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The objective of this study is to demonstrate the feasibility and safety of Versius Platform (CMR) for surgical systematization and treatment of endometriosis. Edited Video demonstrating a systematical surgical procedure for endometriosis using the Versius robotic platform. 4-port System from CMR Surgical which consists of bedside units for instrument and a surgical console. A 31-year-old woman with pelvic pain, dysmenorrhea, dyspareunia and infertility. Suffered from dyschezia that initiated 2 days before menstrual cycle. MRI / US and physical examination showed thickening of the uterosacral ligament that infiltrates the para rectal space and a nodule at the left paracolpus. Initial case experience with the CMR – Versius platform for a case of grade III endometriosis. Realized in a systematic fashion dissection for en bloc peritoniectomy, resection of the utero sacral ligament, recto vaginal septum and paracolpus. There was no complications in the procedure, it took a similar time than laparoscopy and with minimal bleeding. Patient was discharged at PO day 1. Sixty days after the procedure patient has important pain relief and symptoms with normal menstrual cycles. The robotic approach brings good advantages for better dissection and preservation of endopelvic fascia and anatomical structures underneath. The 3 D visualization and the 360 degrees movements of the robotic arms are the main responsible for these results. Systematization for dissection of the layers of the pelvis and en bloc peritoniectomy associated with a good anatomical knowledge appears to be the main factor contributing for a safe and effective surgery. Robotic platforms as CMR Versius surgery for endometriosis is feasible and contributes with even better visualization, ergonomics, surgeon dexterity and reproducibility of the procedure. [ABSTRACT FROM AUTHOR]

BACKGROUND: Randomized controlled trials (RCTs) reported conflicting results on the impact of high-dose chemotherapy (HDCT) and autologous stem cell transplantation in the first-line treatment of patients with aggressive non-Hodgkin lymphoma (NHL). METHODS: We performed a systematic meta-analysis to assess the efficacy HDCT compared to conventional chemotherapy in aggressive NHL patients with regard to complete response (CR), overall survival (OS), event-free survival (EFS), toxicity, and impact of the age-adjusted International Prognostic Index (aaIPI) risk factors. We searched the Cochrane Library, MEDLINE and other databases (1/1990 to 1/2005). Hazard ratio (HR), relative risks (RR) and 95% confidence intervals (CIs) were calculated using the fixed effect model. RESULTS: Fifteen RCTs including 2728 patients were identified. HDCT improved CR when compared to conventional chemotherapy (RR 1.11, CI 1.04-1.18). Overall, there was no evidence for HDCT to improve OS (HR 1.05, 95% CI 0.92-1.19) or EFS (HR 0.92, 95% CI 0.80-1.05) when compared with conventional chemotherapy. However, subgroup analysis indicated OS differences (p=0.032) between good (HR 1.46, 95% CI 1.02-2.09) and poor risk (HR 0.95, 95% CI 0.81-1.11) patients. Conflicting results were reported for poor risk patients, where some studies reported improved and others reduced OS and EFS after HDCT. CONCLUSION: There was no evidence that HDCT improved OS and EFS in good risk NHL patients. The evidence for poor risk patients is inconclusive. HDCT should not be further investigated in good risk patients with aggressive NHL but high quality studies in poor risk patients are warranted. [ABSTRACT FROM AUTHOR]

This study aimed to describe a novel access route to the sacrospinous ligament and the coccygeal muscle. The overarching goal was to show our team's standard systematization to this technique and state it's safety in low parametric injuries. Video description of the novel technique with clear illustrations of each step. N/A. The surgery was performed in a 27-year-old woman who suffered from deep endometriosis in the pelvic floor. Her diagnosis was performed through physical examination, with innervation compression symptoms, ultrasound and MRI imaging techniques. After the identification and release of the central structures, we proceed to the lateral approach with the isolation of the internal iliac artery, which should be medially tractioned, enabling the identification of the bifurcation of the common iliac vein into the internal and external iliac vein. We then start the systematization of the approach with the dissection of the avascular space between the "V" shape formed by the umbilical artery and uterine artery, subsequently heading towards the sacrum. Next, we identify the rectovaginal fascia, being the first structure to be identified, extending from the rectovaginal space to the tendon arch. Behind this structure, we can find the coccygeal muscle and the sacrospinous ligament extending from the sciatic spine towards the sacrococcyx. We conclude the systematization of the pelvic floor approach being able to safely perform the resection of the endometriotic nodules with intact innervation, tension-free muscles and greater damage control. In summary this novel approach to the pelvic floor is thought to be a simpler and less risky alternative to treat low parametric injuries afflicting the sacrospinous ligament and the coccygeal muscle. [ABSTRACT FROM AUTHOR]

