T. Falcone

Consensus statement of the consortium for laparoendoscopic single-site surgery

Inderbir S. Gill • Arnold P. Advincula • Monish Aron • Jeffrey Caddedu • David Canes • Paul G. Curcillo II • Mihir M. Desai • John C. Evanko • Tomasso Falcone • Victor Fazio • Matthew Gettman • Andrew A. Gumbs • Georges-Pascal Haber • Jihad H. Kaouk • Fernando Kim • Stephanie A. King • Jeffrey Ponsky • Feza Remzi • Homero Rivas • Alexander Rosemurgy • Sharona Ross • Philip Schauer • Rene Sotelo • Jose Speranza • John Sweeney • Julio Teixeira

Laparoscopic management of colorectal endometriosis

AbstractBackground: In the past, intestinal endometriosis diagnosed at laparoscopy has generally required conversion to conventional surgery. The purpose of this study was to describe the laparoscopic management of colorectal endometriosis at a tertiary referral center. Methods: From November 1994 to March 1998, 509 consecutive patients with endometriosis requiring laparoscopic intervention were prospectively evaluated. Those with colorectal involvement were analyzed for stage of disease, procedure, operative time, conversion rate, length of hospitalization, and complications. Results: In 30 of the 509 patients (5.9%), colorectal involvement was identified. Twenty-eight of these 30 had stage IV disease. Intestinal involvement was suspected preoperatively in 13 of 30. Twelve required superficial excision of colon or rectal endometriomas. Protectomy/proctosigmoidectomy was done in seven cases, and rectal disc excision was performed in five patients. Four cases required conversion due to the overall severity of the pelvic disease. For those who did (n= 12) and did not (n= 18) require full-thickness excisions/resections, the median operative time was 180 min (range, 90–390) and 110 min (range, 45–355), respectively; the median length of hospitalization was 4 days (range, 3–7) and 1 day (range, 0–4), respectively. A major complication occurred in one patient (colovaginal fistula). At a median follow-up of 10 months (range 1–32), 28 patients were improved, and 24 of these had near or total resolution of preoperative symptoms. Conclusions: Extensive pelvic endometriosis generally requires rectal disc excision or bowel resection. In our experience, laparoscopic treatment of colorectal endometriosis, even in advanced stages, is safe, feasible, and effective in nearly all patients.

MOUSE OVARIAN FOLLICLE CRYOPRESERVATION USING VITRIFICATION OR SLOW PROGRAMMED COOLING: ASSESSMENT OF IN VITRO DEVELOPMENT, MATURATION, ULTRA-STRUCTURE AND MEIOTIC SPINDLE ORGANIZATION

Aim:  To compare different outcomes of vitrification and slow freezing of isolated pre‐antral follicles and to evaluate different cryo‐devices for vitrification of isolated follicles.

Robotics in reproductive surgery: Strengths and limitations

Minimally invasive surgical techniques are becoming increasingly common in gynecologic surgery. However, traditional laparoscopy can be challenging. A robotic surgical system gives several advantages over traditional laparoscopy and has been incorporated into reproductive gynecological surgeries. The objective of this article is to review recent publications on robotically-assisted laparoscopy for reproductive surgery. Recent clinical research supports robotic surgery as resulting in less post-operative pain, shorter hospital stays, faster return to normal activities, and decreased blood loss. Reproductive outcomes appear similar to alternative approaches. Drawbacks of robotic surgery include longer operating room times, the need for specialized training, and increased cost. Larger prospective studies comparing robotic approaches with laparoscopy and conventional open surgery have been initiated and information regarding long-term outcomes after robotic surgery will be important in determining the ultimate utility of these procedures.

Post-menopausal endometriosis with inferior vena cava invasion requiring surgical management

Post-menopausal endometriosis is rare after hysterectomy, and preliminary data support treatment with aromatase inhibitors (AIs). Sites for extrapelvic recurrent disease are wide-ranging; however, no previous case reports have described endometriosis invading the inferior vena cava. A 59-year-old woman status post hysterectomy and bilateral salpingo-oophorectomy for endometriosis developed a periaortic mass with ureteral obstruction. Computerized tomography-guided biopsy confirmed recurrent endometriosis and the lesion enlarged despite treatment with AIs. Vascular surgery, urology and gynecology were involved. The mass was resected surgically and pathology confirmed invasion of the inferior vena cava. Medical management with AIs can be attempted for extra-pelvic endometriosis status post hysterectomy; however, the efficacy in this setting is limited. Surgical management may be necessary for bulky or invasive disease.

