorithm and the use of 99mTc and indocyanine green for its detection. Methodology Patients with confirmed ovarian cancer were included. 99mTc and indocyanine green were injected into the ovarian and infundubulo-pelvic ligament stump. A gamma probe and near-infrared fluorescence imaging were used for sentinel lymph node detection. Results The sentinel lymph node technique was performed in 10 patients in the pilot study and in 20 patients in the clinical trial with a detection rate in the pelvic and/or para-aortic region of 100%. Conclusion The sentinel lymph node technique appears to be applicable in early-stage ovarian cancer with excellent detection rate. further studies are needed to establish the negative predictive value of the technique. Disclosure Nothing to disclose.

In apparent early stage ovarian cancer, complete surgical staging surgery including systematic lymphadenectomy is recommended at the time of diagnosis. Although minimally invasive surgery can be carried out for re-staging, laparotomy is the standard surgical approach recommendation to treat and

Study Objective To demonstrate the feasibility of laparoscopic sentinel lymph node technique in presumed early-stage ovarian cancer. Design Video illustrating the laparoscopic performance of the sentinel lymph node technique in ovarian cancer. Setting The Oncologic Gynecology Department at the University Hospital La Fe. Patients Candidates for the technique presented an apparent early stage ovarian cancer. The technique was performed in the context of a clinical trial called SENTOV (NCT03452982). Interventions To date, lymphadenectomy is recommended after the diagnosis of apparent early-stage ovarian cancer as part of the surgical staging. Minimally invasive surgery can be considered for the purpose of restaging [1] . Up to 14% of the patients are upstaged because of positive lymph nodes after pelvic and para-aortic lymphadenectomy [2] . Regarding low-grade tumors, a lower rate of lymph node involvement has been reported [3] . Sentinel lymph node technique has been reported to be feasible in a recent pilot study [4] . Two clinical trials (Sentinel Lymph Node in Early Ovarian Cancer and Sentine Lymph Node in Early Ovarian Cancer) are currently ongoing to clarify the use of sentinel lymph node technique in early ovarian cancer. The injection points were at the infundibulopelvic and ovarian ligament stumps. Two hundred microliters of saline solution containing 37 MBq of technetium-99m nanocolloid followed by 0.5 mL of indocyanine green (ICG) was injected subperitoneally. We used a 27 G needle at each injection point. Immediately after injection and also at 15 and 30 minutes after injection, the operative field was checked guided by the acoustic signal of the gamma probe and the near-infrared camera. We performed a minimum dissection looking for the sentinel lymph node or nodes in the pelvic and para-aortic region. Any lymph node with a remarkable radioactivity count as high as 10 times the background and/or dyed with ICG was considered a sentinel lymph node and was harvested separately. A systematic surgical staging was performed after the sentinel lymph node procedure was completed. Because of its small size, the ICG molecule is not caught in the lymph node valve system and keeps migrating when performing lymphography. An exhaustive direct view of the dye path is required to avoid misleading detection of the real sentinel lymph node. This theoretical problem is resolved by the use of the 99mTC-nanocolloid. This tracer gets trapped into the lymph node valve system because of its molecular size and does not keep migrating as does ICG. As such, a combination of both methods is proposed. Conclusion Laparoscopic performance of sentinel lymph node technique in ovarian cancer seems to achievable. Between 2017 and 2019, this procedure was performed in 30 patients (13 laparoscopic), in the context of our pilot experience [4] and the Sentinel Lymph Node in Early Ovarian Cancer clinical trial (NCT03452982).

