Search

The choice of whether or not to preserve the uterus in the case of patients with urogenital prolapse who undergo sacral colpopexy is still debated. We compared objective and subjective outcomes of laparoscopic sacral hysteropexy (LSHP) and laparoscopic sacral colpopexy with concomitant supracervical hysterectomy (LSCP/SCH) in patients with symptomatic pelvic organ prolapse. This is a multicenter retrospective cohort study conducted at the Urogynecology Department of the Fondazione Policlinico Universitario A. Gemelli IRCCS of Rome and at the Diaconesses Croix Saint Simon Hospital of Paris. We collected data of 136 patients; 78 underwent LSHP and 58 underwent LSCP/SCH for pelvic organ prolapse between January 2016 and December 2017. Patients of the two groups had similar preoperative characteristics. All patients completed 24-month follow-up evaluation. Overall, anatomical cure rate was 84.6% and 87.9% in the LSHP group and LSCP/SCH group, respectively, without statistically significant differences. In particular, in the LSHP group the anatomical success rate was 94.9%, 92.3% and 92.3% for the apical, anterior and posterior vaginal compartment whereas in the LSHP group LSCP/SCH was 100%, 91.4% and 94.8%, respectively. Subjective success rate was 89.7% among patients who underwent LSHP and 93.1% among women who underwent LSCP/SCH (p = 0.494). The median operative time (OT) was significantly shorter in LSHP. There were no significant differences between the groups in terms of estimated blood loss, conversion to laparotomy and intra- and postoperative complications. Patients’ satisfaction was high in both groups without statistical differences. Both laparoscopic procedures are safe and effective in the treatment of pelvic organ prolapse. LSHP can be offered as an alternative in women who are strongly motivated to preserve the uterus in the absence of abnormal uterine findings.

BACKGROUND We compared surgical outcome of sacral colpopexy (SCP) performed with the most recent minimally invasive surgery such as 3-mm laparoscopy (Mini-LPS), percutaneous system (PSS), standard laparoscopy (LPS), and robotic surgery. METHODS This is a multicenter retrospective cohort study conducted at Urogynecological Department of the IRCCS A. Gemelli University Polyclinic Foundation in Rome and at the Gynecological Clinic of Maggiore della Carita Hospital in Novara, and of the Polyclinic of Abano. We collected data of 115 patients who underwent laparoscopic SCP for pelvic organ prolapse between June 2017 and June 2018 using PSS, Mini-LPS, standard LPS, and da Vinci Si. RESULTS Patients of all four groups had similar characteristics. The median operative time (OT) was significantly longer in robotic procedure compared to all other groups There were no significant differences between the four groups in terms of estimated blood loss, conversion to laparotomy, intraoperative complications and median postoperative ileus. Visual Analogue Scale (VAS) at 4 hours was significantly less for Mini-LPS compared to the other techniques. VAS at 24 hours was higher for robotic procedures than other techniques. CONCLUSIONS Results rule out that minimize surgical invasiveness of laparoscopic techniques could bring improvements in SCP not only from a cosmetic point of view but also from a functional one without requiring longer OT and maintaining the same standard laparoscopic configuration. Even if robotic SCP is useful and safe because of its guarantee of efficiency, it cannot be considered the first choice for many women.

Background The role of the intrauterine manipulator in minimally invasive hysterectomy for endometrial cancer has been widely debated in terms of impact on the oncological outcomes. To date, definitive conclusions on the possible advantages and oncological safety of its use in endometrial cancer staging are still awaited. Objectives This randomized trial aimed to assess the role of the uterine manipulator in terms of oncological and perioperative outcomes in patients undergoing minimally invasive (laparoscopic/robotic) staging for presumed low-risk endometrial cancer. Study Design Enrolled patients were randomly allocated in two groups according to the use (Group A) or no use (Group B) of the uterine manipulator. The variables collected included baseline demographic characteristics, perioperative data, final pathology report, adjuvant treatment, and follow-up. Results 154 patients were randomly allocated in Group A (n=78) and Group B (n=76). A statistically significant difference was found in OT for the laparoscopic staging (p=0.005), while no differences were reported for the robotic procedures. The EBL was significantly lower in Group B (p=0.030). Only one conversion to laparotomy (1.3%) occurred in Group A. Comparable results were recorded in terms of peritoneal cytology, LVSI (p=0.584), and pattern of lymphovascular spread (p=0.790). With a median follow-up of 38.7 months, no differences were detected in terms of OS and DFS, and in the number of recurrences. The uterine manipulator had no impact on DFS both at univariate and multivariable analysis. Conclusions The intrauterine manipulator does not affect the perioperative and oncological outcomes of presumed low-risk endometrial cancer patients undergoing laparoscopic/robotic staging.

