Martino Rolla

Behaviour of ovarian tumors of low malignant potential treated with conservative surgery

OBJECTIVE Fertility-sparing surgery has been proposed for the treatment of borderline ovarian tumors. The aim of this study was to evaluate the outcome of patients submitted to cystectomy (CYS) compared with patients treated by unilateral salpingo-oophorectomy (USO) or bilateral salpingo-oophorectomy with/without total hysterectomy (radical surgery, RS). METHODS We reviewed retrospectively the data of patients treated in 3 institutions for borderline ovarian tumors. One hundred and sixty-eight patients underwent laparoscopic or laparotomic surgical treatment from 1985 to 2006. Tumor recurrence rate, disease-free survival and site of recurrences were evaluated. Specific prognostic factors, such as stage, histology, micropapillary subtype, exophytic tumor growth, intraoperative spillage, endosalpingiosis, staging procedures, and route of surgery were analysed. RESULTS Thirty-five patients underwent cystectomy, 50 unilateral salpingo-oopohorectomy, and 83 radical surgery. Twelve patients in the CYS group (34.3%), 10 in the USO group (20.0%), and 5 (6.0%) in RS group relapsed. Five-year progression-free survival (PFS) was 59.6%, 78.4%, and 93.5% in CYS, USO and RS groups, respectively. None of the relapsed patients died of disease. CONCLUSIONS Cystectomy is an effective surgical strategy for patients with borderline ovarian tumor. The higher risk of local relapses is not associated with a reduction in the overall survival. The procedure should be offered to young patients with bilateral tumors and to very young ones, considering the higher risk of local relapse.

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 conservative surgery for stage IV symptomatic endometriosis: short-term surgical complications

OBJECTIVE To study severe endometriosis as a cause of pelvic pain, which represents one of the most challenging disorders in gynecology. DESIGN Retrospective study. SETTING Teaching hospital. PATIENT(S) A total of 1,363 women with severe endometriosis (revised American Society for Reproductive Medicine [rASRM] stage IV). INTERVENTIONS A detailed survey of all patients with severe endometriosis (rASRM stage IV) who underwent laparoscopy at our center between January 2004 and December 2007 was carried out. MAIN OUTCOME MEASURE(S) Clinical and surgical data were retrieved and assessed according to the extent of surgery performed. Intraoperative, ultra-short, and short-term clinical complications were assessed. RESULTS A total of 1,201 women underwent laparoscopic radical surgery with excision of all visible endometriotic lesions, with a significant improvement of symptoms at 1-month follow-up evaluation. The overall intraoperative complication rate was 2.0%. The morbidity was significantly increased when bowel surgery was performed, with a risk of intraoperative complications that was threefold higher. Of the patients who had bowel surgery, 18 (4.1%) required reintervention within the first week after surgery. CONCLUSION(S) We report on the safety and efficacy of laparoscopic eradication of all visible implants in cases of rASRM stage IV endometriosis when surgery is performed in a referral center.

Uterine smooth muscle tumor of uncertain malignant potential: a three-case report

Based on the degree of cytologic atypia, mitotic activity, and other features, uterine smooth muscle tumors have historically been grouped into two classes: benign leiomyomas and malignant leiomyosarcomas. However, this separation holds true more in principle than in practice because the tumors biological potential may not always be determined with certainty, complicating diagnosis, and therapy. We report three cases of patients with uterine smooth muscle tumors of uncertain malignant potential. Surgery was radical in two and conservative in one. During the follow-up, one patient developed diffuse lung metastases. The two other patients have not shown any signs of relapse to date. Uterine smooth muscle tumors of uncertain malignant potential may have an unpredictable clinical course and may metastasize to seemingly low-grade neoplasms in distant sites even after several years and even in the absence of important negative prognostic predictors, such as coagulative tumor cell necrosis. At present, no final consensus has been reached on the choice of the best strategy for surgery and adjuvant therapy

