Robotic Assisted En-Bloc Removal of Kidney, Ureter and Bladder Wall for Endometriosis

STUDY OBJECTIVE

To highlight a case where a nephroureterectomy and partial bladder cystectomy needed to be done due to endometriosis.

DESIGN

A video article demonstrating a case study and the surgical management.

SETTING

Ureteral endometriosis is a complex form of endometriosis [1]. If left untreated, the ureter can become significantly compressed leading to hydroureter, hydronephrosis and complete loss of kidney function [2].

INTERVENTIONS

This is a case of a 29-year-old patient with pelvic pain and cyclical rectal bleeding. Further investigation showed significant left hydronephrosis and almost complete loss of left kidney function (8% on renogram). MRI revealed endometriosis involving the posterior bladder wall and distal left ureter, a large full-thickness sigmoid nodule and a large left endometrioma. The patient underwent a robotic-assisted left nephroureterectomy, partial cystectomy (bladder), excision of pelvic endometriosis and sigmoid resection. This procedure was performed jointly with the gynecologist, urologist, and colorectal surgeon and the SOSURE technique was employed [3]. The specimen (left kidney, whole length of ureter and bladder wall around ureteric orifice) was removed en-bloc through a small 3cm extension of the umbilical incision. As the distance between the sigmoid nodule and the anal verge was 35cm, which was above the limit of the transanal circular stapler, a limited resection was performed over a discoid excision. The patient made a good recovery postoperatively.

CONCLUSION

Ureteral endometriosis is an indolent and aggressive condition which can lead to silent kidney loss. It is essential that hydronephrosis and hydroureter is ruled out in cases with deep endometriosis. Isolated hydronephrosis should also prompt a suspicion for endometriosis.

Development and validation of GLVS (Generic Laparoscopic Video Scoring System), a tool for assessment of laparoscopic skills in gynaecology using videotaped procedures: Are edited videos representative of their full-length version?

Background

Anonymized videotaped endoscopic procedures can be used for the assessment of surgical competence, but a reliable non-procedure-specific scoring system is needed for gynaecology.

Objectives

To design and evaluate the validity of the Generic Laparoscopic Video Scoring System (GLVS), a novel tool in the assessment of various gynaecological laparoscopic procedures.

Materials and Methods

Seventeen anonymized unedited video recordings of various gynaecological laparoscopic procedures and the 4-minute-long edited versions of the same videos were independently scored by two experts, twice, using GLVS.

Main outcome measures

Internal consistency reliability, test-retest, and inter-rater reliability of GLVS. We also compared the scored achieved by edited videos with those of the full-length version of the same videos.

Results

The mean score achieved by 4-minute-long edited videos was similar to that of the unedited version (p= 0.13 - 0.19). There was excellent correlation between the pooled scores for edited and unedited versions (intra-class correlation coefficient = 0.86). GLVS had excellent internal consistency reliability (Cronbach's alpha 0.92-0.97). Test-retest and inter-rater reliability were generally better for edited 4-minute-long videos compared to their full-length version. Test-retest reliability for edited videos was excellent for scorer 1 and good for scorer 2 with intra-class correlation coefficient (ICC) of 0.88 and 0.62 respectively. Inter-rater reliability was good for edited videos (ICC=0.64) but poor for full-length versions (ICC= -0.24).

Conclusion

GLVS allows for objective surgical skills assessment using anonymized shortened self-edited videos of basic gynaecological laparoscopic procedures. Shortened video clips of procedures seem to be representative of their full-length version for the assessment of surgical skills.

What’s new?

We devised and undertook a validation study for a novel tool to assess surgical skills using surgical video clips. We believe this addition clearly delineates the unique contributions of our study.

The combined robotic-assisted laparoscopic and thoracic approach in the management of diaphragmatic, pleural and pericardial endometriosis

OBJECTIVE

To demonstrate the advantages of a combined robotic-assisted laparoscopic and thoracic approach in the management of extensive diaphragmatic, pleural and pericardial endometriosis DESIGN: A video article demonstrating excision of endometriosis from pericardium, diaphragm and pleura.

Indocyanine Green tattooing for marking the caudal excision margin of a full-thickness vaginal endometriotic nodule

Background: The use of Indocyanine Green (ICG) is well-described in oncology and more recently in benign gynaecological surgery. In this article we describe submucosal transvaginal ICG infiltration caudal to a vaginal endometriotic nodule to visualise the lower margin of excision laparoscopically. Objectives: To demonstrates the use of submucosal ICG tattooing to mark and delineate the caudal margin of an ultra-low full thickness vaginal nodule and aid its excision laparoscopically. Material and methods: A stepwise approach highlighting the “SOSURE” surgical technique for the excision of endometriosis and the practical use of the ICG to delineate the lowest margin of the full thickness vaginal nodule. Main outcome measures: Laparoscopic complete excision of a 5 cm full-thickness vaginal nodule invading the right parametrium and involving the superficial muscularis layer of the rectum. Result: ICG tattooing was helpful in identifying the lower margin of dissection of the rectovaginal space. Conclusion: ICG tattooing of the margins of full-thickness vaginal nodules could be another use of ICG in benign gynaecology to complement the surgeon’s tactile and visual identification of the lower edge of dissection.

