Gianluca Raffaello Damiani

Robotic Shaving Technique in 25 Patients Affected by Deep Infiltrating Endometriosis of the Rectovaginal Space

Minimally invasive surgery represents the gold standard for the management of deep infiltrating endometriosis (DIE) involving the rectovaginal septum (RVS). This analysis aimed to evaluate the feasibility of robotic-assisted laparoscopy (RAL) and clinical outcomes in terms of long-term complications, pain relief, and recurrence rate for the treatment of DIE of the RVS. A prospective cohort study of robotic procedures was performed between October 2010 and July 2014, including removal of endometriotic nodules from the RVS with rectal shaving alone or in combination with accessory procedures. In all cases, the revised American Society for Reproductive Medicine (rASRM) score for endometriosis was >40 points (stage IV). Twenty-five consecutive patients underwent RAL, with a successful complete nodule debulking by the wall shaving technique. Pathology confirmed the adequacy of the surgical specimen and the median largest endometriotic nodule was of 21 mm (range, 10-60 mm), with free margins in all cases. The median operative time from skin opening to closure was 174 minutes (range, 75-300 minutes), and blood loss was close to 0 mL. The median revised Enzian score for location A (RVS) was 2 (range, 1-3). The most frequent Enzian class was A2B0C0 (48%), followed by A3B0C0 (12%). In 3 cases (12%), partial vaginal resection was required to remove endometriotic nodules of the RVS (1 each in classes A3B0C1FI, A3B0C0FO, and A3B0C0). No intraoperative complications occurred. This series has a median long-term follow up of 22 months (range, 6-50 months) currently available with an optimal operative time, demonstrating good long-term outcomes. Our data support robotics as a safe and attractive alternative for comprehensive surgical treatment of DIE.

Intermittent low-dose finasteride administration is effective for treatment of hirsutism in adolescent girls: a pilot study.

STUDY OBJECTIVE Hirsutism has negative impact on adolescent psychosocial development for both cosmetic and endocrine reasons. This study evaluated the effectiveness of a new intermittent, low-dose finasteride regimen consisting of 2.5 mg of drug given every 3 days (1 day of treatment, 2 days of drug withdrawal) for 6 months in girls with hirsutism by polycystic ovarian syndrome (PCOS) or idiopathic hirsutism (IH). DESIGN AND PARTICIPANTS Twenty-eight girls (15-19 y old) with hirsutism were randomly assigned to 2 treatment groups and treated for 6 months. Fourteen patients (7 with IH, 7 with PCOS) received finasteride; fourteen patients (7 with IH, 7 with PCOS) received placebo. Hirsutism score (HS), clinical, and hormonal effects were compared between the 2 groups. RESULTS In patients treated with finasteride, the HS value at 6 months was 52.9% lower than that observed at baseline in girls with IH, and 52.8% lower in girls with PCOS (P < .0001 for both). Similarly, the 3α-17 β-androstenediol glucuronide serum levels were decreased by 34.8% in patients with IH, and by 47.5% in patients with PCOS (P < .0001, respectively). Finasteride treatment was well tolerated and did not alter values of BMI, serum levels of sexual hormones, metabolic parameters related to liver and kidney function as well as glycemic and lipidic asset. CONCLUSIONS A low-dose of finasteride, given every 3 days, reduces the HS in young patients affected by PCOS or IH. Compared with conventional continuous finasteride administration, the intermittent low-dose regimen has similar efficacy with the advantage to be safer and less expensive.