Livebirth and utero-placental insufficiency in Papio hamadryas baboons with uterus angiosome perfused by bilateral utero-ovarian microsurgical anastomoses alone

STUDY QUESTION Can the baboon uterus support a gestation to livebirth with an angiosome using microsurgically anastomosed utero-ovarian vessels and lacking uterine arteries and veins? SUMMARY ANSWER Our angiosome model allows healthy livebirth albeit with risk of fetal growth restriction and stillbirth. WHAT IS KNOWN ALREADY Uterine transplant can provide livebirth in humans, but requires a living donor to undergo a prolonged laparotomy for hysterectomy. In an attempt to avoid the time-consuming dissection of the uterine vein, our group has previously shown maintenance of baboon uterine menstrual function after ligation of the uterine vein and after ligation of both the uterine artery and uterine vein. STUDY DESIGN, SIZE, DURATION In a 19-month timespan, three baboons underwent laparotomy to surgically alter uterine perfusion, and pregnancy outcomes were monitored after spontaneous mating in a breeding colony. PARTICIPANTS/MATERIALS, SETTING, METHODS Three nulligravid female Papio hamadryas baboons in a breeding colony underwent laparotomy to ligate uterine arteries and veins along with colpotomy and cervico-vaginal anastomosis. During the same surgery, the utero-ovarian arteries and veins were microsurgically transected and re-anastomosed to themselves. Intraoperative organ perfusion was confirmed with laser angiography. After a recovery period, monitoring of menstrual cycling via menstrual blood flow and sex-skin cycling occurred, as well as uterine viability via sonography and cervical biopsy. Each baboon was released to the breeding colony for spontaneous mating and pregnancies dated by menstrual calendar and compared with early ultrasound. Delivery outcomes were monitored in each including neonate weight and placental pathology. In the event of a stillbirth, the animal was returned to the breeding colony for repeat mating attempts. After achieving a livebirth, the maternal baboon was removed from the study. MAIN RESULTS AND THE ROLE OF CHANCE Each baboon in the trial underwent successful surgery with all uteri demonstrating viability and return of menstrual function within 10 weeks of surgery. Pregnancies occurred within two menstrual cycles in breeding colony. Baboons one and two initially had vaginal breech stillbirths, both with appearance of placental insufficiency, and one with fetal growth restriction. Baboon three underwent scheduled cesarean delivery resulting in a normally grown livebirth. Baboon one had a subsequent pregnancy resulting in a livebirth via cesarean delivery. LIMITATIONS, REASONS FOR CAUTION Stillbirth in two of four gestations, and fetal growth restriction in one of four, are the largest concerns in our perfusion model. It remains uncertain whether the stillbirths resulted from placental insufficiency, or birth trauma from breech deliveries. WIDER IMPLICATIONS OF THE FINDINGS The success of two livebirths warrants further attempts at improving consistency of our proposed uterine angiosome. This may allow living uterine donors to undergo less-invasive and shorter donor hysterectomy procedures. STUDY FUNDING/COMPETING INTEREST(S) The study had no external sponsors, and was supported by the Cleveland Clinic Foundation. Some equipment was loaned without cost to the research team including a laser angiography system courtesy of Novadaq Technologies, Inc. (Missaugua, ON, Canada) and a surgical microscope courtesy of DB Surgical (Coral Springs, FL, USA). B.B., K.A., M.S., K.R., M.M., P.F.E., A.T. and T.F. have no conflicts of interest. M.L.S. and S.Z. report activity as consultants for Medtronic-Covidien, and S.Z. also is a consultant to Applied Medical.