Preoperative Transvaginal Ultrasonography and Intraoperative Gross Examination for Assessing Myometrial Invasion by Endometrial Cancer

Endometrial cancer is the most common gynecologic malignancy. The cornerstone of treatment remains surgery according to International Federation of Gynecology and Obstetrics staging. The aim of this study was to evaluate the concordance between myometrial infiltration detected by ultrasonography and gross examination with respect to definitive histologic examination and to select a population in which lymphadenectomy could be excluded. We also evaluated the concordance for the degree of tumor differentiation between diagnostic biopsy and final histologic results.

Assessment of tumor size as a useful marker for the surgical staging of endometrial cancer

Accumulating evidence suggests that the estimation of tumor size may improve endometrial cancer treatment. We conducted an observational study aimed at elucidating the association between tumor size and other universally accepted prognostic factors in order to identify suitable preoperative parameters which can guide surgery in a subgroup of early corpus endometrial cancer. We found that when tumor size increased, both stage and grading were significantly increased. Tumor size was correlated with CA 125 serum values, node metastasis and peritoneal cytology status. Patients who have grade 1 or 2 endometrioid corpus cancer, myometrial invasion < 50% and ≤ 3 cm largest tumor diameter can only be treated with hysterectomy. The tumor largest diameter should be evaluated as a preoperative parameter that indicates patients who do not require lymphadenectomy.

Randomised prospective study of abdominal wall closure in patients with gynaecological cancer.

Background:  Median laparotomy is the most common approach to the abdominopelvic cavity in patients with gynaecological tumours.

Role of D-dimer testing in severe pelvic inflammatory disease: a new usable marker to assess the need for fertility-impairing surgery?

Pelvic inflammatory disease (PID), like many other inflammatory diseases, can be characterized by an inflammation-induced activation of the coagulation cascade, resulting in the production of D-dimers. In this study it is demonstrated how high levels of D-dimers, assayed at the time of hospitalization, are encountered in patients diagnosed with PID and how the levels of this parameter are significantly higher in patients, which due to the severity of the disease, needed surgical treatment. Therefore the d-dimer is shown to be an important parameter to be considered in the therapeutic counseling of severe forms of PID.

Isolated Ovarian Relapse of Pre-B Acute Lymphoblastic Leukemia: A Case Report

BACKGROUND Acute lymphoblastic leukemia is a malignant disease of the bone marrow in which early lymphoid precursors proliferate and replace normal marrow hematopoietic cells, resulting in a marked decrease in the production of normal blood cells. CASE REPORT We report a case of isolated ovarian relapse 7 years after the primary diagnosis in a patient, who was seemingly in clinical remission following unilateral ovariectomy and second-line chemotherapy. CONCLUSION In contrast to testicular relapse, ovarian relapses in acute lymphoblastic leukemia are rarely reported. Surgical removal of the mass followed by chemotherapy is the therapeutic standard.

Laparoscopic management of gynaecological cancer in pregnancy.

prompted by laparotomy or colpotomy and not following laparoscopic removal (Grimaldi et al. 2005). However, the most common cause of failure of laparoscopic removal is the fact that the IUCD is embedded in the omentum and cannot be visualised. Therefore, the feasibility of laparoscopic retrieval depends on the ability to spot the device within the peritoneal cavity and the degree of attachment of the device to intraperitoneal structures, especially vascular and intestinal ones. We were contemplating hand assisted laparoscopic removal if laparoscopy failed to spot the device, as a hand within the abdominal cavity will help to restore the tactile sensation which is lacking in laparoscopic procedures. In the event of this failure to localise the device, an image intensifier may be used to help find the migrated device during laparotomy. This case highlights the fact that IUCDs can migrate to unusual sites with minimal symptoms and some potential complications. It also demonstrates the ease of laparoscopic localisation and retrieval, which should be the mainstay of surgical treatment if removal is contemplated.