Objective This prospective pilot study aims to validate feasibility, efficacy and safeness of the innovative technique of video endoscopy inguinal lymphadenectomy (VEIL) and compare it to open inguinal lymphadenectomy (OIL) in the staging and treatment of vulvar cancer (VC). Material and methods All patients affected by VC suitable for bilateral inguinal-femoral lymphadenectomy were prospectively enrolled and submitted to VEIL on one side and OIL contralaterally, sparing the saphenous vein. The surgical and post-surgical data were collected. Univariate analysis included chi square analysis or Fisher's exact test, when appropriate for categorical variables, and the Student t test and Mann–Whitney test when appropriate for continuous variables. Results Between October 2014 and June 2015 fifteen patients were valuable for the study. Although nodal retrieval was comparable for both procedures, operative time was higher after VEIL. No intraoperative complications were observed in both techniques. Postoperative complications were observed in 3 and 2 cases for OIL and VEIL respectively. One patient needed reoperation after OIL for wound necrosis and infection. According to Campisi's stage, lymphedema resulted significantly to be lower after VEIL (p = 0.024). Conclusions Waiting for larger series and longer follow-up data, the VEIL seems to be feasible allowing a radical removal of inguinal lymph nodes as well as OIL with lower morbidity.

Objective This multicentric prospective phase II study aimed to investigate the feasibility, safety, and efficacy of percutaneous-assisted laparoscopic hysterectomy in terms of perioperative outcomes, feasibility, VAS score, and cosmetic outcomes. Study Design Between May 2015 and October 2017, 382 patients were considered eligible for minimally invasive percutaneous-assisted laparoscopic hysterectomy using Percuvance™, Percutaneous Surgical System - PSS, TELEFLEX ltd. Among them, 80 patients (20.9 %) met the inclusion criteria and were enrolled in the study. The coordinator center was the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Enrolled patients underwent total percutaneous-assisted laparoscopic hysterectomy ± bilateral salpingo-oophorectomy ± nodal assessment. Results The median age was 52 (range, 32–80) years, and the median body mass index was 25 kg/m2 (range, 16–37). Thirty-five patients (43.8 %) had previous surgery. A median operative time of 82.5 (range, 40–190) minutes and a median estimated blood loss of 50 (50–500) mL were registered. We observed 1 (1.3 %) intraoperative complication. The median time to discharge was 1 (range, 1–5) day. Patients were extremely satisfied with the scar evaluation and postoperative pain control. Five (6.25 %) complications were recorded within 30 days after surgery. Conclusion Percutaneous-assisted technique for extrafascial hysterectomy achieved excellent results in terms of feasibility, safety, and efficacy, even in complex cases and advanced surgical procedures. Therefore, the technique appears to balance the limitations and advantages of minimal surgical invasiveness and standard approach efficacy.

To assess the feasibility and the safety of the ultra-minimally invasive (U-MIS) approaches in gynecology, we compared our experience in percutaneous assisted hysterectomy (PSS-H) with a series of 3mm mini-laparoscopy hysterectomy (m-LPS-H). 126 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive hysterectomy: 80 patients received PSS approach and 46m-LPS approach. For both groups, we evaluated intra and perioperative outcomes, post-operative pain and cosmetic outcomes. The baseline characteristics were comparable between the two study groups. As well, no differences were reported in the clinical indications for hysterectomy, principally fibroids/adenomyosis, endometrial hyperplasia and early stage endometrial cancer. The median operative time was 88.5 (40–190) minutes for PSS-H group and 95.0 (42–231) minutes in m-LPS-H group (p = 0.131). No differences were detected in median estimated blood loss (p = 0.104) as well, in the uterine manipulator usage (p = 0.127) between the two different surgical approaches. Only 1 (2.2%) conversion to standard laparoscopy occurred in m-LPS-H group (p = 0.691). One intra-operative complication was recorded 1 (1.3%) in the PSS-H group (p = 0.367). The post-operative early complication was recorded in five cases of PSS-H group (p = 0.158), none for m-LPS-H procedures. The results in post-operative pain detection was statistically significant after 4h in favor of m-LPS-H group (p = 0.001). After 30days no differences in cosmetic satisfaction were detected between the two groups (p = 0.206). PSS-H and m-LPS-H are two valid U-MIS alternatives for benign gynecological conditions and low/intermediate risk endometrial cancer.