Robot-assisted laparoscopic transperitoneal deep pelvic lymphadenectomy for metastatic melanoma of the lower limb: initial report of four cases and outcomes at 1-year follow-up

Current treatment for melanoma of the lower limb includes excision of the primary tumor with ilioinguinal lymphadenectomy in the case of lymph node metastases [1–4]. Robotic deep pelvic lymphadenectomy (RDPL) is a welldescribed procedure of staging and treatment of gynecologic and urologic malignancies. Herein we present our initial report of RDPL in malignant melanoma. To our knowledge only one report is present in literature [5], but no follow-up was performed. Clinical staging were performed using total body tomography. The patients were given cephalosporins and antithrombotic prophylaxis with low-weight heparins. The patients were placed on spreader bars in 30–35 Trendelenburg position. The Da Vinci robot (Intuitive Surgical, CA, USA) was docked in standard fashion, with the column positioned between the patient’s legs. Pneumoperitoneum to 20 mmHg was established with closed Veress needle insertion just above the umbilicus. A 12-mm port was placed above the umbilicus, two 8-mm robotic ports were placed just lateral to the medial umbilical ligaments 14–16 cm from the pubic symphysis and 10 cm from the midline. A third 8-mm robotic port was placed for robotic arm on the left side 10 cm lateral to the left-sided 8-mm robotic port. A 12-mm assistant port was placed in the right lower quadrant. After the intestinal bundle is replaced from the pelvis and adhesiolysis is performed, we first open the lateral leaf of the broad ligament. In the retroperitoneum, the first structure to be identified is the psoas muscle, and then ureter and iliac bifurcation are detected. The obturator nerve, the obturator muscle, and the whole course proximal to the internal iliac artery must be visualized. Lymphadenectomy then begins from the proximal side of the lateral external iliac nodes. The lymph node packet between the external iliac artery and the vein was dissected up to the bifurcation of the common iliac artery. After, excision of superficial and deep obturator lymph node chains and retro crural lymph nodes was performed. The packets were placed in 10-mm Endobags and the specimens were removed through the midline port site. The first patient was a 48-year-old woman, who initially underwent a wide local excision of a 1.3-cm melanoma over the right fibular head. Pathology revealed a nodulartype malignant pigmented melanoma (Clark IV, Breslow 2.75 mm; pT3b) with epithelioid cells (MART1-), with negative margins (no-brisk tumor). One month later, the patient was underwent radicalization of the previous excision and a biopsy of the sentinel lymph node. Two of three sentinel lymph nodes were positive for micrometastatic disease. Two months later a RDPL (ileo-crural inguinal/obturator) with deep inguinal groin lymph node dissection was performed, with removal of 18 negative lymph nodes. The second case concerned a pigmented melanoma of the right thigh with spindles cells (Clark IV, Breslow 1.93 mm; pT2a; no-brisk tumor; MART-1) in a 40 year-old patient. At radicalization and biopsy, micrometastatic disease was A. Pellegrino G. R. Damiani (&) Operative Unit of Gynecology and Obstetrics, Alessandro Manzoni Hospital, Lecco, Italy e-mail: damiani14@alice.it

Intussusception and incarceration of a fallopian tube: report of 2 atypical cases, with differential considerations, clinical evaluation, and current management strategies.

Herein are presented 2 cases from the last 5 years. In case 1, a fallopian tube intussusception without perforation, misdiagnosed as a myoma, was observed at hysteroscopy of the uterine cavity 18 months after last vacuum aspiration. In case 2, a fallopian tube incarceration, misdiagnosed as a placental polyp, was observed 3 months after last suction curettage. Although uterine perforation caused by suction curettage after abortion or of afterbirth occurs rarely, it is a complication that must be taken into account because after this procedure there may be painful symptoms such as the typical triad of abdominal pain, vaginal discharge, and dyspareunia. In some situations, as in case 2, amenorrhea occurs alone, without other distressing symptoms. In both cases, a hysteroscopic approach was used; laparoscopy was necessary only in case 2.

Robotic approach using simple and radical hysterectomy for endometrial cancer with long-term follow-up evaluation.

Feasibility and outcome of robotic‐assisted laparoscopy (RAL) for endometrial cancer was evaluated with a mean follow‐up of 4 years.

