monthly focus

surgical intervention video

This is the case of a 39-year-old female patient with a history of suprapubic cystourethropexy and anterior colporrhaphy with a recurrent anterior and apical prolapse. She had a sensation of a vaginal mass and abnormal uterine bleeding with no presence of urinary incontinence. Due to the patient’s physical examination and symptoms, a laparoscopic sacral colpopexy with subtotal hysterectomy was considered to correct the recurrent prolapse and treat abnormal uterine bleeding. It was decided to perform a subtotal hysterectomy to reduce the risks of mesh extrusion.



Take-home messages:

Conventionally, anterior compartment recurrence has been higher when compared to apical and posterior compartment recurrence. Synthetic meshes aiming to decrease such recurrence rates have been the subject of much controversy. They led to an improvement in the staging of pelvic support in relation to the Pelvic Organ Prolapse Quantification System (POP-Q) and to provide a subjective sensation of relief from the vaginal mass, yet with an increase in complications and no improvement in quality-of-life surveys as compared to surgery with native tissue. Likewise, the rates of reoperation for prolapse are similar between the two groups. Similarly, apical suspension has been shown to be an essential factor for the successful treatment of the anterior compartment. 

Sacral colpopexy via laparotomy or laparoscopy has become the gold standard for treatment of vaginal vault prolapse with a greater anatomical success and a lower probability of reoperation, when compared to surgery performed vaginally.  This technique has been extrapolated to hystero-preservation surgeries or in patients with uterine prolapse, with similar results. Likewise, in this group of patients, there is controversy as to whether to perform a total hysterectomy or a subtotal hysterectomy. 

Some authors report a decrease of up to 4 times regarding the probability of synthetic material exposure in the larger group of patients that were submitted to a sub-total hysterectomy with the same anatomical and subjective success rates.  

In this patient with recurrent anterior prolapse and associated apical prolapse, this surgery was chosen, considering that it uses a multicompartmental surgical technique. It also addresses the three compartments and allows adequate correction of the anterior prolapse if the mesh is advanced to the bladder trigone. Likewise, the laparoscopic approach allows reduced intraoperative bleeding, diminished recovery time with similar results to an open approach. In this group of patients, it is essential to rule out any cervical pathology and to screen for cervical cancer. 



Bibliography:

1. Rosati, M., Bramante, S. and Conti, F. (2014) ‘A review on the role of Laparoscopic Sacrocervicopexy’, Current Opinion in Obstetrics &amp; Gynecology, 26(4), pp. 281–289. doi:10.1097/gco.0000000000000079. 

2. Lang, P. and Whiteside, J.L. (2017) ‘Anterior compartment prolapse: What’s new?’, Current Opinion in Obstetrics &amp; Gynecology, 29(5), pp. 337–342. doi:10.1097/gco.0000000000000392. 

3. Geoffrion, R. and Larouche, M. (2021) ‘Guideline no. 413: Surgical management of apical pelvic organ prolapse in women’, Journal of Obstetrics and Gynaecology Canada, 43(4), pp. 511–523. doi: 10.1016/j.jogc.2021.02.001. 

4. Campagna, G. et al. (2021) ‘Laparoscopic sacral hysteropexy versus laparoscopic sacral colpopexy plus supracervical hysterectomy in patients with pelvic organ prolapse’, International Urogynecology Journal, 33(2), pp. 359–368. doi:10.1007/s00192-021-04865-0.

Supracervical laparoscopic sacrocolpopexy for recurrent prolapse and abnormal uterine bleeding

Masse utérine cavitaire accessoire, une anomalie müllerienne rare : excision laparoscopique

This video demonstrates a rare congenital Mullerian uterine anomaly, namely an accessory cavitated uterine mass (ACUM). It occurs due to the duplication of the ductal Mullerian tissue at the level of the round ligament and it is related to gubernaculum dysfunction. The video demonstrates the pre-surgical work-up, the surgical demonstration, and the histopathology report confirming the diagnosis. 



