Rodrigo Fernandes

Single-Site Robotic Radical Hysterectomy and Sentinel Lymphnode Biopsy in Cervical Cancer: A Case Report

Robotic surgeries for cervical cancer have several advantages compared with laparotomic or laparoscopic surgeries. Robotic single-site surgery has many advantages compared with the multiport approach, but its safety and feasibility are not established in radical oncologic surgeries. We report a case of a Federation of Gynecology and Obstetrics (FIGO) stage IB1 cervical carcinoma whose radical hysterectomy, sentinel lymph node mapping, and lymph node dissection were entirely performed by robotic single-site approach. The patient recovered very well, and was discharged from the hospital within 24 hours.

Step-by-step Type C Laparoscopic Radical Hysterectomy With Nerve-sparing Approach

STUDY OBJECTIVE To show the laparoscopic technique to perform type C radical hysterectomy with a nerve-sparing approach and pelvic lymphadenectomy. DESIGN Educational video with step-by-step explanation of the technique using videos and pictures to highlight the anatomic landmark that guides the procedure. SETTING The goal of this procedure is to enlarge the resection of the paracervix at the junction with internal iliac vascular system, leaving the neural part of the structure under the deep uterine vein untouched. Type C consists in the resection of the uterosacral ligament at the rectum level and the vesicouterine ligament at the bladder level. The ureter is mobilized completely, and 15 to 20 mm of the vagina from the tumor or cervix is resected. Performing such an enlarged hysterectomy, the preservation of the nerve supply to the bladder is crucial, leading to the creation of the subclasses. Type C1 conserves a nerve-sparing approach remaining above the deep uterine vein, whereas in type C2 a resection beyond this landmark including the neural part of the paracervix is performed. INTERVENTIONS Total laparoscopic type C1 radical hysterectomy with pelvic lymphadenectomy. CONCLUSION This video shows the feasibility of type C radical hysterectomy through a minimally invasive approach. The possibility to perform this type of procedure laparoscopically matches with the more conservative approach to cervical cancer, bringing all the advantages of this technique into this field of gynecologic surgery.

Surgical Treatment of Deep Endometriosis

Endometriosis is a complex gynecological disease, which presents a challenge for researchers and surgeons alike. Ectopic deposits of endometrial tissue typically found in the pelvis contribute to disease progression. Associated symptoms of pain and infertility are often attributed to adhesion formation and anatomical distortion frequently responsible for the clinical consequences of the disease [1]. Endometrial tissue within the uterine cavity is responsible for preparing the embryo implantation and nourishing the developing fetus. In the absence of a pregnancy, the corpus luteum degenerates, and hormone levels drop, the effect of which results in shedding of the endometrial lining. This continuous cycle exposes women to constant fluctuations in hormones levels, which in turn regulates the endometrium. Endometriosis most commonly affects the ovaries, posterior cul-de-sac, and uterosacral ligaments [2]. Less frequently affected sites including the diaphragm, lungs, and even endometriotic implants involving the brain have been described [3].

Treatment for Uterine Isthmocele, A Pouchlike Defect at the Site of a Cesarean Section Scar

An isthmocele appears as a fluid pouchlike defect in the anterior uterine wall at the site of a prior cesarean section and ranges in prevalence from 19% to 84%, a direct relation to the increase in cesarean sections performed worldwide. Many definitions have been suggested for the dehiscence resulting from cesarean sections, and we propose standardization with a single term for all cases-isthmocele. Patients are not always symptomatic, but symptoms typically include intermittent abnormal bleeding, pain, and infertility. Pregnancy complications that result from an isthmocele include ectopic pregnancy, low implantation, and uterine rupture. Magnetic resonance imaging and transvaginal ultrasound are the gold standard imaging techniques for diagnosis. Surgical treatment of an isthmocele is still a controversial issue but should be offered to symptomatic women or the asymptomatic patient who desires future pregnancy. When surgery is the treatment choice, laparoscopy guided by hysteroscopy, hysteroscopy alone, or vaginal repair are the best options depending on the isthmoceles characteristics and surgeon expertise.