Outcomes of Bleomycin-based electrochemotherapy in patients with repeated loco-regional recurrences of vulvar cancer

Abstract Objective To evaluate the safety, local tumor efficacy and relief of symptoms of electrochemotherapy (ECT) treatment in patients affected by recurrence of vulvar cancer (VC), unsuitable for standard treatments. Methods Ten patients were recruited with histological diagnosis of recurrence of VC. Intravenous bleomycin was injected, after an accurate mapping of all lesions and ECT was performed. Response to therapy was evaluated and quality of life (QoL) was evaluated via questionnaires. Results Diagnosis stage of primary tumors, according to the FIGO system, was: four patients respectively at stage IB (40%), and at stage II (40%), one patient at stage IIIA (10%), one patient with Paget cancer (10%). Mean age was 76 years (SD ± 7) at time of enrollment. Eight patients (80%) were previously submitted to surgery and/or radio-chemotherapy. Mean treatment time was 20 (range 10–20) min. After a median follow-up of 12 (3–22) months, six patients (60%) were alive. Conclusions Objective responses (ORs) with local control of the tumor were obtained in 80%. After a mean follow-up of 12 (3–22) months six patients (60%) were alive. The favorable outcome of this study, indicates that ECT is a reliable treatment option that may improve their functioning, thus enhancing the care provided in the palliative setting.

Pregnancy in a woman with premature ovarian insufficiency undergoing intracytoplasmic sperm injection after pretreatment with estrogens followed by therapy with estrogens associated with ovarian stimulation with gonadotropins: remarks about oocyte and embryo quality.

Objective:The aim of this study was to achieve pregnancy in a woman with premature ovarian insufficiency (POI) by means of estrogen pretreatment, a combination of estrogen therapy and gonadotropin ovarian stimulation, and intracytoplasmic sperm injection (ICSI). Methods:A 34-year-old woman with POI who failed to achieve follicular growth in two previous ovarian stimulation protocols using high doses of gonadotropins alone underwent an ICSI trial after estrogen pretreatment (ethinyl estradiol 0.05 mg three times a day for 10 d) followed by estrogens (at the same dose) and recombinant &bgr;-follicle-stimulating hormone (250 IU/d for 12 d). Results:Delivery of a healthy female baby was achieved. Conclusions:Stimulation with gonadotropins plus estrogens after pretreatment with estrogen can be considered a useful intervention in women with POI trying to conceive.

Caesarean scar pregnancy complicated by placenta percreta followed by suppurative appendicitis after conservative management with methotrexate

node chain or area and often asymptomatic. The histological examination is usually of hyaline vascular variant. UCD is usually curable by surgical excision of the mass and the prognosis is good. The systemic or multicentric variant of CD (MCD) is a less common and more aggressive form. Its corresponding histological pattern is the plasma cell variant, and rarely the plasmablastic type. It is frequently accompanied by systemic manifestations, such as fever and night sweats. Patients with MCD require systemic treatment and their prognosis is unfavourable (El-Osta and Kurzrock 2011; Ye et al. 2010; Talat and Schulte 2011). UCD is most commonly found in the mediastinum. However, it can develop anywhere lymphoid tissue is found. The distribution of localised Castleman ’ s disease has been reported as 65% in the mediastinum, 16% in the neck, 12% in the abdomen and 3% in the axilla (Bucher et al. 2005). The pelvic cavity is an unusual site for Castleman ’ s disease. The diagnosis of CD was still mostly dependent on the postoperative histological examination. For this patient, complaints, symptoms, physical examination and accessory examination were all nonspecific. Because of the relatively high incidence of adnexal masses in the female population, the preoperative diagnosis of the patient was gynaecological adnexal mass. But during the operation, we found the mass was localised behind the peritoneum. The diagnosis of the CD was according to the postoperative histological examination. For this kind of the solitary mass, exploratory laparoscopic operation is suitable. In this case, the laparoscopic operation has the advantage of good surgical fi elds and an easier to perform operation, compared with laparotomy. Laparoscopy off ers multiple advantages over traditional laparotomy, including smaller incisions, less blood loss, reduction in the need for analgesics, decreased morbidity and a more rapid recovery (Demir and Marchand 2012). The aetiology of CD is still not clear. The chronic inflammation, immunodeficiency state and autoimmune disorders (such as viral infection involving the human herpes virus 8, the Epstein – Barr virus or autoimmune haemolytic anaemia) are considered to be the possible causal factors of CD (Oksenhendler 2009). Although this patient was not examined for infection of the human herpes virus 8 or the Epstein – Barr virus, she did not have any manifestation of chronic inflammation, immunodeficiency state or autoimmune disorders. The possible susceptibility for her could be her family history of tumour. In conclusion, Castleman ’ s disease should be considered as a rare differential diagnosis in patients with a gynaecological adnexal mass. Preoperative and intraoperative differential diagnosis of CD is important. Exploratory laparoscopic operation is a suitable surgical choice.

