Javier De Santiago

Urinary Tract Endometriosis: Clinical, Diagnostic, and Therapeutic Aspects

OBJECTIVES To describe our experience at La Paz University Hospital with 12 patients with urinary tract endometriosis, an uncommon pathologic finding, the most extensive series published by Spanish investigators to our knowledge. METHODS We performed a retrospective analysis of 12 cases of urinary tract endometriosis diagnosed from 1993 to 2008. RESULTS The mean patient age was 37.75 years. Of the 12 patients, 5 had bladder involvement and 7 had ureteral involvement, 2 bilateral, 2 left, and 3 right. In those with bladder endometriosis, the diagnosis was made by cystoscopy and biopsy in 4 patients. Treatment consisted of laparoscopic hysterectomy and partial cystectomy in 1 patient and exploratory laparotomy, transvesical resection, and transurethral resection of the bladder in 3 patients. One of the patients who underwent transurethral resection of the bladder experienced 2 relapses. The first relapse was treated with transurethral resection of the bladder and the second with laparoscopic partial cystectomy. In the patients with ureteral endometriosis, the diagnosis was mainly established by magnetic resonance imaging. Treatment consisted of ureteroneocystostomy in 5 patients (bilateral in 1) and laparoscopic ureterolysis in 2, with later ureteral resection and end-to-end anastomosis in 1 of them. The patient who underwent bilateral ureteroneocystostomy finally required right autotransplantation because of early ureteral relapses. CONCLUSIONS Urinary tract endometriosis is an uncommon pathologic finding. Surgery is the treatment of choice. We believe partial cystectomy should be considered as an initial option in selected cases, depending on the extent and location of lesions. For cases of ureteral endometriosis, the initial technique depends on the location and depth of the lesion.

Prognostic factors associated with local recurrence in squamous cell carcinoma of the vulva

Objective To analyze the prognostic factors related to the recurrence rate of vulvar cancer. Methods Retrospective study of 87 patients diagnosed of vulvar squamous cell carcinoma diagnosed at a tertiary hospital in Madrid between January 2000 and December 2010. Results The pathological mean tumor size was 35.1±22.8 mm, with stromal invasion of 7.7±6.6 mm. The mean free margin after surgery was 16.8±10.5 mm. Among all patients, 31 (35.6%) presented local recurrence (mean time 10 months; range, 1 to 114 months) and 7 (8%) had distant metastases (mean time, 5 months; range, 1 to 114 months). We found significant differences in the mean tumor size between patients who presented a relapse and those who did not (37.6±21.3 mm vs. 28.9±12.1 mm; p=0.05). Patients with free margins equal or less than 8 mm presented a relapse rate of 52.6% vs. 43.5% of those with free margin greater than 8 mm (p=0.50). However, with a cut-off of 15 mm, we observed a local recurrence rate of 55.6% vs. 34.5%, respectively (p=0.09). When the stromal invasion cut-off was >4 mm, local recurrence rate increased up to 52.9% compared to 37.5% when the stromal invasion was ≤4 mm (p=0.20). Conclusion Tumor size, pathologic margin distance and stromal invasion seem to be the most important predictors of local vulvar recurrence. We consider the cut-off of 35 mm of tumor size, 15 mm tumor-free surgical margin and stromal invasion >4 mm, high risk predictors of local recurrence rate.

Evaluation of pain in office hysteroscopy with prior analgesic medication: a prospective randomized study

OBJECTIVE To evaluate whether administration of analgesic medication one hour before undergoing office hysteroscopy decreased pain and other side effects. STUDY DESIGN A prospective randomized study was carried out in 200 patients who underwent office hysteroscopy from November 2011 until May 2012. 100 patients received 1000 mg paracetamol and 600 mg ibuprofen one hour before the procedure and 100 did not receive any medication. RESULTS We observed significant differences (p = 0.013) regarding the occurrence of non-pain side effects, 6% in the non-medicated group and none of the patients in the medicated group. The main pain score was always slightly higher in the group receiving no medication, though there was no statistically significant difference when compared to the medicated group. CONCLUSION Administration of 1 g paracetamol and 600 mg ibuprofen one hour prior to office hysteroscopy decreased statistically the occurrence of non-pain side effects such as nausea, emesis, and hypotension. No differences in pain scores were observed.

Polypoid adenocarcinoma of the cervix during pregnancy managed with conservative treatment

basis of the case presented here, the potential discovery of a retroperitoneal hemorrhage presenting as a vaginal hematoma could favor an operative approach. In conclusion, a worsening vaginal hematoma in the postpartum setting can be the presenting sign of a retroperitoneal hemorrhage. Percutaneous arterial embolization is an effective method of hemostasis. A high index of suspicion and early diagnosis can be lifesaving.

The efficacy of robotic driven handheld instruments for the acquisition of basic laparoscopic suturing skills

OBJECTIVE To evaluate the efficacy of robotic-driven handheld laparoscopic instruments for the acquisition and improvement of basic laparoscopic suturing skills. STUDY DESIGN A prospective study was carried out on 15 physicians grouped by previous experience. They were evaluated on the completion of basic surgical laparoscopic skills. First, they used traditional non-articulating laparoscopic instruments, and later they used robotic-driven articulating instruments. RESULTS Significant time reduction was observed in the group of inexperienced physicians when they used robotic-driven instruments for needle loading and placing stitches. An 8.3% time reduction was observed in the same group when considering total times for the completion of all exercises. No significant differences for the experienced groups were found. CONCLUSIONS Robotic-driven handheld instruments could help inexperienced physicians acquire basic skills in laparoscopic techniques. No benefit has been observed when previous laparoscopic experience is present.