ObjectiveAnastomotic leak remains the main concern after colorectal anastomosis in ovarian cancer. Our objective was to compare the use of three different management approaches after colorectal resection and anastomosis in patients with ovarian cancer.MethodsBetween January 2010 and June 2018, a total of 133 patients with International Federation of Gynecology and Obstetrics (FIGO) stage II–IV ovarian cancer who underwent colorectal resection and anastomosis were included. According to the approach followed after colorectal anastomosis and during the post-operative period, patients were stratified into three groups: conservative management and observation, diverting ileostomy, or ghost ileostomy technique. Univariate analyses were performed for quantitative variables by applying Student’s t test or Mann-Whitney U test and for qualitative variables by using the χ2 test (or Fisher’s test according to the sample size).ResultsA total of 145 patients underwent colorectal resection during cytoreduction for FIGO stage II–IV ovarian cancer. Twelve patients were excluded because a colostomy was required. Thus, 133 patients were included in the final analysis. Modified posterior pelvic exenteration was performed in 121 (91%) patients and recto-sigmoid resection in 12 (9%) patients with relapse. The approach after anastomosis was wait-and-see in 72 patients (54.1%), diverting ileostomy in 19 patients (14.4%), and ghost ileostomy in 42 patients (31.5%). There were no differences in diagnosis, age, body mass index, ECOG (Eastern Cooperative Oncology Group), histology, tumor grade, FIGO stage, or type of surgery between the groups. No differences were found regarding the anastomosis leak related factors or the rate of anastomotic leak between the three groups (5.6% vs 5.3% vs 4.8%; p=0.98). Two patients died because of the anastomotic leak in the wait-and-see group, and none died in the diverting ileostomy or ghost ileostomy group. In the diverting ileostomy group, a higher number of patients had complications compared with the ghost ileostomy group (78.9% vs 7.1%; p1500 mL) causing electrolyte imbalance in the diverting ileostomy group, and one patient (2.4%) in the ghost ileostomy group (p=0.03). The stoma reversal rate was 73.7% for the diverting ileostomy group and 100% for the ghost ileostomy group.ConclusionsThere were no differences found in the rate of anastomotic leak among the three groups of patients. The use of ghost ileostomy avoids the drawbacks of diverting ileostomy and seems to have advantages over routine diverting ileostomy and wait-and-see approaches for ovarian cancer patients undergoing colorectal anastomosis. Rates of stoma reversal are lower after diverting ileostomy when compared with ghost ileostomy.

Objective. To determine pre-/intraoperative risk factors for anastomotic leak after modified posterior pelvic exenteration (MPE) or colorectal resection in ovarian cancer and to create a practical instrument for predicting anastomotic leak risk. Background. In advanced ovarian cancer surgery, there is rather limited published evidence, drawn from a small sample, providing information about risk factors for anastomotic leak. Methods. Eight hospitals participated in this retrospective study. Data on 695 patients operated for ovarian cancer with primary anastomosis were included (January 2010-June 2018). Twelve pre-/intraoperative variables were analysed as potential independent risk factors for anastomotic leak. A predictive model was created to stablish the risk of anastomotic leak for a given patient. Results. The anastomotic leak rate was 6.6% (46/695; range 1.7%-12.5%). A total of 457 patients were included in the final multivariate analysis. The following variables were found to be independently associated with anastomotic leakage: age at surgery (OR 1.046, 95% CI 1.013-1.080, p = 0.005), serum albumin level (OR 0.621, 95% CI 0.407-0.948, p = 0.027), one or more additional small bowel resections (OR 3.544, 95% CI 1.228-10.23, p = 0.019), manual anastomosis (OR 8.356, 95% CI 1.777-39.301, p = 0.007) and distance of the anastomosis from the anal verge (OR 0.839, 95% CI 0.726-0.971, p = 0.018). Conclusions. Due to the low incidence of AL in ovarian cancer patients, a restrictive stoma policy based on the presence of risk factors should be the actual recommendation. Hand-sewn anastomosis should be avoided. Crown Copyright (C) 2019 Published by Elsevier Inc. All rights reserved.