Study Objective To investigate the feasibility and safety of laparoscopic cytoreduction in ovarian cancer patients with localized carcinomatosis or lymph node involvement. Design Retrospective cohort study (Canadian Task Force classification II-2). Setting Multi-institutional study performed in 6 referral gynecologic oncology units. Patients Between June 2005 and December 2014, preoperatively presumed early-stage ovarian cancer patients, who accidentally revealed localized carcinomatosis or lymph node involvement at laparoscopic evaluation or at postoperative pathological examination managed by the laparoscopic approach. Interventions All patients with limited carcinomatosis and/or lymph node metastases underwent complete laparoscopic cytoreduction. Measurements and results Sixty-nine patients were included in the analysis. Twenty-eight (40.6%) patients were staged III C because they had lymph node metastases. Pelvic lymphadenectomy was performed in 75.4% of cases, whereas aortic lymphadenectomy was performed in 79.7% of cases. Lymph node metastases were found in pelvic and aortic regions in 11 and 13 patients, respectively, whereas 4 patients had lymph node metastases in both regions. Twelve (17.4%) patients underwent complete pelvic peritonectomy because of the presence of nodules localized in several pelvic region sites. As of May 2015, the median follow-up was 35 months, and the median disease-free survival was 29 months. The 2-year disease-free survival rate was 77.1%, whereas the 2-year overall survival rate was 90.6%. The median time to recurrence was 26 months (range, 6 -55 months); 15 (21.7%) patients developed recurrence. Conclusion The present study shows the technical and clinical feasibility of laparoscopic cytoreduction in ovarian cancer patients with limited carcinomatosis or lymph node involvement.

Aims Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by long operative times and, when combined with supracervical hysterectomy, by a high risk of spreading of unsuspected cancerous tissue. The aim of the present study was to compare, in patients who underwent hysterectomy plus LSC for severe POP, different methods for cervical incision and uterine morcellation. Methods This is a prospective single Institution randomized double-blinded clinical trial enrolling 124 patients with severe POP from June 2014 to May 2015. Patients underwent laparoscopic supracervical hysterectomy (LSH) plus LSC for pelvic organ prolapse and were randomized in Group 1 (monopolar hook and conventional mechanical morcellator) and Group 2 (bipolar laparoscopic loop and bipolar morcellator), for supracervical incision and uterine morcellation, respectively. Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications. Results A total of 50 patients for group completed the study. Baseline characteristics were similar between the groups. Cervical cutting time (32 vs. 3.10 sec; P

A hysterectomy for enlarged uteri is considered a challenge for gynaecologic surgeons, due to the limit of exposure to surgical spaces. Our objective is to investigate the different variables that may have an impact on the risk of conversion to open surgery. This is a retrospective cohort study consisting of 133 women who were submitted to surgery for uterine fibroids and who underwent total hysterectomy by laparoscopic approach attempt. The median uterus weight was 622 grams (range 301–3882) and the median maximum diameter of the bigger fibroid was 74 mm (range 33–148). We registered 13 (9.8%) cases of conversion to laparotomy. Minor and major post-operative complications were recorded in 4 (3%) and in 4 (3%) cases, respectively. After multivariable analysis, the surgeon’s experience (OR: 0.24; 95% CI: 0.06–0.94, p =.027) and a maximum diameter of the biggest fibroid ≥10 cm (4.7; 1.39–15.87; p =.046), but not the uterus weight were associated with the risk of conversion to open surgery.IMPACT STATEMENTWhat is already known on this subject? Laparoscopic procedures for enlarged uteri are well described in literature; however, the only parameters that have been studied for the success of a laparoscopic procedure have been the uterus weight and the surgeon’s experience. What do the results of this study add? This study aimed to value all the possible variables related to the successful of laparoscopic procedures; in fact, we investigated not only the uterine weight, but in our multivariate analysis, the position of the fibroids, the trocar’s setting, etc. were analysed. What are the implications of these findings for clinical practice and/or further research? This study reported novel data about the feasibility of laparoscopic hysterectomy for enlarged uteri. In opposition to the literature, the uterine weight is not a predictive value for laparotomic conversion. Moreover, we discussed the possible reasons of our novel findings. It opens new perspective to create a predictive value of laparoscopic feasibility for the different types of enlarged uteri.