Bibliography:

1. Mondal R, Bhave P. Accessory cavitated uterine malformation: Enhancing awareness about this unexplored perpetrator of dysmenorrhea. Int J Gynaecol Obstet. 2023 Aug;162(2):409-432. doi: 10.1002/ijgo.14681. Epub 2023 Feb 7. PMID: 36656754.

2. Peters A, Rindos NB, Guido RS, Donnellan NM. Uterine-sparing Laparoscopic Resection of Accessory Cavitated Uterine Masses. J Minim Invasive Gynecol. 2018 Jan;25(1):24-25. doi: 10.1016/j.jmig.2017.06.001. Epub 2017 Jul 21. PMID: 28599883.

3. Arya S, Burks HR. Juvenile cystic adenomyoma, a rare diagnostic challenge: Case Reports and literature review. F S Rep. 2021 Feb 10;2(2):166-171. doi: 10.1016/j.xfre.2021.02.002. PMID: 34278349; PMCID: PMC8267394.



Accessory cavitated uterine mass, a rare Mullerian anomaly: laparoscopic excision

Introduction: 

Non-puerperal uterine inversion (NPUI) is a rare gynecologic condition with diagnostic and surgical challenges, characterized by the turning inside out of the uterus in women who are not pregnant or have recently given birth. It is unrelated to the postpartum period and can happen at any time.

The actual incidence is unknown and most of the published literature on NPUI is in the form of case reports. There have been 170 cases reports in the literature since 1940.

The mechanism of non-puerperal inversion is not so clear. However, it is often associated with the presence of benign or malignant tumors within or attached to the uterus, such as fibroids or polyps.

Clinical case presentation: This video presents the case of a 48-year-old woman with NPUI stage 4 associated with a large uterine myoma managed with a combined laparoscopic and vaginal approach.

The technical steps for its laparoscopic and vaginal management are demonstrated.

Conclusion: 

The laparoscopic and vaginal management of NPUI is feasible with satisfying results.



Bibliography:

1. Rosa Silva, B., de Oliveira Meller, F., Uggioni, M. L., Grande, A. J., Chiaramonte Silva, N., Colonetti,T., ... & da Rosa, M. I. (2018). Non-puerperal uterine inversion: a systematic review. Gynecologic and Obstetric Investigation, 83(5), 428-436.

2. Kesrouani A, Cortbaoui E, Khaddage A, Ghossein M, Nemr E. Characteristics and Outcome in Non-Puerperal Uterine Inversion. Cureus. 2021 Feb 15;13(2):e13345. doi: 10.7759/cureus.13345. PMID: 33754086; PMCID: PMC7971731.

3. Thakur M, Thakur A. Uterine Inversion. 2022 Nov 28. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2023 Jan–. PMID: 30247846.

4. Moshayedi F, Seidaei HS, Salehi AM. A Case Report of Non-puerperal Uterine Inversion due to Submucosa Leiomyoma in a Young Virgin Woman. Case Rep Surg. 2022 Aug 16;2022:5240830. doi:10.1155/2022/5240830. PMID: 36017477; PMCID: PMC9398870.



Non-puerperal uterine inversion managed using a combined laparoscopic and vaginal approach

Inversion utérine non puerpérale traitée par une double approche laparoscopique et vaginale

This video presents the case of a 42-year-old female patient with a history of difficult birth, gravida 2, parity 2, and vaginal birth 2. She had no surgery or any significant medical history. She had a BMI of 29.8. The patient reported experiencing urinary leakage during coughing. A routine urinalysis was conducted; the result was normal. Valsalva and Boney tests were applied to the patient. A urodynamic test was performed. A diagnosis of type 2 stress urinary incontinence (SUI) was established, and it was decided to perform an extraperitoneal laparoscopic Burch colposuspension, which is a widely accepted technique for the treatment of stress urinary incontinence. Laparoscopic Burch colposuspension offers advantages over the open Burch colposuspension (i.e., reduced bleeding, shorter postoperative recovery time), and it is more minimally invasive. However, the surgery duration is longer. In our patient, we performed the extraperitoneal Burch colposuspension technique, and total surgical time was 37 minutes. Skipping the steps of opening and closing the peritoneum and directly entering the space of Retzius allow to save significant time. An appropriate dissection strategy allows to clearly visualize anatomical landmarks. 

