B. Jones

Maximal effort cytoreductive surgery for disseminated ovarian cancer in a UK setting: challenges and possibilities

ObjectiveTo assess surgical morbidity and mortality of maximal effort cytoreductive surgery for disseminated epithelial ovarian cancer (EOC) in a UK tertiary center.Methods/materialsA monocentric prospective analysis of surgical morbidity and mortality was performed for all consecutive EOC patients who underwent extensive cytoreductive surgery between 01/2013 and 12/2014. Surgical complexity was assessed by the Mayo clinic surgical complexity score (SCS). Only patients with high SCS ≥5 were included in the analysis.ResultsWe evaluated 118 stage IIIC/IV patients, with a median age of 63xa0years (range 19–91); 47.5xa0% had ascites and 29xa0% a pleural effusion. Median duration of surgery was 247xa0min (range 100–540xa0min). Median surgical complexity score was 10 (range 5–15) consisting of bowel resection (71xa0%), stoma formation (13.6xa0%), diaphragmatic stripping/resection (67xa0%), liver/liver capsule resection (39xa0%), splenectomy (20xa0%), resection stomach/lesser sac (26.3xa0%), pleurectomy (17xa0%), coeliac trunk/subdiaphragmatic lymphadenectomy (8xa0%). Total macroscopic tumor clearance rate was 89xa0%. Major surgical complication rate was 18.6xa0% (nxa0=xa022), with a 28-day and 3-month mortality of 1.7 and 3.4xa0%, respectively. The anastomotic leak rate was 0.8xa0%; fistula/bowel perforation 3.4xa0%; thromboembolism 3.4xa0% and reoperation 4.2xa0%. Median intensive care unit and hospital stay were 1.7 (range 0–104) and 8xa0days (range 4–118), respectively. Four patients (3.3xa0%) failed to receive chemotherapy within the first 8 postoperative weeks.ConclusionsMaximal effort cytoreductive surgery for EOC is feasible within a UK setting with acceptable morbidity, low intestinal stoma rates and without clinically relevant delays to postoperative chemotherapy. Careful patient selection, and coordinated multidisciplinary effort appear to be the key for good outcome. Future evaluations should include quality of life analyses.

Uterine transplantation: past, present and future.

Absolute uterine factor infertility (AUFI) is a term used to describe women who cannot carry a pregnancy because of the absence of a uterus or the presence of an anatomically or physiologically non-functioning uterus. Causes of AUFI can be categorised into congenital, such as Mayer–Rokitansky–Kuster–Hauser syndrome and acquired, due to Asherman syndrome or following hysterectomy to treat postpartum haemorrhage, benign gynaecological disease or gynaecological cancer. AUFI affects one in 500 women of childbearing age. The present options to acquire motherhood include adoption or surrogacy, both of which are associated with moral and ethical difficulties in addition to complex legal, financial and religious factors. The fact that surrogacy is prohibited in many countries, including Italy, Germany, Pakistan and Saudi Arabia, epitomises the difficulties that such women experience to have children. Uterine transplantation (UTx) may overcome many of these difficulties and could become a realistic future treatment option for AUFI.

Does the use of calcium ionophore during artificial oocyte activation demonstrate an effect on pregnancy rate? A meta-analysis