Objective To investigate the safety, feasibility and oncological adequacy of the Percutaneous Surgical System - PSS in a consecutive series of low-risk endometrial cancer staging. Study Design From May 2015 to April 2017, we prospectively performed 30 consecutive percutaneous staging for low/intermediate risk endometrial cancer (FIGO stage IA G1-G2, IB G1-G2, IA G3). All patients were divided in two different groups on the basis of surgical procedure received: Group A included patients submitted to radical Class A hysterectomy and bilateral salpingo-oophorectomy; Group B concerned patients that received a lymph nodal assessment also. Results The time needed to install percutaneous instruments and suprapubic trocar was 4 min. (range 2–10). The recorded median operative time (OT) was 80 min. (range 65–120) for Gr.A and 143 min. (range 107–190) for Gr.B, in which the median time of lymph nodal assessment was 55 min. (range 20–76). The median time for hysterectomy was 60 min. (range 40–110) in all cases. Lymph nodal assessment was performed in 14 (46.6%) cases: 7 sentinel node mapping, 7 pelvic lymphadenectomy. No intraoperative complications or LPS/LPT conversions were recorded. Median discharge time was 2 days (range 1–4), 5 patients were discharged in 3rd post-op day, and only 1 patient was discharged in 4th day for fever. All patients conveyed high satisfaction with the cosmetic results. A progressive overall reduction of pain perception was observed at 24 h after surgery. Median follow-up was of 14 months (range 12–36), no recurrences have been detected. Conclusions PSS seems to be a feasible approach for endometrial cancer staging. Larger experiences and prospective comparative studies are important to assess our assumptions and further investigate the real benefits of percutaneous surgical system.

This prospective single-institutional clinical trial sought to assess the safety and feasibility of laparoscopic benign ovarian cyst enucleation with a novel robotic-assisted laparoscopic system. Here we report a series of 10 patients treated using the Telelap ALF-X system in the first clinical application on patients at the Division of Gynecologic Oncology, Catholic University of the Sacred Heart of Rome. The primary inclusion criterion was the presence of monolateral ovarian cyst without a preoperative assessment suspicious for malignancy. Intraoperative data, including docking time, operative time, estimated blood loss, intraoperative and perioperative complications, and conversion to either standard laparoscopy or laparotomy, were collected. The cysts were removed with an ovary-sparing technique with respect to conservative surgical principles. The median operative time was 46.3 minutes, and patients without postoperative complications were discharged at 1 or 2 days after the procedure. Telelap ALF-X laparoscopic enucleation of benign ovarian cysts with an ovary-sparing technique is feasible, safe, and effective; however, more clinical data are needed to determine whether this approach can offer any other benefits over other minimally invasive surgical techniques.

Background To assess the learning curve associated with tele-assisted surgery. Methods We performed a training box-based study, describing speed and accuracy in volunteers performing basic and complex laparoscopic tasks, to assess performance and in the skill acquisition of inexperienced users, using the Telelap Alf X system. Ten surgeons in gynaecology who had never received formal instruction on this new surgical device, completed four modules during a consecutive 3 day training programme. Results All the participants completed the training programme with a good learning curve. Conclusions Use of the TELELAP Alf X advanced surgical robotic system is associated with a rapid learning curve among experienced surgeons. Copyright © 2015 John Wiley & Sons, Ltd.

