Eugenio Volpi

Malignant struma ovarii: a case report of laparoscopic management.

BACKGROUND Struma ovarii is a rare disease. Malignant transformation is even rarer. Data about its management are lacking. We describe the first reported case of a malignant struma ovarii treated and staged by laparoscopy. CASE A 49-year-old patient was operated by laparoscopy for a right ovarian teratoma. The patient did not show symptoms of hyperthyroidism. The ovarian teratoma was removed in a plastic bag and definitive histology showed foci of papillary adenocarcinoma in a struma ovarii. The patient was then staged by laparoscopic surgery undergoing left adnexectomy, multiple peritoneal and omental biopsies, and common iliac and paracaval lymph node sampling. Hysterectomy was not performed. The postoperative course was uneventful and the patient was released on the second day. Thyroglobulin level was monitored and the patient is free of disease after more than 1 year. CONCLUSION The preoperative diagnosis of malignant struma ovarii is difficult. Even with cautious evaluation of the patient, some risk of wrong diagnosis is possible. This is why a meticulous technique of laparoscopic surgery in removing the ovary is important. Laparoscopic staging may also intervene in very limited cases; the expertise to perform open staging of the patient is necessary but the postoperative course is fast.

Laparoscopic vs. open treatment of endometrial cancer in the elderly and very elderly: An age-stratified multicenter study on 1606 women

UNLABELLED Objective To investigate in depth the effect of increasing age on the peri-operative outcomes of laparoscopic treatment for endometrial cancer, compared to open surgery, with stratification of patients according to the different definitions of elderly age used in the literature. METHODS Data of consecutive patients who underwent surgery for endometrial cancer staging at six centers were reviewed and analyzed according to surgical approach (laparoscopic or open), different definitions of elderly and very elderly age (≥65years, ≥75years, ≥80years), and class of age (<65; ≥65-<75; ≥75-80; ≥80years). Multivariable analysis to correct for possible confounders and propensity-score matching to minimize selection bias were used. RESULTS A total of 1606 patients were included: 938 and 668 patients received laparoscopic and open surgery, respectively. With increasing age, fewer patients received laparoscopy (P<0.001 with ANOVA). The percentage of patients who received lymphadenectomy declined significantly in both groups for age ≥80years. Blood transfusions, incidence and severity of post-operative complications, and hospital stay were significantly lower among patients who had laparoscopy both in younger (<65years) and elderly (whether defined as ≥65 or ≥75years) patients, with no effect of age on any of the characteristics analyzed ( ANOVA P>0.05). The same tendency was observed among very-elderly patients (≥80years). Multivariable and propensity score-matched analysis confirmed these findings. CONCLUSIONS Laparoscopy for staging endometrial cancer retains its advantages over open surgery even in elderly and very-elderly patients. Our data strongly suggest that minimally-invasive surgery is advantageous even among subjects ≥80years.

Genital and Peritoneal Tuberculosis: Potential Role of Laparoscopy in Diagnosis and Management

Genital and peritoneal tuberculosis are rare in developed countries and can mimic ovarian cancer. We report two different cases that came to our attention, both in a month. The first patient was referred to us for an asymptomatic pelvic mass. The second patient came to us because of weight loss, abdominal swelling, and ascites. Unfortunately, the imaging findings were misleading, and the laboratory analyses were not helpful. Only the laparoscopic approach was useful for final diagnosis. We conclude that the symptoms of abdominal tuberculosis vary greatly, and laparoscopy can be essential for its diagnosis and management.

The Effect of a Uterine Manipulator on the Recurrence and Mortality of Endometrial Cancer: A Multi-Centric Study by the Italian Society of Gynecological Endoscopy.