Intra- and inter-observer reproducibility of r-ASRM endometriosis classification system and its components, using edited videotaped laparoscopic procedures

Several classification systems have been proposed for endometriosis but the search for the ideal system is ongoing. While the most commonly used system has historically been r-ASRM, this system is not fit for purpose, particularly for deep endometriosis. In order to explore strategies to devise a new system and learn from problems with the existing ones, this study was designed to assess the reproducibility of each component in r-ASRM and its total score using videotaped laparoscopic procedures. Two surgeons independently scored 64 edited videos of laparoscopic endometriosis procedure, twice. Using the Kappa statistic, the agreement of the scores given was analyzed. r-ASRM showed a moderate inter-observer agreement (ƙ = 0.503) and good intra-observer agreement (ƙ = 0.774 and 0.682 for scorer 1 and 2 respectively) for overall disease staging. The agreement for each component of the system, however, was highly variable. The least agreement was observed for the peritoneum with ƙ = 0.157 and ƙ = 0.362 respectively for inter-observer and intra-observer. The lowest intra-observer agreement was seen for cul-de-sac for scorer 2 (ƙ = 0.382). Whilst the overall rASRM shows acceptable agreement between two scorers, this agreement seems to be the product of inconsistent scoring for each component.

Pelvic congestion syndrome and May-Thurner syndrome as causes for chronic pelvic pain syndrome: neuropelveological diagnosis and corresponding therapeutic options

Objective

To report on diagnosis and management of pelvic congestion including the May-Thurner syndrome (MTS) as potential etiologies for intractable pelvic neuropathic pain.

Design

Retrospective study of women presented with intractable pelvic neuropathic pain, who had left sided venous uterine plexus above 6mm with reversed and slow flow on Doppler, with dilated arcuate veins passing through the uterine muscle. Those with suspicion of MTS underwent further radiological investigations and if applicable, endovascular interventions.

Intervention

61 consecutive patients were included. 14 with visceral pain presumed to be caused by Pelvic Congestion Syndrome were treated by ovarian vein embolization. An improvement of pain was observed in all patients – mean pain reduction of 3.93 points, from 7.21 (±1.42; 4-10) to 3.28 pts (±1.54; 1-6) over 6 months (p<0.01). 47 presented with pelvic somatic neuropathic pain; 19 underwent endovascular intervention (angioplasty, stenting) and finally all of them a laparoscopic exploration/decompression of the sacral plexus and the endopelvic portion of the pudendal nerves, with an overall VAS reduction from 8.56 (±1.1712;7-10) to 2.63 (±1.53; 0-6) at one-year- follow-up (p<0.01).

Conclusion

Laparoscopic exploration/decompression of the nerves seems to be effective in a carefully selected group of patients. Endovascular interventions for pelvic somatic neuropathies may not be an effective treatment. We recommend that Doppler studies of the uterine vessels are performed as an extension to gynaecological examination in women with intractable pelvic pain.

Laparoscopic excision of deeply infiltrating endometriosis: a prospective observational study assessing perioperative complications in 244 patients

PURPOSE

To examine peri-operative complications in patients undergoing laparoscopic excision of deeply infiltrating endometriosis (DIE).

METHODS

This was a prospective study of a case series of women having laparoscopic excision of deeply infiltrating endometriosis from September 2013 through August 2016 in a tertiary referral center for endometriosis and minimally invasive gynaecological surgery in Iran. Data collected included demographics, baseline characteristics, intraoperative and postoperative data up to 1 month following surgery.

RESULTS

We analysed data from 244 consecutive patients, who underwent radical laparoscopic excision of all visible DIE. Major postoperative complications occurred in 3 (1.2%) and minor complications in 27 (11.1%) of patients. 80.3% of our patient group had Stage IV endometriosis. Segmental bowel resection was performed in 34 (13.9%), disc resection in 7 (2.9%), rectal shave in 53 (21.7%). Joint operating between a gynaecologist and colorectal and/or urological colleague was required in 29.6% of cases. The mean operating time was 223.8 min (± 80.7 standard deviation, range 60-440 min) and mean hospital stay was 2.9 days (± 1.5 standard deviation, range 1-11). The conversion to laparotomy rate was 1.6%.

CONCLUSIONS

A combination of different laparoscopic surgical techniques to completely excise all visible DIE, within the context of a tertiary referral center offering multi-disciplinary approach, produces safe outcomes with low complication rates.

Effects of silymarin, cabergoline and letrozole on rat model of endometriosis

OBJECTIVE

Silymarin as an herbal drug has potent antioxidant effects that could make it a good choice for endometriosis therapy. The aim of the current study was to determine the effects of silymarin as an herbal drug on induced endometrial lesion in rat model of endometriosis.

MATERIALS AND METHODS

A total of 32 mature, female Sprague-Dawley rats were allocated into 4 experimental groups. The duration of study was about 6 months. Endometriosis implants were surgically prepared and autografted into 32 rats. Three weeks after endometriosis induction, animals were randomly allocated into four groups: Group 1 received cabergoline (CAB group); Group 2 received letrozole (LET group); Group 3 received silymarin (SIL group) and Group 4 received no medication (CONT group). Experimental groups were treated for 3 weeks and then were sacrificed for volume and histopathological evaluation of implants and biochemical assessment. Serum and peritoneal levels of vascular endothelial growth factor (VEGF), total antioxidant activity (TAC) and tumor necrosis (TNF)-α were measured.

RESULTS

Mean volume of the implants decreased significantly in silymarin (p < 0.001), letrozole (p < 0.001) and cabergoline (p < 0.001) groups compared to the control. Histopathologic score was significantly lower in silymarin (p: 0.039), letrozole (p: 0.017) and cabergoline (p < 0.001) groups compared to the control. Those receiving silymarin had significantly higher serum TAC compared to control after 21 days of therapy (p < 0.001).

CONCLUSION

Silymarin, Letrozole, and Cabergoline administration resulted in decreased size and histopathologic grade of the induced endometrial lesions in a rat model. Silymarin appears to be a virtual novel therapeutic agent for treatment of endometriosis.