Study Objective To further investigate the psycho-oncologic effect of minimally invasive surgery comparing patients submitted to minimally invasive interval debulking surgery (MI-IDS) with a balanced population treated by standard laparotomy (L-IDS). Design Single-institution propensity-matched study (Canadian Task Force classification II-2). Setting Division of Gynecologic Oncology, “Policlinico A. Gemelli” Foundation, Rome, Italy. Patients The investigational arm included 30 patients with advanced ovarian cancer treated with MI-IDS, whereas the control arm included a consecutive series of 30 patients with advanced ovarian cancer submitted to L-IDS. For every patient preoperative data were collected to assess the response to neoadjuvant chemotherapy. Perioperative data were also recorded. Interventions A General Well-Being Schedule (GWBS) and a clinical assessment of body uneasiness, the Body Uneasiness Test, were administered by a psycho-oncologist immediately before IDS and within 30 days after surgery to evaluate the psychological burden in both groups. Measurement and Main Results Both groups were matched as closely as possible. No statistical differences were registered in terms of surgical procedures and residual tumor. A significantly longer median operative time in patients was counterbalanced by more favorable estimated blood loss and median length of stay and time to chemotherapy. No statistically significant differences were registered in terms of postoperative complications. Starting from a substantially homogenous psychological condition, psychometric evaluation underlined statistically significant differences in favor of MI-IDS. The mean GWBS score was 64.17 ± 11.77 in patients and 54.15 ± 14.76 in control subjects, with a statistically significant difference between the 2 groups (p = .004). Conclusion MI-IDS seems to play an important role in the quality of life and oncologic outcomes. Even if presented data testified a further evolutionary step in oncologic patient care, more experience with larger groups of patients is desirable to deeply investigate and assess our results.

Minimally invasive surgery represents the gold standard for benign and malignant gynecological disease. Laparoendoscopic single-site surgery has emerged as a new technical concept to decrease parietal trauma and improve body image. Laparoendoscopic single-site surgery is not a new essay, but recent developments in surgical technology have resulted in an exponential enlargement of indications. Recently published data showed feasibility, safety, and reproducibility of single-port hysterectomy for benign and malignant gynecological diseases. This approach represents a new challenge in minimally invasive surgery and appears to be feasible and safe to perform in a variety of gynecologic diseases. The aim of this chapter is to show the needed instruments, the main surgical step of single-site hysterectomy according to our surgical experience starded on 2008.

This pilot study was aimed to value the feasibility and safety of Senhance Robotic Platform for hysterectomy in obese patients. Ten obese patients (30&nbsp

Video Objective Laparoscopic sacrocolpopexy (LSC) is known to achieve lower recurrence rates, shorter recovery time, and less dyspareunia. However, LSC is problematic because it requires specific laparoscopic skills and the laparoscopy takes longer than other competing operations. In this video, we present the surgical techniques for LSC we are using with a view to shortening operation times and reducing complications. We named this approach Time Sparing Sacrocolpexy (TSS) Design Prospective Clinical Trial Setting San Carlo di Nancy Hospital GVM Care & Research, Rome Patients: Ninety women with symptomatic stage 3 or greater POP underwent LSC in our hospital between November 2016 and January 2019. Interventions Ninety women with symptomatic stage 3 or greater POP underwent LSC in our hospital between November 2016 and January 2019. In the first 80 operations we followed the nerve-preserving technique described by Ercoli et al. in 2017. In the final 10 operations we modified the technique in order to reduce operative time. The main changes were: (1) Use of Bipolar loop to cut the cervix instead of the monopolar hook, (2) make a stitch on the meshes in order to reduce the time of introduction e positioning of them in the pelvis, (3) replacing part of the classic LSC stitches with (i) AbstackT fixations to fix meshes to the anterior and posterior vaginal wall, but maintaining nonabsorbable stitches at the urethrovesical junction, at the cervix, at the level of levator ani muscle and at the sacrum. Measurements and Main Results Operative Time. Intra and post operative related complications. The operation time decreased (around 40%) as the surgical technique improved through experience. No major intra- or postoperative complications occurred. Conclusion These modifications to the technique will help shorten operation times and reduce complications of LSC.