Demonstrate the functionality and capabilities of the FlexDex platform in a high technical complexity procedure, a videolaproscopy supracervical hysterectomy with cervicosacropexy. A 76-years-old patient with uterine prolapse (POP-Q stage III) was selected for laparoscopic treatment with the aid of the FlexDex platform. Initially, the supracervical hysterectomy was performed, followed by the cervix closure and the opening of the peritoneum at the level of the promontory – identifying the hypogastric nerve, lateralizing it with the endopelvic fascia and medializing the mesosigmoid fascia for the development of the pararectal space. Thus, allowing continuity to rectovaginal space and preparing the mesh bed. Next, a lightweight, macroporous, Y-shaped polypropylene mesh was fixated to the cervix stump – being assisted by the FlexDex platform, which enables the suturing to be made backhanded in a angulated topography. Then, the anatomical landmarks were identified before proceeding to the sacropexy - middle sacral vessels, sacral promontory, anterior longitudinal ligament, aortic bifurcation, inferior vena cava, right common iliac vessels and right ureter. After the mesh fixation to the promontory, the burial of the mesh was achieved with the closure of the peritoneum with a continuous suture. All the suturing during the surgery was accomplished utilizing only one trocar arrangement, enabled by the virtual center of rotation of the FlexDex platform. The surgical specimen was removed by posterior colpotomy, avoiding its morcellation. Once again, the closure of the posterior vaginal wall was facilitated by the endless rotation of the platform, enabling the ideal movement of the needle, following its curvature. The FlexDex platform allows similar amplitude and intuitive wrist movement of the surgeon during complex procedures such as the one here presented – being a cost-effective alternative to the robot technology in countries where it is not readily available. [ABSTRACT FROM AUTHOR]

Our aim is to raise awareness of pelvic floor endometriosis and describe a technique to dissect the pelvis until the pelvic floor muscles identifying the lumbosacral nerves and the main structures of the pelvis. A 23-year-old woman with cyclic pelvic pain since menarche had a history of claudication and pain in the right lower limb accompanied by dyschezia. At the vaginal and rectal examination, the patient had a nodule in the region of the right sacrospinous ligament, fixed in the pelvis and painful to palpation. The MRI showed a right posterolateral vaginal wall lesion on the uterosacral ligament and the anterior wall of the rectum, that touched the levator ani muscle infiltrating the sacrospinous ligament. The medial dissection of the lesion was performed by developing the pararectal space, resecting the uterosacral ligaments, ureterolysis and identifying the hypogastric nerve. Then, during lateral dissection of the lesion, we identified the iliac vessels and the obturator nerve after pelvic lymphadenectomy. The lumbar trunk, the sacral root S1, the superior gluteal artery and the S2 and S3 roots were identified posteriorly. Thus, we identified the lesion extending from the paracolpus and the rectal wall to the sacrospinous ligament in contact with the levator ani muscle. With both sides dissected, it was possible to approach the lesion preserving noble structures such as the ureter, uterine artery and splanchnic nerves. Although endometriosis on the pelvic floor is a rare condition, deeply infiltrating endometriosis is more often diagnosed in young woman such as our patient. Surgical techniques must be developed to asses those type of lesions and videos like this are a form to discuss different approaches to the pelvic floor. [ABSTRACT FROM AUTHOR]

Demonstrate a surgical technique variation for the laparoscopic radical trachelectomy by initiating the procedure through the development of the pararectal space and the identification of the hypogastric nerve. A 26 years-old patient was diagnosed with a papillary squamous cell carcinoma of the uterine cervix – (FIGO - stage IB1) With the advancement of surgical techniques in frozen pelvis for the treatment of deep endometriosis - we, from the School of Minimally Invasive Surgery from the Crispi Institute (Brazil), adopted a systematic approach, as to always initiate with the dissection of the pararectal space at the level of the promontory, medializing the mesorectal fascia and lateralizing the hypogastric nerve, along with the endopelvic fascia. We follow this dissection caudally towards the pelvic floor – establishing the "base" for the known spaces – Okabayashi, Latsko and paravescial. With the lateralization of the ureter, the isolation of the hypogastric nerve is facilitated and resection of the uterosacral ligaments is performed. Next, the development of the rectovaginal septum and the dissection of the loose areolar tissue can be accomplished – maintaining the adipose tissue attached to the intestinal wall. After medializing and tunelizing the ureter, we develop the Latsko space, communicating this region to the "base" of the pararectal space, previously established. Next, we can easily dissect the paravesical space, opening the anterior leaflet of the broad ligament, medializing the vesical wall until we reach the floor of the pararectal space. By medially dissecting the obliterated umbilical artery, we develop the lateral paravesical spaces. Connecting the right and left spaces, through the anterior compartment, we resect the vesical pillars and develop the Yabuki and vesicovaginal spaces. After developing all the spaces and isolating the hypogastric nerves, we follow the trachelectomy as usual. This is a viable and secure approach to initiate a trachelectomy. [ABSTRACT FROM AUTHOR]