 

Bibliography:

1. Ye Y, Wang Y, Tian W, et al. Burch colposuspension for stress urinary 

incontinence: a 14-year prospective follow-up. Sci China Life Sci. 2022;65(8):1667- 

1672. doi:10.1007/s11427-021-2042-9 



2. Bulent Tiras M, Sendag F, Dilek U, Guner H. Laparoscopic burch colposuspension: 

comparison of effectiveness of extraperitoneal and transperitoneal techniques. Eur J 

Obstet Gynecol Reprod Biol. 2004;116(1):79-84. doi:10.1016/j.ejogrb.2004.02.003 



3. Obaid AA, Al-Hamzawi SA, Alwan AA. Laparoscopic and open burch 

colposuspension for stress urinary incontinence: advantages and disadvantages. J 

Popul Ther Clin Pharmacol. 2022;29(2):e20-e26. Published 2022 Jun 16. 

doi:10.47750/jptcp.2022.926 

Extraperitoneal laparoscopic Burch colposuspension

Colposuspension laparoscopique extrapéritonéale selon Burch

Traitement laparoscopique de l'endométriose vésicale

This video shows the case of a female patient presenting with bladder endometriosis managed safely and effectively using laparoscopic surgery. The patient presented with urinary discomfort, primarily during the initiation of micturition. A magnetic resonance imaging was performed, revealing a fibrotic focus measuring approximately 20 by 14.5mm in relation to the cesarean scar. This focus involved the posterior and upper wall of the bladder in close vicinity with the distal left ureter and the ureteral meatus. This surgery was performed by gynecology surgeons with the assistance of urological surgeons. The video is a stepwise demonstration of the technique with narrated video footage. This procedure is recommended to a gynecological surgical audience. 

Endometriosis is estimated to affect around 10% of women in their reproductive age. Bladder endometriosis is considered a relatively rare form of endometriosis, accounting for a small subset of all endometriosis cases. It is estimated that bladder involvement occurs in about 1 to 7% of women with endometriosis. The common symptoms of bladder endometriosis include chronic pelvic pain, urinary symptoms, and painful intercourse. The approach involves a combination of continued hormone therapy and surgical intervention, including nodule resection. 



Bibliography:

1. Tomasi MC, Ribeiro PAA, Farah D, Vidoto Cervantes G, Nicola AL, Abdalla-Ribeiro HS. Symptoms and Surgical Technique of Bladder Endometriosis: A Systematic Review. J Minim Invasive Gynecol. 2022 Dec;29(12):1294-1302. doi: 10.1016/j.jmig.2022.10.003. Epub 2022 Oct 15. PMID: 36252916. https://pubmed.ncbi.nlm.nih.gov/36252916/ 



2. Allaire C, Bedaiwy MA, Yong PJ. Diagnosis and management of endometriosis. CMAJ. 2023 Mar 14;195(10):E363-E371. doi: 10.1503/cmaj.220637. PMID: 36918177; PMCID: PMC10120420. https://pubmed.ncbi.nlm.nih.gov/36918177/ 



3. Piriyev E, Schiermeier S, Römer T. Laparoscopic Approach in Bladder Endometriosis, Intraoperative and Postoperative Outcomes. In Vivo. 2023 Jan-Feb;37(1):357-365. doi: 10.21873/invivo.13086. PMID: 36593051; PMCID: PMC9843782. https://pubmed.ncbi.nlm.nih.gov/36593051/ 



4. Diniz ALL, Resende JAD Jr, de Andrade CM Jr, Brandão AC, Gasparoni MP Jr, Favorito LA. Urological knowledge and tools applied to diagnosis and surgery in deep infiltrating endometriosis - a narrative review. Int Braz J Urol. 2023 Sep-Oct;49(5):564-579. doi: 10.1590/S1677-5538.IBJU.2023.9907. PMID: 37450770; PMCID: PMC10482465. https://pubmed.ncbi.nlm.nih.gov/37450770/ 



Bladder endometriosis: laparoscopic treatment

In this educational video, the authors present the case of a 53-year-old female patient presenting with recurrent post-menopausal bleeding and anemia. The patient did not report any family history of gynecologic cancer, but only obesity and hypertension as comorbidities. The preoperative work-up consisted of a gynecologic examination, pelvic ultrasound, and cervical cytology. Transvaginal ultrasound highlighted an abnormal thickness of the endometrium measuring 12mm including a soft tissue lesion measuring 12mm. 