Study Objective To evaluate the feasibility of percutaneous approach, we prospectively compared our percutaneous hysterectomy (PPS-H) experience with a series of laparoscopic hysterectomies (LPS-H). Design Multicentric comparative prospective study. Setting Fondazione Policlinico Universitario A. Gemelli IRCCS, in Rome, a tertiary health-care center, was the coordinator center. Patients or Participants From May 2015 to September 2017, 160 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive surgery (MIS). Eightypatients received PSS-Hand 80 LPS-H. In each group, 30 cases of low/intermediate risk endometrial cancer were enrolled. Interventions hysterectomy ± bilateral salpingo-oophorectomy with or without lymph nodal staging. Measurements and Main Results No statistically significant differences were noted in baseline characteristics or operative time (OT) between the two groups. We observed significant differences in estimated blood loss (EBL): median of 50 cc (PSS-H) and 100 cc (LPS-H), P= 0.0001. In LPS-H, we reported 4 (5.0%) intraoperative complications and one (1.3%) in PSS-H. One post-operative fever for each group was reported. Thirty-day complications were 4 (5%) in PSS-H and 11 (13.8%) in LHS-H, P = 0.058. No significative differences were found in VAS(Visual Analogue Scale) score, despite a relevant disparity in cosmetic outcome (P=0.0001). For oncological cases, the two techniques had comparable intraoperative outcomes and oncological accuracy. Five (16.7%) 30-days complications occurred (P=0.052) in LPS-H. No significant differences were noted in FIGO stage or post-operative management. All patients enrolled were alive at the time of follow-up. Conclusion PSS-H is comparable to the LPS-H for intra and peri-operative outcomes and post-operative pain. Our study indicates PSS-H seems to be superior to LPS-H in cosmetic outcomes and patient satisfaction. We conclude PSS-H is a promising alternative in ultra-MIS in Gynecology.

INTRODUCTION The current management of vulvar cancer depends on the extension of disease, and includes primary tumor resection with safety margin as well as inguinofemoral lymph node staging. We report the case of the first leg videoendoscopic inguinal lymphadenectomy performed in a woman with a squamous cell vulvar carcinoma. PRESENTATION OF CASE A 74 years old female referred to our institution complaining of vulvar mass associated with bleeding and swelling from external genitals, vaginal burning sensation and dysuria for 5 months. A vulvar–vaginal examination under narcosis reported a right major labium lesion of 5 cm with an irregular and ulcerated surface, easily bleeding on palpation, involving anteriorly the clitoral region and with a histological finding of a poorly differentiated squamous cell invasive carcinoma of the vulva ulcerating the surface epithelium. We performed, after adequate informed consent, a radical vulvectomy with a standard right inguinofemoral lymphadenectomy and a contralateral simultaneous video endoscopic inguinal lymphadenectomy-Leg procedure. DISCUSSION Our minimally invasive VEIL-Leg approach, performed for the first time in literature in a woman with vulvar cancer, could reduce the presence of high risk factors represented by surgical incision and by procedure-related complications, including wound infection and breakdown, hematoma, cellulitis and hernia formation. CONCLUSION A multicenter prospective randomized study will be helpful to clarify how this procedure could replace the standard laparotomic approach to inguinal lymphadenectomy in the vulvar cancer treatment and staging.

PURPOSE OF REVIEW To provide an overview of the available evidence on the role of the different methods in laparoscopic training, and to summarize the results obtained with standardized training programmes in advanced laparoscopic gynaecological surgery. RECENT FINDINGS Box trainers as well as virtual reality simulators ensure a benefit in terms of surgical skills development. No data are available showing superiority of one method compared to another. Global Operative Assessment of Laparoscopic Skills (GOALS) remains the most widely used and established scoring system to assess the acquired laparoscopic abilities, also in the field of advanced gynaecological surgery. Standardized training programmes have been recognized as reliable tools able to improve the development of surgical skills, particularly for innovative surgical techniques, such as laparoscopic endoscopic single-site surgery. SUMMARY The traditional approach based on observing and assisting needs to be updated incorporating box trainers and virtual reality simulators. The development of innovative training methods, integrating box trainers and virtual reality simulators, represents the future horizon. All tertiary centres involved in advanced laparoscopic gynaecological surgery should contribute to the development of an integrated network of standardized training programmes, in order to ensure a high-quality laparoscopic training to gynaecologists.