Isobaric laparoscopy using LaparoTenser system in surgical gynecologic oncology.

In this prospective analysis, the feasibility and outcome of isobaric laparoscopy in gynecologic oncology was evaluated. Total laparoscopic radical hysterectomy type A and B, with or without pelvic lymphadenectomy, according to the Querleu-Morrow classification was performed in 22 consecutive patients. Seven patients had early cervical cancer (adenocarcinoma stage 1B1 in 1, and squamous carcinoma stage 1B1 in 4, stage 1A2 in 1, and stage 1B2 in 1), and 15 patients had endometrial cancer (stage IA in 4, stage IB in 9, and stage IIIA in 2). Radical hysterectomy was performed using the LaparoTenser, a subcutaneous wall-lifting device. Visual analog score, duration of surgery, blood loss, complications, and postoperative course were recorded. Pathologic analysis confirmed the adequacy of the surgical specimens in type B radical hysterectomies and the number of lymph nodes removed. Low-pressure CO2 insufflation was us to improve field exposure in patients with high body mass index. Postoperatively, no patient reported substantial abdominal discomfort caused by lifting of the abdominal wall. Operative time, blood loss, and hospital stay were consistent with published data for CO2 laparoscopy. One complication related to insertion of the subcutaneous needle of the wall lifter occurred. We conclude that total laparoscopic radical hysterectomy can be successfully completed via isobaric laparoscopy using the LaparoTenser device in patients with early cervical and endometrial cancer. Gasless laparoscopy has become the first choice in our department to overcome the detrimental effects of pneumoperitoneum and represents a logical advance in the evolution of minimally invasive surgery. The LaparoTenser device is being used to perform increasingly complex procedures in high-risk patients and situations.

Conventional fascial technique versus mesh repair for advanced pelvic organ prolapse: Analysis of recurrences in treated and untreated compartments.

117 women with severe pelvic organ prolapse (POP; stage > 2) were enrolled to elucidate a 24-month outcome of POP surgery, using conventional or mesh repair with 3 techniques. 59 patients underwent conventional repair and 58 underwent mesh repair. Two types of mesh were used: a trocar-guided transobturator polypropylene (Avaulta, Bard Inc.) and a porcine dermis mesh (Pelvisoft, Bard Inc.). Women with recurrences, who underwent previous unsuccessful conventional repair, were randomised. Primary outcome was the evaluation of anatomic failures (prolapse stage > 1) in treated and untreated compartments. Anatomic failure was observed in 11 of 58 patients (19%; CI 8.9–29) in the mesh group and in 16 of 59 patients (27.1%; p value = 0.3) in the conventional group. 9 of 11 failures in the mesh group (15.5%; CI 6.2–24.8) were observed in the untreated compartment (de novo recurrences), 14.3% in Pelvisoft and 16.7% in Avaulta arm, while only 1 recurrence in the untreated compartment (1.7%) was observed in the conventional group (odds ratio 10.6, p = 0.03).