Giovanni Roviglione

Vaginal cuff dehiscence after hysterectomy: a multicenter retrospective study

OBJECTIVE This study estimates the incidence of vaginal cuff dehiscence resulting from different approaches to hysterectomy. STUDY DESIGN This multicentric study was carried out retrospectively. We retrospectively analyzed 8635 patients; 37% underwent abdominal hysterectomy, 31.2% vaginal hysterectomy, and 31.8% laparoscopic hysterectomy. All the hysterectomies were considered, vaginal evisceration was registered and analyzed for time of onset, trigger event, presenting symptoms, details of prolapsed organs and type of repair surgery. Continuous variables were compared using the one-way analysis of variance between groups as all data followed a Gaussian distribution, as confirmed by the Kolmogorov-Smirnov test. Differences among subgroups were assessed using the Tukey-Kramer multiple comparisons test. Categorical variables were compared with two tailed Chi-square tests with Yates correction or Fishers exact test, as appropriate. Pearsons linear correlation was used to verify linear relationships between the dehiscence interval and patients age at surgery. RESULTS Thirty-four patients (0.39%) experienced vaginal evisceration. The laparoscopic route was associated with a significantly higher incidence of dehiscence (p<0.05). No differences were found between the 6027 patients (69.8%) who had closure of the vaginal cuff and the 2608 (30.2%) who had an unclosed cuff closure technique. CONCLUSION Vaginal evisceration after hysterectomy is a rare gynecological surgical complication. Sexual intercourse before the complete healing of the vaginal cuff is the main trigger event in young patients, while evisceration presents as a spontaneous event in elderly patients. Surgical repair can be performed either vaginally or laparoscopically with similar outcomes.

Laparoscopic nerve-sparing transperitoneal approach for endometriosis infiltrating the pelvic wall and somatic nerves: anatomical considerations and surgical technique

PurposeEndometriotic or fibrotic involvement of sacral plexus and pudendal and sciatic nerves may be quite frequently the endopelvic cause of ano-genital and pelvic pain. Feasibility of a laparoscopic transperitoneal approach to the somatic nerves of the pelvis was determined and showed by Possover et al. for diagnosis and treatment of ano-genital pain caused by pudendal and/or sacral nerve roots lesions and adopted at our institution. In this paper we report our experience and anatomo-surgical consideration regarding this technique.MethodsConfidence with this technique was obtained after several laparoscopic and laparotomic dissections on fresh, embalmed and formalin-fixed female cadavers and is now routinely performed at our institution in all cases of extensive endometriosis of the pelvic wall, involving the somatic nerves.ResultsWe describe two different laparoscopic transperitoneal approaches to the lateral pelvic wall in case of: (A) deep pelvic endometriosis with rectal and/or parametrial involvement extending to pelvic wall and somatic nerves; (B) isolated endometriosis of pelvic wall and somatic nerves.ConclusionsLaparoscopic transperitoneal retroperitoneal nerve-sparing approach to the pelvic wall proved to be a feasible and useful procedure even if limited to referred laparoscopic centers and anatomically experienced and skilled surgeons.

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.

Neuro-anatomy of the posterior parametrium and surgical considerations for a nerve-sparing approach in radical pelvic surgery

BackgroundEfforts to improve approaches to the so called “parametrium” with minimally invasive and less dangerous techniques have led to a better study of the anatomic location and composition of that region. Nevertheless, many misconceptions and confusions about the anatomy of the posterior parametrium and its structures still remain. This study aimed to review anatomic and surgical data and to identify several clear landmarks and surgical steps for a nerve-sparing approach to posterior parametrectomy in the course of radical pelvic surgery with or without rectal resection.MethodsThe literature and anatomic dissections of fresh, embalmed, and formalin-fixed female pelvis cadavers were reviewed. The authors’ laparotomic and laparoscopic case series also was reviewed for deep-infiltrating endometriosis as well as uterine, ovarian, and rectal cancer.ResultsThe anatomic entity commonly termed the “posterior parametrium” can be identified as the conjunction of three important anatomic structures (ligaments): the cranial structure (uterosacral ligaments), the caudad structure (rectovaginal ligaments), and the laterocaudad structure (lateral rectal ligaments). Identification of these structures (containing autonomic innervations for pelvic viscera) may allow an accurate nerve-sparing surgical approach in many radical pelvic operations.ConclusionsThe incidences of urinary, rectal, and sexual morbidity after radical pelvic surgical procedures for oncologic diseases (rectal/ovarian cancer, advanced endometrial/cervical cancer, posterior pelvic recurrences) and deep severe endometriosis can be reduced by better knowing and dissecting the right embryo-anatomic planes of the so-called “posterior parametrium.”

Total laparoscopic hysterectomy of very enlarged uterus (3030 g): case report and review of the literature

Fibromatosis is the most frequent benign uterine pathology of fertile women, rarely causing anomalous enlargement of the uterus. Traditionally the surgical treatment has been abdominal hysterectomy. However, development of minimally invasive techniques has led to major safeness of the laparoscopic route. We report a case of total laparoscopic hysterectomy performed on a uterus weighting more than 3,000 g and present a review of the literature about the laparoscopic approach to very enlarged uteri.

Pericardial, pleural and diaphragmatic endometriosis in association with pelvic peritoneal and bowel endometriosis: a case report and review of the literature.