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Response of Immature and Mature Mouse Oocyte Spindle Structure to Oxidative Stress

Objective: The present study was undertaken to evaluate the effect of oxidative stress (OS) on the spindle structure of immature and mature oocytes induced by exogenous exposure to hydrogen peroxide during in vitro culture. Design: Prospective, animal study Materials and Methods: Based on the presence or absence of first polar body, a total of 52 oocytes were grouped as mature (n = 32) and immature (n = 20) and exposed to 25μM of hydrogen peroxide (H2O2) for 30 min. Mature oocytes (n = 50) incubated with human tubal fluid (HTF) media alone served as control. After fixation, immunohistochemical staining was done to evaluate the effects of H2O2 on the oocyte microtubule morphology (MT) and staining with propidium iodide staining to evaluate alteration of chromosomal alignment (CH). Stained oocytes were scored for alterations in MT and CH under a Fluorescent and scanning confocal microscope. Spindle structure was scored for microtubule and chromosome alterations (modified from Saunders and Parks, 1999). Microtubules were scored as: 1) normal = score 1-2; 2) abnormal = score 3; and 3) missing = score 4. For chromosomes: 1) normal = score 1-2; 2) slightly abnormal = score 3; and 3) abnormal = score 4. Results: Results of the alterations in MT are in Table 1 and CH analyses in Table 2. Compared with control, statistically significant differences were seen in both abnormal and missing microtubules category from both mature and immature oocytes following H2O2 exposure (P <0.05). An inverse trend was seen in the proportion of abnormal and missing microtubules in the mature and immature oocytes (P <0.05) following H2O2 exposure. Statistically significant differences were observed in both slightly abnormal and abnormal CH from mature and immature oocytes compared with control (P <0.05). However there were no differences in slightly abnormal and abnormal CH seen in both mature and immature oocytes. Table 1. Percentage of mature and immature oocytes showing alterations in the MT following H2O2 exposure Microtubule morphology

Alterations in mitochondrial membrane potential (δϕ) and oxidative stress in men with male infertility.

AND OXIDATIVE STRESS IN MEN WITH MALE INFERTILITY Xia Wang, Rakesh K. Sharma, Valal George, Tommaso Falcone, Anthony J. Thomas, Ashok Agarwal, The Cleveland Clinic Foundation Objective: Oxidative stress due to excessive production of reactive oxygen species (ROS) is known to impair male fertility. Sperm mitochondria possess a distinct genome (mtDNA) which is more susceptible to ROS-induced damage than nuclear DNA. Fragmentation of genomic DNA is one of the hallmarks of apoptosis. Functional integrity of sperm mitochondria is indicative of apoptosis. Alterations in mitochondrial membrane potential (∆Ψ) may occur during early stages of apoptosis. The ability to discriminate between mitochondria exhibiting high membrane potential from those having low ∆Ψ provides a rigorous estimate to metabolic function. The purpose of this study was to determine the effect of ROS on mitochondrial membrane potential and to evaluate its correlation with conventional semen parameter.

Is There a Relationship between Oxidative Stress and the Embryotoxicity of Hydrosalpinx Fluid on Mouse Embryo Development

Objective: The pathophysiology of hydrosalpinx remains unclear. In the present study we examined the role of oxidative stress and embryotoxic effect of hydrosalpinx fluid (HSF) on mouse blastocyst development rate (BDR). Design: Prospective study in a tertiary care facility. Material and Methods: Hydrosalpinx fluid was collected from six infertile patients undergoing laparoscopic examination. Levels of reactive oxygen species (ROS) and total non-enzymatic antioxidant capacity (TAC) were measured by chemiluminescence assay and lipid peroxidation (LPO) by the thiobarbituric acid method. Mouse embryotoxicity was measured by observing the BDR of 2-cell embryos incubated with 25%, 50% and 75% concentration of HSF. Results: Varying but very small amounts of ROS and TAC levels were seen in HSF. LPO activity was detected in all samples [median (25% and 75% interquartile range (10450 (2700 10840)]. Significant differences were seen in the hydrosalpinx embryotoxicity at different concentrations (p< 0.0001). Percentage blastocyst development rate Patient No. HSF Vol. (mL) LPO (μM/L) 25% HSF 50% HSF 75% HSF