The patient underwent a total hysterectomy with a bilateral salpingectomy using the Anovo™ Surgical System (Momentis Surgical) at the HCA Florida Kendall Hospital, Miami, Florida, United States. 

This surgical robotic platform is a novel system, specifically designed for robotic vaginal natural orifice transluminal endoscopic surgery (RvNOTES), which represents the enhancement of the disruptive and more common approach, namely Vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) [1, 2]. 

This is the first articulated humanoid-shaped robot, which mimics the surgeon’s entire upper extremity with every joint, namely shoulder, elbow, and wrist. The surgeon controls the two arms with two joystick controllers. In this video, the authors show the technology of RvNOTES performing a total hysterectomy with a bilateral salpingectomy in all its aspects, using the Anovo™ Surgical System [3]. The patient was placed in a dorsal lithotomy position with both legs in Allen® stirrups. A 30-degree Trendelenburg tilt was also used. 

The surgical procedure was performed using a standardized technique. 

No intraoperative complication was observed. The patient was discharged on the same day of surgery with no postoperative complications. 

Final pathological findings showed the presence of adenomyosis, fibroids, and negative evidence of hyperplasia or malignancy. 



Bibliography:

[1] Lowenstein, Lior et al. “Robotic transvaginal natural orifice transluminal endoscopic surgery for bilateral salpingo oophorectomy.” European journal of obstetrics & gynecology and reproductive biology: X vol. 7 100113. 23 Jun. 2020, doi:10.1016/j.eurox.2020.100113

[2] Lerner, Veronica T et al. “Vaginal Natural Orifice Transluminal Endoscopic Surgery Revolution: The Next Frontier in Gynecologic Minimally Invasive Surgery.” JSLS : Journal of the Society of Laparoendoscopic Surgeons vol. 27,1 (2023): e2022.00082. doi:10.4293/JSLS.2022.00082 

[3] Lowenstein, Lior et al. “Robotic Vaginal Natural Orifice Transluminal Endoscopic Hysterectomy for Benign Indications.” Journal of minimally invasive gynecology vol. 28,5 (2021): 1101-1106. doi:10.1016/j.jmig.2020.10.021

Robot-assisted transvaginal total hysterectomy and bilateral salpingectomy with the Anovo™ Surgical System

Hystérectomie totale transvaginale assistée par robot et salpingectomie bilatérale avec le robot chirurgical Anovo™

Traitement par laparoscopie d’une endométriose profonde impliquant une résection intestinale et la préservation des nerfs

Objective: This video aims to show how deep intestinal endometriosis (DIE) can be managed safely and effectively through intestinal resection with terminal anastomosis without the need for an ostomy using laparoscopy with nerve sparing.

Design: The procedure is performed in a stepwise fashion with narrated video footage.

Setting: The surgical management of deep endometriosis infiltrating the rectum necessitates either colorectal segmental resection or conservative techniques (i.e., shaving and discoid resection). When the intestinal nodule is extensive or involves two distant portions of the bowel, as in this case, decision is made to perform an intestinal resection with nerve sparing. For this surgery, the patient was placed in a dorsal modified lithotomy position. The surgeon stood on the patient’s left side, the first assistant on the right, and the second assistant between the patient’s legs. 