Female sexuality is a complex phenomenon with important repercussions on patients' quality of life. Women survivors of gynecological malignancy might have sexual dysfunction after cancer treatment. Surgical radicality and radiation therapy might cause scar tissue in the vagina, being a common long

Introduction Pelvic exenteration (PE) is indicated in cases of unresponsive, recurrent pelvic cancer or for palliative intent. Despite the fact that the surgery is associated with a high rate of morbidity, it is currently the only real option that can effect a cure. Material and methods Patients who underwent PE between January 2011 and July 2017 in our centre were retrospectively reviewed. Data related to surgery, complications and outcomes were recorded. Results Twenty-three patients were included. PE was performed due to recurrent gynaecological cancer, persistence of disease and after first diagnosis in 19 (82%), 2 (9%) and 2 patients (9%), respectively. Total PE was performed in 15 cases (65%), followed by anterior PE in 5 cases (22%) and posterior PE in 3 cases (13%). Early grade II, III and IV complications occurred in 15 (65%), 5 (22%) and 2 patients (9%), respectively. No mortality was observed within 30 days. Medium-late grade II, III, IV and V complications occurred in 15 (65%), 11 (48%), 3 (13%) and 2 cases (9%), respectively. Two patients died after > 30-day period from surgery-related complications. The overall survival (OS) and disease-free survival (DFS) at 48 months after PE was 41.6% and 30.8% respectively. Conclusions PE provides about a 40% 4-year survival chance in a selected group of patients. The early-complications rate and 30-day mortality were acceptable. Nevertheless, the medium-late complication grades II–V were 65, 48, 18 and 9%, respectively. We must focus on identifying those patients who could potentially benefit most from PE.

Urinary and fecal diversion is needed to restore normal function after total pelvic exenteration because of gynecological cancer.[1][1] In these patients, the Bricker procedure and end colostomy are often used for this purpose. Nevertheless, their use may lead to complications in patients with

ObjectiveDiverting ileostomy (DI) has been proposed to reduce the incidence and consequences anastomotic leakage after bowel resection. In colorectal cancer treatment, ghost ileostomy (GI) has been proposed as an alternative to DI. Our objective was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer.Materials and MethodsThis is an observational pilot study performed in a single institution. The main objective sought was to report the results of GI associated with colorectal resection in the treatment of ovarian cancer: 26 patients were included.ResultsModified posterior exenteration was performed in 24 cases (92.3%) and rectum resection in the 2 cases of relapse (7.7%). After the main procedure GI was created, to check up the anastomosis status, a sequential postoperative rectoscopy was performed on postoperative day 5 ± 1 (range, 4–7). Serum levels were monitored in first and third postoperative days just with a descriptive intention to establish its relationship with the rectoscopy findings. In 2 cases, rectoscopy demonstrated a leakage. During postoperative course, no other complication related with the GI or DI was observed. No case of clinical anastomotic leakage was found.ConclusionsTo the extent of our knowledge, this is the first study in which GI has been performed for the treatment of patients with ovarian cancer. Ghost ileostomy represents a real option that may reduce the number of ileostomies performed in ovarian cancer without increasing the morbimortality. Ghost ileostomy presents the advantages of DI while avoiding its drawbacks. It also seems to be a safe, feasible, and reproducible technique that does not add significant costs to the surgery.

Introduction The use of laparoscopy in the treatment and management of advanced ovarian cancer is increasing among the gynaecologic oncologists. The development of port site metastases after laparoscopy is a concern and a matter of debate due to theoretical iatrogenic disease spread. Port site resection (PSR) has been proposed as an option to avoid this scenario. Material and methods One hundred and twenty-three patients with advanced ovarian cancer (FIGO III-IV) and with diagnostic laparoscopy were included and after cytoreductive surgery were classified into two groups: no port site resection (No-PSR) and port site resection (PSR). Based on the pathological results of all port site specimens, PSR was classified as positive port site metastasis (PSM+) and negative port site metastasis (PSM-). Results In 82 cases, the laparoscopic port site access was resected in the debulking surgery. At the final specimen examination, 49% presented as PSM+. No statistical differences regarding survival were found, either between the No-PSR and PSR groups (p = 0.28) or between the PSM+ and PSM - groups (p = 0.92). A higher wound complication rate was found in the PSR group (17% vs. 34%; p = 0.047). The RR (Relative Risk) of wound events for PSR was 2.42 (95% CI 1.09–5.35; p = 0.0296). Conclusions To date, not only there is no data supporting PSR after laparoscopy in advanced ovarian cancer, but the role of PSM+ in prognosis also remains unclear. In patients in which laparoscopy is performed prior to the debulking procedure, the PSR may not be recommended in those cases of no macroscopic port site metastasis.