BACKGROUND: Although widely adopted, the use of a uterine manipulator during laparoscopic treatment of endometrial cancer represents a debated issue, and some authors hypothesize that it potentially may cause an increased risk of relapse, particularly at specific sites. OBJECTIVE: Our aim was to evaluate the risk and site of disease recurrence, overall survival, and disease‐specific survival in women who had laparoscopic surgery with and without the use of a uterine manipulator. STUDY DESIGN: Data were reviewed from consecutive patients who had laparoscopic surgery for endometrial cancer staging in 7 Italian centers. Subjects were stratified according to whether a uterine manipulator was used during surgery; if so, the type of manipulator was identified. Multivariable analysis to correct for possible confounders and propensity score that matched the minimize selection bias were utilized. The primary outcome was the risk of disease recurrence. Secondary outcomes were disease‐specific and overall survival and the site of recurrence, according to the use or no use of the uterine manipulator and to the different types of manipulators used. RESULTS: We included 951 patients: 579 patients in the manipulator group and 372 patients in the no manipulator group. After a median follow‐up period of 46 months (range,12–163 months), the rate of recurrence was 13.5% and 11.6% in the manipulator and no manipulator groups, respectively (P=.37). Positive lymph nodes and myometrial invasion of >50% were associated independently with the risk of recurrence after adjustment for possible confounders. The use of a uterine manipulator did not affect the risk of recurrence, both at univariate (odds ratio, 1.18; 95% confidence interval, 0.80–1.77) and multivariable analysis (odds ratio, 1.00; 95% confidence interval, 0.60–1.70). Disease‐free, disease‐specific, and overall survivals were similar between groups. Propensity‐matched analysis confirmed these findings. The site of recurrence was comparable between groups. In addition, the type of uterine manipulator and the presence or not of a balloon at the tip of the device were not associated significantly with the risk of recurrence. CONCLUSION: The use of a uterine manipulator during laparoscopic surgery does not affect the risk of recurrence and has no impact on disease‐specific or overall survival and on the site of recurrence in women affected by endometrial cancer.

Suspecting malignancy in endometrial polyps: value of hysteroscopy.

AIMS AND BACKGROUND Hysteroscopic polypectomy is the gold standard to treat endometrial polyps and obtain specimens for histological evaluation. There is continuing debate as to when to offer hysteroscopic polypectomy, especially in asymptomatic women with incidental lesions. The aims of this study were to assess the accuracy of hysteroscopy and Vabra sampling in diagnosing atypical hyperplasia and cancer growing on the surface of endometrial polyps and to investigate the association between atypical endometrial polyps and some potential clinical risk factors. METHODS AND STUDY DESIGN This was a retrospective study. We assessed 1039 hysteroscopies and we identified 345 women with endometrial polyps. All patients with endometrial polyps underwent hysteroscopic polypectomy. Data about age, menopausal status, abnormal uterine bleeding (AUB), hormone replacement therapy and tamoxifen use were collected. Hysteroscopic, histological and clinical data were analyzed. RESULTS The incidence of endometrial hyperplasia or cancer growing on the surface of endometrial polyps was significantly low (1.7%). Hysteroscopy correctly excluded (negative predictive value: 100%) and accurately predicted (positive predictive value: 85.7%) preneoplastic or neoplastic lesions growing within the epithelial layer of endometrial polyps. Vabra sampling was inadequate for the histological diagnosis in 38.5% of cases. Age over 60 years and postmenopausal AUB were associated with an 8.3-fold ( P = 0.022) and 8.8-fold (P = 0.020) increased risk, respectively, of preneoplastic and neoplastic lesions growing on the surface of endometrial polyps. CONCLUSIONS Diagnostic hysteroscopy is a good tool to predict malignancy of the epithelial layer of endometrial polyps. Age over 60 years and AUB are associated with an increased risk of malignant polyps. Few suspicious endometrial polyps should undergo surgical resection.

Ovarian lymphoma and hydronephrosis.

This report discusses the association of ovarian lymphoma and hydroureteronephrosis managed by laparoscopic surgery and endoscopy.