Clinical case presentation: The authors present the case of a nulligravida 41-year-old patient with no relevant medical history. She was referred to our center due to dysmenorrhea, dyspareunia, dyschezia, and chronic pelvic pain. The patient was under hormone treatment with Dienogest 2mg for 24 months, without any response. On physical exam, she presented with a fixed uterus in the anterior vaginal fornix. A mild thickening of the anterior vaginal fornix was observed. In the posterior cul-de-sac, there was a palpable painful nodule. On MRI, a nodule involving the upper rectal wall, measuring 26mm in length and 11mm in thickness, located 12cm from the anal margin, was observed. It infiltrated the outer myometrium of the uterus. Lamellar fibrotic tissue was found at the level of the rectouterine pouch, blocking it. Another nodule was found in the sigmoid colon, measuring 14mm in length and 9mm in thickness, leaving an impression in the lumen. The vesicouterine space presented with endometriotic tissue, which did not involve the bladder. It had a cystic component with infiltration of the outer myometrium. A bilateral hematosalpinx was noted. There were endometriomas in both ovaries.

Interventions: A laparoscopic approach with intestinal resection and nerve sparing was decided upon to treat deep infiltrating endometriosis. In this video, the authors demonstrated a stepwise surgical demonstration with key steps through a narrated video.

Measurements and main results: Postoperative outcomes were uneventful. She was discharged on postoperative day 3. At the 3-month follow-up, the patient was symptom-free. 

Conclusion: In cases where the intestinal disease is extensive and conservative treatment (shaving or discal) is not possible, it is necessary to perform intestinal resection with terminal anastomosis. Nerve sparing in such cases is crucial to prevent evacuatory disorders.



Bibliography:

1. Donnez O, Roman H. Choosing the right surgical technique for deep endometriosis: shaving, disc excision, or bowel resection? Fertil Steril. 2017 Dec;108(6):931-942. doi: 10.1016/j.fertnstert.2017.09.006. PMID: 29202966.

2. Nezhat C, Li A, Falik R, Copeland D, Razavi G, Shakib A, Mihailide C, Bamford H, DiFrancesco L, Tazuke S, Ghanouni P, Rivas H, Nezhat A, Nezhat C, Nezhat F. Bowel endometriosis: diagnosis and management. Am J Obstet Gynecol. 2018 Jun;218(6):549-562. doi: 10.1016/j.ajog.2017.09.023. Epub 2017 Oct 13. PMID: 29032051.

3. Roman H, Vassilieff M, Gourcerol G, Savoye G, Leroi AM, Marpeau L, Michot F, Tuech JJ. Surgical management of deep infiltrating endometriosis of the rectum: pleading for a symptom-guided approach. Hum Reprod. 2011 Feb;26(2):274-81. doi: 10.1093/humrep/deq332. Epub 2010 Dec 2. PMID: 21131296.

4. Alabiso G, Alio L, Arena S, di Prun AB, Bergamini V, Berlanda N, Busacca M, Candiani M, Centini G, Di Cello A, Exacoustos C, Fedele L, Gabbi L, Geraci E, Lavarini E, Incandela D, Lazzeri L, Luisi S, Maiorana A, Maneschi F, Mattei A, Muzii L, Pagliardini L, Perandini A, Perelli F, Pinzauti S, Remorgida V, Sanchez AM, Seracchioli R, Somigliana E, Tosti C, Venturella R, Vercellini P, Viganò P, Vignali M, Zullo F, Zupi E. How to Manage Bowel Endometriosis: The ETIC Approach. J Minim Invasive Gynecol. 2015 May-Jun;22(4):517-29. doi: 10.1016/j.jmig.2015.01.021. Epub 2015 Feb 10. PMID: 25678420.



Deep infiltrating endometriosis (DIE): laparoscopic treatment with intestinal resection and nerve sparing

This educational video highlights the case of a symptomatic patient with deep endometriosis that remained unresponsive to medical treatment, hence necessitating surgical intervention. Given the specific localization of the lesions, the patient underwent a comprehensive intervention involving a modified radical hysterectomy, bilateral salpingectomy, bilateral postero-lateral parametrectomy, and tangential cecum resection. The purpose of this video is to demonstrate the intricate management of a challenging deep endometriosis case using the innovative robotic platform, Hugo™ RAS (manufactured by Medtronic). 

In the current landscape, several platforms are available, with numerous other systems in various stages of development (1). The use of the Hugo™ RAS system for gynecologic procedures has demonstrated effectiveness (2), and its application in the targeted treatment of endometriosis has yielded promising outcomes (3-4). 