IntroductionThere is limited evidence favoring the use of the sentinel lymph node technique in ovarian cancer, and no standardized approach has been studied. The objective of the present pilot study is to determine the feasibility of the sentinel lymph node technique by applying a clinical algorithm.MethodsPatients with confirmed ovarian cancer were included. 99mTc and indocyanine green were injected into the ovarian and infundubulo-pelvic ligament stump. A gamma probe and near-infrared fluorescence imaging were used for sentinel lymph node detection.ResultsThe sentinel lymph node technique was performed in ten patients with a detection rate in the pelvic and/or para-aortic region of 100%. The tracer distribution rates of sentinel lymph nodes in the pelvic and para-aortic regions were 87.5% and 70%, respectively.ConclusionThe detection of sentinel lymph nodes in early-stage ovarian cancer appears to be achievable. Based on these results, a clinical trial entitled SENTOV (SENtinel lymph node Technique in OVarian cancer) will be performed.

In order to reach cytoreduction in advanced ovarian cancer, peritonectomy and diaphragmatic stripping are procedures required to remove the disease in the upper abdomen. Diaphragm involvement is estimated in up to 40% of cases. Nevertheless, in some of these patients, the tumour volume may constitute a limitation of the technique due to the association with abdominal wall involvement, bulky tumour at the Morrison's pouch or liver infiltration. Extensive upper abdominal procedures should represent a basic resource for the gynaecologic oncologist in order to reach an optimal cytoreduction. A radical peritonectomy with en bloc resection for treating advanced ovarian cancer with extensive widespread diaphragmatic peritoneal carcinomatosis is showed in this surgical film.

Study Objective To compare operative and postoperative results of ovarian cortex retrieval by conventional laparoscopy (1cm umbilical site and 3 accessory 5-mm-reusable working ports) (HASS) versus single site laparoscopy (SSL). Design Prospective cohort study. Setting Fertility Preservation Programme at La Fe University Hospital-University of Valencia, Valencia, Spain, 2011 to 2012. Fertility Preservation Programme at La Fe University Hospital of Valencia, Valencia, Spain. Patients Twenty-one patients with cancer (breast cancer: n = 17; Hodgkin's lymphoma: n = 3; and non-Hodgkin's lymphoma: n = 1). Intervention Ovarian cortex retrieval either by conventional laparoscopy using an umbilical Hasson port and 3 accessory ports (HASS group: n = 11) or by SSL (SSL group: n = 10). Measurements and Main Results Operative length, blood loss, postoperative pain (visual analog scale for pain at 6, 24, and 48 hours), need of additional analgesia, quality of life (European Quality of Life-5 Dimensions), cosmesis of the scar, and patient's self-perception were assessed at 24 and 48 hours and 3 months after surgery. Baseline characteristics were similar between groups. Estimated blood loss, operative length, and postoperative pain did not differ between groups. The start of chemotherapy was not delayed in either group, and cosmesis and image self-perception were also similar. Conclusion The SSL approach can be considered a safe option compared with the classic multisite approach.

Resumen Objetivo Analizar y comparar los resultados perioperatorios y los costes economicos de la histerectomia total laparoscopica (HTL) y de la histerectomia vaginal (HV). Sujetos y metodos Estudio retrospectivo realizado durante 2013 que incluye pacientes con similar perfil sometidas a HV (n = 20) o HTL (n = 29). La principal indicacion quirurgica fue utero miomatoso. Se recogen datos epidemiologicos, resultados perioperatorios y datos economicos. Resultados Las caracteristicas basales de las pacientes fueron similares. En resultados perioperatorios, el tiempo quirurgico fue menor en HV (64,8 ± 14,5 min) que en HTL (102,8 ± 20,5 min) p Conclusiones En la eleccion de la via quirurgica, la HV parece ser un procedimiento mas economico y con similares resultados perioperatorios que la HTL. No obstante, es importante individualizar segun las caracteristicas de la paciente. Son necesarios estudios con mayor tamano muestral para confirmar los resultados.