OBJECTIVEnTo study the effect, if any, of calcium ionophore as a method of artificial oocyte activation (AOA) on pregnancy outcomes and fertilization rates.nnnDESIGNnMeta-analysis of randomized controlled trials, prospective observational and retrospective trials, case reports, and a case-control trial.nnnSETTINGnUniversity-affiliated teaching hospital.nnnPATIENT(S)nInfertile couples undergoing fertilization treatment.nnnINTERVENTION(S)nUse of calcium ionophore during AOA.nnnMAIN OUTCOME MEASURE(S)nOdds ratio (OR) as the summary statistic for binary variables was used. Both a fixed and random effects model were applied. Subgroup analysis using quantitative methodology (risk of bias, metaregression) and graphical comparison (funnel plot) assessed statistical heterogeneity.nnnRESULT(S)nFourteen studies were selected. AOA with calcium ionophore increased the overall clinical pregnancy rate (per ET; OR = 3.48; 95% confidence interval [CI], 1.65-7.37) and the live birth rate (OR = 3.33; 95% CI, 1.50-7.39). This effect of adding calcium ionophore was further demonstrated with fertilization, cleavage, blastocyst, and implantation rates. Subgroup analysis further supported our findings (studies where n > 10 in both arms; random and fixed effects models). A metaregression (beta = -.145) found that as the quality of the study increases, the effect of calcium ionophore is significantly more pronounced with regards to overall pregnancy rate.nnnCONCLUSION(S)nAOA with calcium ionophore treatment after intracytoplasmic sperm injection (ICSI) results in a statistically significant improvement in fertilization, cleavage, blastulation, and implantation rates, as well as overall pregnancy and live-birth rates. The conclusion of this systematic review, demonstrating a strong effect of calcium ionophore use, is reassuring and promising, particularly for couples for whom ICSI alone yields poor fertilization rates.

Correlation of pre-operative CT findings with surgical & histological tumor dissemination patterns at cytoreduction for primary advanced and relapsed epithelial ovarian cancer: A retrospective evaluation

OBJECTIVESnComputed tomography (CT) is an essential part of preoperative planning prior to cytoreductive surgery for primary and relapsed epithelial ovarian cancer (EOC). Our aim is to correlate pre-operative CT results with intraoperative surgical and histopathological findings at debulking surgery.nnnMETHODSnWe performed a systematic comparison of intraoperative tumor dissemination patterns and surgical resections with preoperative CT assessments of infiltrative disease at key resection sites, in women who underwent multivisceral debulking surgery due to EOC between January 2013 and December 2014 at a tertiary referral center. The key sites were defined as follows: diaphragmatic involvement(DI), splenic disease (SI), large (LBI) and small (SBI) bowel involvement, rectal involvement (RI), porta hepatis involvement (PHI), mesenteric disease (MI) and lymph node involvement (LNI).nnnRESULTSnA total of 155 patients, mostly with FIGO stage IIIC disease (65%) were evaluated (primary=105, relapsed=50). Total macroscopic cytoreduction rates were: 89%. Pre-operative CT findings displayed high specificity across all tumor sites apart from the retroperitoneal lymph node status, with a specificity of 65%. The ability however of the CT to accurately identify sites affected by invasive disease was relatively low with the following sensitivities as relating to final histology: 32% (DI), 26% (SI), 46% (LBI), 44% (SBI), 39% (RI), 57% (PHI), 31% (MI), 63% (LNI).nnnCONCLUSIONnPre-operative CT imaging shows high specificity but low sensitivity in detecting tumor involvement at key sites in ovarian cancer surgery. CT findings alone should not be used for surgical decision making.

The dawn of a new ice age: social egg freezing

Given the age‐related decline in ovarian reserve and oocyte quality, it is unsurprising the global trend of deferring motherhood has resulted in increased levels of involuntary childlessness. The development of oocyte vitrification, with pregnancy and livebirth rates now comparable to using fresh oocytes, has provided an opportunity to cryopreserve oocytes electively for future use, empowering women with the capacity to delay their childbearing years. While it enhances reproductive autonomy, age‐related obstetric complications, economic implications and the risk of unsuccessful future treatment make this a controversial therapeutic option. However, some women have no reasonable alternative, such as single women approaching their late thirties, in whom egg freezing, although not a guarantee against involuntary childlessness, offers hope by extending the window of opportunity to find a partner. Given the upward trend in women electively cryopreserving their eggs, it would appear that a new ice age, from a fertility perspective, is upon us.