Bibliography:

1. Pavone M, Marescaux J, Seeliger B (2023). Current status of robotic abdominopelvic surgery. Show-Chwan Med J 22(3):467473. https://doi.org/10.30185/scmj.202307/pp.0003

2. Monterossi G, Pedone Anchora L, Gueli Alletti S, Fagotti A, Fanfani F, Scambia G (2022) The first European gynaecological procedure with the new surgical robot HugoTM RAS. A total hysterectomy and salpingo-oophorectomy in a woman affected by BRCA-1 mutation. Facts Views Vis ObGyn 14(1):91–4. https:// doi.org/10.52054/FVVO.14.1.014. PMID: 35373554 PMCID: PMC9612853 DOI: 10.52054/FVVO.14.1.014 

3. Pavone M, Goglia M, Campolo F, Scambia G, Ianieri MM. En-block butterfly excision of posterior compartment deep endometriosis: The first experience with the new surgical robot Hugo™ RAS. Facts Views Vis Obgyn. 2023 Dec;15(4):359–62. PMID: 38128095 PMCID: PMC10832646 DOI: 10.52054/FVVO.14.5.104 

4. Pavone M, Seeliger B, Alesi MV, Goglia M, Marescaux J, Scambia G, et al. Initial experience of robotically assisted endometriosis surgery with a novel robotic system: first case series in a tertiary care center. Updates Surg. 2024 Jan;76(1):271–7. PMID: 38133880 DOI: 10.1007/s13304-023-01724-z  

Robot-assisted radical hysterectomy and bilateral salpingectomy with bilateral postero-lateral parametrectomy and cecum resection for deep endometriosis with the new Hugo™ RAS system

Laparoscopic uterine artery clipping can be managed at its origin as opposed to uterus level. There is no current evidence to support the superiority of one technique over another (1). There is a higher chance of successful uterine artery ligation after the appropriate dissection of retroperitoneal spaces with a significant reduction in mean blood loss (2). The learning curve is not steep, and ideally a trained laparoscopic surgeon can easily reproduce this technique after performing one case under guidance. Exercising this for every hysterectomy performed for uterine leiomyoma or adenomyosis is not associated with increased surgical time. It is considered a safe procedure with no increased risk of bleeding or complications (3). Total laparoscopic hysterectomy (TLH) requires the highest degree of laparoscopic surgical skills, and a good knowledge of the pelvic anatomy defines a safe space for sharp entry into the retroperitoneum, as well as a safe identification of pelvic vasculature. The author would recommend that every gynecologist should understand the principle of opening the retroperitoneum and maintain skills (4). 



Bibliography:

1. Uccella S, Garzon S, Lanzo G, et al. Uterine artery closure at the origin vs at the uterus level in total laparoscopic hysterectomy: A randomized controlled trial. Acta Obstet Gynecol Scand. 2021; 100: 1840–1848. https://doi.org/10.1111/aogs.14238

2. Hyun Jin Choi, Myeong Seon Kim, Tae-Joong Kim,Uterine artery ligation at its origin following retroperitoneal space development decreases blood loss during single-port total laparoscopic hysterectomy,Taiwanese Journal of Obstetrics and Gynecology,Volume 59, Issue 2,2020, Pages 262-268, https://doi.org/10.1016/j.tjog.2020.01.015

3. Abo-Hashem, U., Rashed, R., El-Bassioune, W., & Abdou, H. (2021). Laparoscopic Hysterectomy with Prior Uterine Artery Ligation versus Conventional Laparoscopic Hysterectomy. International Journal of Medical Arts, 3(4), 1879-1883. doi: 10.21608/ijma.2021.91017.1352

4. Gueli Alletti S, Restaino S, Finelli A, et al. Step by Step Total Laparoscopic Hysterectomy with Uterine Arteries Ligation at the Origin. Journal of Minimally Invasive Gynecology. 2020 Jan;27(1):22-23. DOI: 10.1016/j.jmig.2019.06.001. PMID: 31201941.

Focus on gynecologic surgery