In order to reach cytoreduction in advanced ovarian cancer, peritonectomy and diaphragmatic stripping are procedures required to remove the disease in the upper abdomen. Diaphragm involvement is estimated in up to 40% of cases. Nevertheless, in some of these patients, the tumour volume may constitute a limitation of the technique due to the association with abdominal wall involvement, bulky tumour at the Morrison’s pouch or liver infiltration. Extensive upper abdominal procedures should represent a basic resource for the gynaecologic oncologist in order to reach an optimal cytoreduction. A radical peritonectomy with en bloc resection for treating advanced ovarian cancer with extensive widespread diaphragmatic peritoneal carcinomatosis is showed in this surgical film.

It is important to know what a young gynecologic oncologist perceives as a need to achieve a good training in gynecologic oncology. This study aims to evaluate the level of training in gynecologic oncology in Spain. A Web-based anonymous questionnaire was sent via e-mail to Spanish trainees listed in European Network of Young Gynecological Oncology (ENYGO). The survey was developed in four sections: (1) general training in gynecologic oncology, (2) distribution of current clinical activity, (3) surgical training, and (4) perspective future gynecologic oncology. It contained 51 questions, with multiple-choice answers that had to be answered by the ENYGO members. The questionnaire was sent to 64 people listed in the ENYGO database. Of these, 37 members responded (response rate of 58%). Overall, more training in surgery is necessary, to perform radical oncological surgeries. It is claimed a sub-specialty recognition, to ensure an equalitarian and homogeneous training.

The purpose of this study is to asses the impact of lymphovascular space invasion (LVSI) present in early-stage endometrial cancer, regarding its therapeutic management and prognosis knowledge, based on a survey among Spanish oncologic gynecologist.Between October and November 2014, the Young Spanish Onco-gynecologist Group carried out a survey to perform a cross-sectional study about the management of LVSI. All active members in the oncology field of the Spanish Society of Gynecology and Obstetrics were invited to participate in the survey.Most respondents consider LVSI a bad prognosis factor for endometrial cancer (66%) and also consider that it should be included in the International Federation of Gynecology and Obstetrics classification (56%). Seventy-five percent of all gynecologists did not modify their surgical treatment. Regarding follow-up, 38% of the respondents do not change their surveillance, 28% modify it, and 31% reported any change only with additional factors. Forty-seven percent of respondents advise systemic treatment with chemotherapy.Data were dichotomized between less than or equal to 20 versus greater than 20 years of OB-GYN specialist and less than or equal to 5 versus greater than 5 years of main dedication to gynecology oncology, but it was not possible to show any significant differences among the groups. The response rate (34 individuals) was too low to expect any significant differences.Results suggest that LVSI remains a controversial issue in the management of patients with endometrial cancer. Acquiring a deeper knowledge and uniform criteria could avoid the risk of undertreatment and overtreatment in this group of patients with early-stage endometrial cancer. The identification of vascular pseudoinvasion is recommended, although the clinical and prognostic implications still need to be determined.

To evaluate the obstetric management and neonatal outcomes in twin pregnancies with delayed delivery of the second twin, including follow-up.This study is a review of four cases of delayed delivery of the second twin in our hospital from 2009 to 2012. The obstetric management of the cases from the expulsion of the first twin to the delivery of the second twin is analyzed. The neonatal outcomes including follow-up for 2 years were reviewed.The first twins were delivered between 15 and 25 weeks (average 21 weeks) and the second twins were delivered between 25 and 31 weeks (average 27 weeks). One first twin (25 %) survived, while three (75 %) second twins survived. Two out of the three second twins delivered after 28 weeks were in satisfactory condition.The delayed delivery of the second twins which occurred in the third trimester is associated with favorable outcome, however, the risks should not be ignored.