The role of surgery in advanced epithelial ovarian cancer.

Nowadays, the standard management of advanced epithelial ovarian cancer is correct surgical staging and optimal tumour cytoreduction followed by platinum and taxane-based chemotherapy. Standard surgical staging consists of peritoneal washings, total hysterectomy, and bilateral salpingo-oophorectomy, inspection of all abdominal organs and the peritoneal surface, biopsies of suspicious areas or randomised biopsies if they are not present, omentectomy and para-aortic lymphadenectomy. After this complete surgical staging, the International Federation of Gynaecology and Obstetrics (FIGO) staging system for ovarian cancer is applied to determine the management and prognosis of the patient. Complete tumour cytoreduction has shown an improvement in survival. There are some criteria to predict cytoreduction outcomes based on serum biomarkers levels, preoperative imaging techniques, and laparoscopic-based scores. Optimised patient selection for primary cytoreduction would determine patients who could benefit from an optimal cytoreduction and might benefit from interval surgery. The administration of intraperitoneal chemotherapy after debulking surgery has shown an increase in progression-free survival and overall survival, especially in patients with no residual disease after surgery. It is considered that 3–17% of all epithelial ovarian carcinoma (EOC) occur in young women that have not fulfilled their reproductive desires. In these patients, fertility-sparing surgery is a worthy option in early ovarian cancer.

Management of thoracic endometriosis: single institution experience

OBJECTIVE Thoracic endometriosis is a relatively rare type of endometriosis and includes catamenial pneumothorax, hemothorax and hemoptysis, and presence of intrathoracic endometriotic nodules. We want to clarify and resume the most appropriate management of this pathology. STUDY DESIGN We retrospectively reviewed all the cases of thoracic endometriosis diagnosed and followed up in our Unit from 2005 to 2013. This search revealed five women, with a mean age of 34.5 (26-44). Four had previous history of endometriosis or severe dysmenorrhea. One patient complained of chronic shoulder pain with diaphragmatic implants, another one presented catamenial hemoptysis, and three women suffered from catamenial pneumothorax, with right-side preference. RESULTS Three patients underwent surgery and all of them were treated with GnRH agonists at least during 6 month referring improvement in symptoms. After 1-8 years follow-up, all these patients remain asymptomatic. CONCLUSION The optimal management of thoracic endometriosis needs further evaluation but the combined approach by hormonal therapy and surgery could be the best option.

Management of borderline ovarian tumours: a comprehensive review of the literature

Borderline ovarian tumours differ from epithelial ovarian cancer by their low incidence, frequent association with infertility, low association with mutations in BCRA genes, different percentages of the most common histological types, early stage diagnosis, and high survival rate, even when associated with peritoneal involvement. They occur in younger women, which is why one of the objectives in these patients will be the preservation of fertility. The management of these tumours has been widely discussed and still continues to be controversial. The latest findings underscore the importance of full staging in both radical and conservative surgery, to choose the most comprehensive treatment and obtain an accurate prognosis. One of the objectives of this article shall be the in-depth review of the indications, benefits, and disadvantages of each type of surgery, as well as the usefulness of the medical treatment. In addition, the article aims to review follow-up guidelines and to clarify the main prognostic factors that affect recurrence and survival of these patients.

Utility of Three-Dimensional Ultrasonography to Assess the Position of Essure Tubal Occlusion Device and Its Complications.

Background: To determine the utility of three-dimensional (3D) sonography to control the position of hysteroscopic sterilizing device compared to hysterosalpingography (HSG). Methods: A prospective observational study was carried out on 139 patients who underwent hysteroscopic tubal occlusion method between February 2012 and May 2013. Patients underwent 3D ultrasound scan to control device positioning, and they also underwent HSG as an additional control method. Comparison between both methods was carried out. Results: In all, 17 (12.2%) devices were inserted due to a hydrosalpinx and 122 (87.8%) due to sterilization purposes. In 124 (89.2%) cases, sonography correlated completely to HSG findings. Sonography-positive predictive value was 89.5% to detect correct device positioning. Just 4 (2.8%) patients did not present complete tubal occlusion 3 months after device insertion; one of them presented device expulsion, 2 of them presented previous hydrosalpinx (tubal occlusion was confirmed after 6 months), and the last case rejected to undergo further controls but device seem to be effective. Conclusions: 3D sonography seems to be effective for the control of sterilization device positioning, but it also detects insertion complications and device migration. Further studies would be required to assess our findings and the role of sonography in case of hydrosalpinx.

Primary Hormonal Therapy for Elderly Breast Cancer Patients: Single Institution Experience

Aims: Breast cancer is the most frequently diagnosed cancer among women. Up to 50% of breast cancer cases occur in patients over the age of 65 years. Hormonal therapy as a single alternative treatment has been used in this population. The aim of this study was to analyze the oncological outcomes in breast cancer patients who received hormonal therapy alone as a primary treatment. Methods: We retrospectively reviewed our database to find all patients with breast cancer from 2006 to 2011 who were treated with hormonal therapy only at our center. The collected data included patients and tumor characteristics, type of drug administered, follow-up details and type of response obtained using RECIST criteria. Results: We included 44 breast cancer patients. The mean age was 83.5 ± 6.0 years. The majority of patients had tumors with less aggressive immunohistochemical characteristics and 100% of them presented positive estrogen receptors. The pharmacological treatment included exemestane, anastrozole, tamoxifen, letrozole and fulvestrant. The effectiveness rate was 60%, evaluated according to tumor reduction or no progression. Conclusion: The efficacy of hormonal therapy in older patients is reasonably high to justify its use in selected patients. Therefore, it is a sensible alternative for patients who refuse or are unfit for surgery.