The Retrograde and Retroperitoneal Totally Laparoscopic Hysterectomy for Endometrial Cancer

Introduction. We retrospectively report our experience with the utilization of an original procedure for total laparoscopic hysterectomy based on completely retrograde and retroperitoneal technique for surgical staging and treatment of the endometrial cancer. The surgical, financial, and oncological advantages are here discussed. Methods. The technique used here has been based on a combination of a retroperitoneal approach with a retrograde and lateral dissection of the bladder and retrograde culdotomy with variable resection of parametrium. No disposable instruments and no uterine manipulator were utilized. Results. Intraoperative and postoperative complications were observed in 10% of the cases overall. Operative time length and mean haemoglobin drop value results were 129 min and 125 mL, respectively. Most patients were dismissed on days 3–5 from the hospital. Seventy-eight percent of the patients were alive with no evidence of disease at mean followup of 49 months. Conclusions. Our original laparoscopic technique is based on a retroperitoneal approach in order to rapidly control main uterine vessels coagulation, constantly check the ureter, and eventually decide type and site of lymph nodes removal. This procedure has important cost saving implications and the avoidance of uterine manipulator is of matter in case such as these of uterine malignancy.

Retroperitoneal and Retrograde Total Laparoscopic Hysterectomy – Technique with Three- and Five-millimeter Trocars

In this chapter, we describe total laparoscopic hysterectomy (TLH) using retroperi‐ toneal and retrograde technique: it combines the retroperitoneal coagulation of the uterine artery and the retrograde approach to the pelvic organs, as in oncological surgeries. We report our experience in applying this modified TLH with 3-mm instruments and without uterine manipulator, in order to demonstrate its safety and feasibility.

A Case Report and Review of the Literature on Uterine Fatty Tumours (UFT): A Field of Heterogeneous Data

A case of uterine fatty tumour of 2 cm studied by transvaginal ultrasound in a 67-year-old woman undergone totally laparoscopic hysterectomy is here presented along with an updated review of this kind of tumours. A total of 226 cases from 75 publications could be found. Traditional definitions of these tumours are here critically reconsidered. The terminology used to define these tumours is confusing and reflects main radiological and pathological points of view (uterine fatty tumours [UFT] vs. lipoma/ lipoleiomyoma). It is here stressed that these tumours by occurring in aged and overweight women are not so uncommon as generally believed, can be very well recognized, as far as they are small (< 4 cm), by transvaginal ultrasound while CT and MR become more specific for decision making in case of larger size tumours. Symptoms largely vary from none to sudden lump enlargement or bleeding or pain. An association with malignancy has been found in 10% suggesting a radical treatment (hysterectomy) in most cases.

Retroperitoneal and retrograde total laparoscopic hysterectomy as a standard treatment in a community hospital

OBJECTIVE To report our experience with a modified procedure for total laparoscopic hysterectomy based on a retrograde and retroperitoneal technique. This surgical approach is analyzed on a consecutive series of patients in a community hospital and theoretical educational advantages are proposed. STUDY DESIGN All patients undergoing hysterectomy from January 2012 to April 2013 were included in the study. A detailed description of the technique is given. As main outcome measures we evaluated: the number and rate of patients excluded from laparoscopic approach, the rate of late complications need readmission, the rate of transfusions, the rate of conversion to laparotomy and the number of minor complications. The main concern of the study was ureteral complications. RESULTS Overall 174 patients underwent hysterectomy in our unit. The rate of patients submitted to laparoscopic hysterectomy was 97.5%. The number of complications needing re-admission was three (2%). The rate of conversion was 2.7%. In the study period, two (1.2%) ureteral complications were observed (late fistulae). There were four bladder lesions but the patients were released on the same day as the patients with no lesion. CONCLUSIONS Opening the retroperitoneum allows rapid control of the main uterine vessels by coagulation, and constant checks on the ureter. Difficult benign situations can be managed. Even in a non-referral center about 94% of hysterectomies can be performed by laparoscopic surgery. This approach is helpful and may be reproducible in gynecological procedures.