Introduction of robotic surgery for endometrial cancer into a Brazilian cancer service: a randomized trial evaluating perioperative clinical outcomes and costs

OBJECTIVE: The purpose of this study was to evaluate the clinical outcome and costs after the implementation of robotic surgery in the treatment of endometrial cancer, compared to the traditional laparoscopic approach. METHODS: In this prospective randomized study from 2015 to 2017, eighty-nine patients with endometrial carcinoma that was clinically restricted to the uterus were randomized in robotic surgery (44 cases) and traditional laparoscopic surgery (45 cases). We compared the number of retrieved lymph nodes, total time of surgery, time of each surgical step, blood loss, length of hospital stay, major and minor complications, conversion rates and costs. RESULTS: The ages of the patients ranged from 47 to 69 years. The median body mass index was 31.1 (21.4-54.2) in the robotic surgery arm and 31.6 (22.9-58.6) in the traditional laparoscopic arm. The median tumor sizes were 4.0 (1.5-10.0) cm and 4.0 (0.0-9.0) cm in the robotic and traditional laparoscopic surgery groups, respectively. The median total numbers of lymph nodes retrieved were 19 (3-61) and 20 (4-34) in the robotic and traditional laparoscopic surgery arms, respectively. The median total duration of the whole procedure was 319.5 (170-520) minutes in the robotic surgery arm and 248 (85-465) minutes in the traditional laparoscopic arm. Eight major complications were registered in each group. The total cost was 41% higher for robotic surgery than for traditional laparoscopic surgery. CONCLUSIONS: Robotic surgery for endometrial cancer presented equivalent perioperative morbidity to that of traditional laparoscopic surgery. The duration and total cost of robotic surgery were higher than those of traditional laparoscopic surgery.

Standard Approach to Urinary Bladder Endometriosis

STUDY OBJECTIVE Urinary endometriosis accounts for 1% of all endometriosis where the bladder is the most affected organ. Although the laparoscopic removal of bladder endometriosis has been demonstrated to be effective in terms of symptom relief with a low recurrence rate, there is no standardized technique. Partial cystectomy allows the complete removal of the disease and is associated with low intra- and postoperative complications. Here we describe a stepwise approach to a rare case of a large endometriosis nodule affecting the trigone of the urinary bladder. DESIGN Step-by-step video explanation of a large endometriotic nodule excision (Canadian Task Force classification III). SETTING IRCAD AMITS - Barretos | Hospital Pio XVI. The video was approved by the local institutional review board. PATIENT A 31-year-old woman. INTERVENTION Laparoscopic approach for bladder endometriosis. MEASUREMENTS AND MAIN RESULTS We present a case of a 31-year-old woman who complained of dysuria and hematuria with a bladder nodule of 3 cm affecting the bladder trigone. Laparoscopic complete excision of the nodule was performed. Laparoscopy began with full inspection of the pelvic and abdominal cavity. Vaginal examination under laparoscopic view helped to determinate the dimensions of the bladder nodule. Strategy consisted of bilateral dissection of the paravesical fossae and the identification of both uterine arteries and ureters. The bladder was slowly dissected from the uterine isthmus and was intentionally opened, thus helping the surgeons to identify the lateral and lower limits of the nodule and its proximity to both ureters. Bilateral double J stents were previously placed to guide the excision and further suture. Once the nodule was removed, the remaining wall consisted of the lower aspect of the trigone, both medial lower parts of the ureter, and the apex of the bladder. Suturing was performed in 2 steps. A simple monofilament interrupted suture was applied vertically at the lower wall between both ureters. The same technique was applied horizontally on the bladder dome. Pressure test demonstrated adequate correction. The patient was discharged 2 days later with a bladder catheter and double J stent. After 15 days, both indwelling catheter and ureteric stent were removed, and patient was submitted to a cystogram where no leakage was found. If a leakage had been found on the cystogram, the bladder should be allowed an additional week of continuous drainage. Early follow-up demonstrated a lower bladder capacity that was resolved within 6 months. After a 1-year follow-up the patient had no symptoms and demonstrated no recurrence. She is now 20 weeks pregnant with no need of assisted reproductive methods. CONCLUSION The technique showed in the video demonstrates the feasibility of a laparoscopic approach for bladder endometriosis. Furthermore, the laparoscopic approach allowed the removal of the large nodule, reducing the risk of small bladder symptoms.