Ultrasound-guided laparoscopic ovarian preserving surgery to treat anti-NMDA receptor encephalitis.

preserving surgery to treat anti-NMDA receptor encephalitis BP Jones, R Rees, S Saso, C Stalder, JR Smith, J Yazbek a West London Gynaecological Cancer Centre, Queen Charlotte’s & Chelsea Hospital, Imperial College NHS Trust, London, UK b Department of Surgery and Cancer, Imperial College London, London, UK c Department of Neurology, Charing Cross Hospital, Imperial College NHS Trust, London, UK Correspondence: BP Jones, Department of Surgery and Cancer, Imperial College London, Du Cane Road, London W12 0NN, UK. Email benjamin.jones@nhs.net

Social egg freezing should be offered to single women approaching their late thirties: FOR: Women should not suffer involuntary childlessness because they have not yet found a partner

Initiated by the success of contraception in the 1960s and accelerated by the subsequent rise in female employment and tertiary academic opportunity, the age of first-time mothers continues to rise. While this has enhanced female reproductive autonomy, advanced reproductive age coincides with a decrease in oocyte quantity and quality, which manifests clinically with reduced fecundity and an exponential age-related increased risk of miscarriage. It is therefore unsurprising that the trend of postponing childbearing has coincided with increased rates of involuntary childlessness.

Ultrasound-Guided Laparoscopic Ovarian Wedge Resection in Recurrent Serous Borderline Ovarian Tumours.

Objective The aim of this study was to demonstrate the use of intraoperative ultrasound-guided ovarian wedge resection in the treatment of recurrent serous borderline ovarian tumors (sBOTs) that are too small to be visualized laparoscopically. Methods This was a prospective analysis of all women with recurrent sBOTs that were not visible laparoscopically, who underwent intraoperative ultrasound-guided ovarian wedge resection between January 2015 and December 2016 at the West London Gynaecological Cancer Centre, Imperial College NHS Trust, London, United Kingdom. Results We evaluated 7 patients, with a median age of 35 years (range, 28–39 years). Six women were nulliparous, whereas 1 woman had a single child. Previous surgical intervention left 5 women with a single ovary, whereas the remaining 2 had previous ovarian-sparing surgery. The median size of recurrence was 18 mm (range, 12–37 mm). All women underwent uncomplicated intraoperative guided ovarian wedge resections. Histological assessment confirmed sBOT in all 7 cases. Six of the women remain disease-free. One woman recurred postoperatively with her third recurrence, who previously had bilateral disease and noninvasive implants with microinvasive disease and micropapillary pattern. No cases progressed to invasive disease. The median follow-up time was 12 months (range, 1–20 months). One pregnancy has been achieved postoperatively but resulted in miscarriage. Conclusions Continuous intraoperative ultrasound can be used to facilitate complete tumor excision in recurrent sBOT while minimizing the removal of ovarian tissue in women with recurrent sBOT. It is essential that surgical techniques evolve simultaneously with diagnostic imaging modalities to enable surgeons to treat such pathology.

Thinking outside the pelvis: cross‐fertilisation learning between specialties

cross-fertilisation learning between specialties Benjamin P Jones BSc (Hons) MRCOG,* Srdjan Saso PhD MRCS MRCOG, J Richard Smith MD FRCOG Clinical Research Fellow, Department of Surgery and Cancer, Imperial College London, Du Cane Road, London W12 0NN, UK Gynecology Oncolology Subspeciality Trainee, Hammersmith Hospital, Imperial College NHS Trust, London W12 OHS, UK Consultant Gynaecologist, Hammersmith Hospital, Imperial College NHS Trust, London, W12 OHS, UK *Correspondence: Benjamin P Jones. Email: benjamin.jones@nhs.net

Use of biomedical photonics in gynecological surgery: a uterine transplantation model

Aim: Uterine transplantation (UTx) has been proposed as a treatment for permanent absolute uterine factor infertility. The study aims were to compare pulse oximetry and multispectral imaging (MSI), for intraoperative tracking of uterine oxygen saturation in animal UTx models (rabbit and sheep). Results/methodology: Imaging results confirmed the re-establishment of adequate perfusion in the transplanted organ after surgery. Comparison of oxygen saturation values between the pre-UTx donor and post-UTx recipient, and pre-UTx and post-UTx recipient reveals a statistically significant decrease in saturation levels post-UTx. Conclusion: The use of MSI is the first case in gynecology and has demonstrated promise of possible future human use. MSI technique has advantages over pulse oximetry – it provides spatial information in a real-time, noncontact manner.