Resumen El embarazo ectopico sobre cicatriz de cesarea previa ha aumentado su incidencia en los ultimos anos, debido probablemente al aumento en el numero de cesareas realizadas. Su importancia se debe a las potenciales graves consecuencias que pueden surgir en caso de progreso del embarazo. El anidamiento embrionario en esta zona se ha explicado aludiendo a que la liberacion de diferentes factores, como citocinas, y la expresion de distintos receptores de superficie facilitarian la adhesion embrionaria, favorecida en las cicatrices de cirugias endometriales por su gran atraccion quimiotactica secundaria al proceso inflamatorio y de reparacion tisular que alli se produce. Su manejo resulta controvertido por el escaso numero de casos publicados, lo que hace dificil establecer un protocolo de actuacion. Se han descrito varios tipos de tratamiento, tanto quirurgicos como farmacologicos, con buenos resultados. Presentamos un caso en el que fue diagnosticada ecograficamente una gestacion ectopica sobre cicatriz de cesarea, resuelta con tratamiento farmacologico con metotrexate. En este caso, se evidencia la importancia del seguimiento, tanto clinico como ecografico y del nivel de beta-HCG, hasta su resolucion completa.

Resumen Las complicaciones de las tecnicas quirurgicas antiincontinencia mediante el uso de mallas via transobturadora son muy infrecuentes, por lo que no existen protocolos establecidos sobre su manejo y seguimiento. Presentamos el caso clinico de aparicion de hematoma de gran tamano tras colocacion de TVT-O, en el cual se opto por un manejo conservador con el uso de la ecografia convencional y 3D como seguimiento de esta complicacion, con resultados muy satisfactorios.

Introduction: The incidence of placenta accreta has risen and this entity can cause postpartum hemorrhage, often requiring obstetric hysterectomy. There are, however, alternative conservative treatments to surgery. Case report: A 38-year-old woman in her first pregnancy underwent manual removal of the placenta, with moderate hemorrhaging and subsequent curettage. The diagnosis was confirmed by ultrasound scan and magnetic resonance imaging. Selective embolization of the nutritional

Gynecologic oncologists have an essential role to treat women with gynecological cancer. It has been demonstrated that specialized physicians who work in multidisciplinary teams to treat women with gynecological cancers are able to obtain the best clinical and oncological outcomes. However, the access to gynecologic oncologists for women with suspected gynecological cancer is scarce. Therefore, this review analyzes the importance of a specialized care of women with ovarian, cervical, endometrial and ovarian cancer. In addition, the roles of gynecologic oncologists who offer fertility-sparing treatment as well as their role to assist general gynecologists and obstetricians are also reviewed.

Robotic surgery is a new technology that has been progressively implemented to treat endometrial and cervical cancer. However, the use of robotic surgery for ovarian cancer is limited to a few series of cases and comparative studies with laparoscopy or laparotomy. The technical issues concerning robotic surgery, as well as clinical evidence, are described in this review. Robotic surgery in early stage, advanced stage, and relapsed ovarian cancer is discussed separately. In conclusion, evidence regarding the use of robotic-assisted surgical treatment for women with ovarian cancer is still scarce, but its use is progressively growing. Robotic-assisted staging in selected patients with early stage disease has an important role in referral institutions when well-trained gynecologists perform surgeries. However, minimally invasive surgery in patients with advanced stage or relapsed ovarian cancer requires further investigation, even in selected cases.

Lymph nodes are the main pathway in the spread of gynaecological malignancies, being a well-known prognostic factor. Lymph node dissection is a complex surgical procedure and requires surgical expertise to perform the procedure, thereby minimising complications. In addition, lymphadenectomy has value in the diagnosis, prognosis, and treatment of patients with gynaecologic cancer. Therefore, a video focused on the para-aortic retroperitoneal anatomy and the surgical technique of the extraperitoneal para-aortic lymphadenectomy is presented.