Diaphragmatic endometriosis is a rare entity, often asymptomatic, which has been described only in small series. It is almost always associated with severe pelvic involvement. The most plausible theory about this condition is based on retrograde menstruation and subsequent transportation of viable cells in peritoneal fluid from the pelvis up the right gutter to the right hemidiaphragm, thus demonstrating its asymmetric distribution on the diaphragm. Pre-operative diagnosis is poorly supported by imaging techniques. In most cases, it is an incidental finding because the lesions may hide behind the right hepatic lobe. In that case it cannot be easily demonstrated with a laparoscope from an umbilical port. Symptomatic diaphragmatic endometriosis is associated with deep lesions which can involve the entire thickness of the diaphragm. In these cases, treatment is more difficult with possible incomplete pain relief and a considerable possibility of recurrence. In this subset, abdominal surgery is recommended. Surgical treatment must be individualized on the basis of the patients age, fertility desires, type and location of disease and symptoms. We report the surgical treatment of a patient with synchronous pericardial, pleural and diaphragmatic endometriosis associated with pelvic peritoneal and bowel involvement. A review of the literature regarding pericardial and diaphragmatic endometriosis focusing on anatomical and surgical aspects of its management is undertaken.

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.

Laparoscopy for primary cytoreduction with multivisceral resections in advanced ovarian cancer: prospective validation. “The times they are a-changin”?

AbstractBackgroundPrimary cytoreduction is the mainstay of treatment for advanced ovarian cancer (AOC). We developed and prospectively evaluated an algorithm to investigate the possible role of laparoscopic primary cytoreduction (LPC) in carefully selected patients, with AOC.MethodsFrom June 2007 to July 2015, all patients with stage III–IV ovarian cancer and clinical conditions allowing aggressive surgery were candidate to primary cytoreduction with the aim of achieving residual tumor (RT) = 0. The possibility of attempting laparoscopic cytoreduction was carefully evaluated using strict selection criteria. The other patients were approached by abdominal primary cytoreduction (APC). At the end of LPC, an ultra-low pubic mini-laparotomy was performed to extract surgical specimens and to accomplish a laparoscopic hand-assisted exploration of the abdominal organs, in order to confirm complete excision of the disease.ResultsOf the included 66 patients, 21 were considered eligible for LPC; the remaining 45 underwent APC. Optimal cytoreduction (i.e., RT = 0) was obtained in 95 and 88.4% in the LPC and APC groups, respectively. No intra-operative complication and 4 (19%) early post-operative complications were observed among patients who received LPC. Patients who underwent APC had 17.8 and 46.7% intra- and early post-operative complications, respectively. Median time to initiation of chemotherapy was 15 (range, 10–30) days in the LPC group and 28 (20–35) days in the APC group. After a median follow-up of 51 months, 2-year disease-free survival was 76.2% in the LPC group and 73.4% in the APC group.ConclusionsAfter strict selection, a group of patients with AOC may undergo LPC with extremely high rates of optimal cytoreduction, satisfactory perioperative morbidity, a short interval to chemotherapy, and encouraging survival outcomes. Clinical trial registration NCT02980185

Anatomical Landmarks in Deep Endometriosis Surgery

Deep endometriosis (DE) represents a chronic inflammatory disease, affecting pelvic viscera and peritoneal and retroperitoneal structures and completely distorting their normal aspect and reciprocal relationships by a mechanism of progressive infiltration and retraction. One of the main objectives of its surgical treatment, together with reducing pelvic pain and improving fertility, is the restoration of normal pelvic anatomy. For this reason, surgeons must have a deep knowledge of pelvic anatomy, in order to reassess a grossly distorted surgical field. Thus, pelvic anatomical landmarks represent essential points of reference to start procedures such as mobilization of the pelvic viscera, wide peritoneal resections, or the identification of further anatomical structures to be preserved, such as parasympathetic and orthosympathetic pelvic neural fibers in nerve-sparing procedures.

Survival in clinical stage I endometrial cancer with single vs. multiple positive pelvic nodes: results of a multi-institutional Italian study

Objective To investigate survival outcomes in endometrioid endometrial cancer (EEC) patients with single vs. multiple positive pelvic lymph nodes. Methods We performed a retrospective evaluation of all consecutive patients with histologically proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 EEC who underwent primary surgical treatment between 2004 and 2014 at seven Italian gynecologic oncology referral centers. Patients with pre- or intra-operative evidence of extra-uterine disease (including the presence of bulky nodes) and patients with stage IIIC2 disease were excluded, in order to obtain a homogeneous population. Results Overall 140 patients met the inclusion criteria. The presence of >1 metastatic pelvic node was significantly associated with an increased risk of recurrence and mortality, compared to only 1 metastatic node, at both univariate (recurrence: hazard ratio [HR]=2.19; 95% confidence interval [CI]=1.2–3.99; p=0.01; mortality: HR=2.8; 95% CI=1.24–6.29; p=0.01) and multivariable analysis (recurrence: HR=1.91; 95% CI=1.02–3.56; p=0.04; mortality: HR=2.62; 95% CI=1.13–6.05; p=0.02) and it was the only independent predictor of prognosis in this subset of patients. Disease-free survival (DFS) and disease-specific survival (DSS) were significantly longer in patients with only 1 metastatic node compared to those with more than 1 metastatic node (p=0.008 and 0.009, respectively). Conclusion The presence of multiple metastatic nodes in stage IIIC1 EEC represents an independent predictor of worse survival, compared to only one positive node. Our data suggest that EEC patients may be categorized according to the number of positive nodes.