Study Objective To investigate the safety and technical feasibility of needleoscopic fertility-sparing staging of borderline ovarian tumors. Design Video article and review of the literature (Canadian Task Force classification Level III). Setting This 29-year-old woman had a right ovarian cyst suspicious for borderline ovarian tumor on preoperative magnetic resonance imaging and ultrasound showing the presence of a right unilocular ovarian cyst with a papillary projection. Informed consent for abdominal or laparoscopic approach was obtained from the patient in accordance with the local legislation. The patient also provided informed consent to use images and videos of the procedure. Institutional Review Board approval was not required for this kind of procedure. Interventions Treatment involved conservative staging with right ovarian cystectomy, peritoneal biopsies, infracolic omental biopsy, and peritoneal cytology. Instrumentation included two 2.4-mm needleoscopic instruments. The total operative time was 62minutes, and estimated blood loss was

Laparoscopic sacral colpopexy (LSC) for pelvic prolapse is a complex procedure, characterized by long operative times and, when combined with supracervical hysterectomy, by a high risk of spreading of unsuspected cancerous tissue. The aim of the present study was to compare, in patients who underwent hysterectomy plus LSC for severe POP, different methods for cervical incision and uterine morcellation.This is a prospective single Institution randomized double-blinded clinical trial enrolling 124 patients with severe POP from June 2014 to May 2015. Patients underwent laparoscopic supracervical hysterectomy (LSH) plus LSC for pelvic organ prolapse and were randomized in Group 1 (monopolar hook and conventional mechanical morcellator) and Group 2 (bipolar laparoscopic loop and bipolar morcellator), for supracervical incision and uterine morcellation, respectively. Our primary endpoints were the operative times and the secondary endpoints the incidence of intra- or post-operative complications.A total of 50 patients for group completed the study. Baseline characteristics were similar between the groups. Cervical cutting time (32 vs. 3.10 sec; P 0.01), morcellation (4.10 vs. 2.13 min; P 0.01) and operative time (131 vs. 118 min; P 0.05) resulted significantly lower in Group 2. No differences were found in terms of intra- or post-operative complications.Laparoscopic bipolar loop and morcellator guaranteed a faster and hemostatic tool during supracervical incision and a controlled and rotation-free uterine extraction. The significant surgical time reduction linked to these devices should be considered even more helpful and effective to perform a complex procedure represented by LSH plus LSC. Neurourol. Urodynam. 36:798-802, 2017. © 2016 Wiley Periodicals, Inc.

Objectives During the last decade endoscopic surgical procedures have been constantly evolving. The latest innovation in ultra-minimally invasive surgery (MIS) is the percutaneous technology (Percuvance™ Percutaneous Surgical System (PSS), Teleflex Inc., USA). We compared surgical outcome of hysterectomy, in a retrospective cohort study using the most recent MIS techniques as single-site (LESS) surgery, 3mm laparoscopy (MiniLPS) and percutaneous system (PSS) with standard laparoscopy (LPS). Study design This is a matched retrospective cohort study. Endometrial Hyperplasia/Early stage endometrial cancer or benign pathology were the indication for surgery. Data of laparoscopic hysterectomies performed between May 2013 and April 2016 using PSS, LPS, MiniLPS, and LESS were collected and compared. Results The characteristics of each group were similar. The median Operative time (OT) was significantly longer in LESS compared to all other groups (120min [range 55–165] in LESS, 91min [range 60–180] in MiniLPS, 70min [range 55–230] in LPS and 65 [range 40–180] in PSS; p=0.0001). No significant differences among the 4 groups were observed in terms of estimated blood loss, conversion to laparoscopy or laparotomy, and intra e post-operative complications. Statistically significant differences were recorded in median VAS 24h (2 [range 0–3] in PSS, 2 [range 0–3] in MiniLPS, 3 [range 2–5] in LESS and 2 [range 1–5] in LPS; p=0.0001). The average time of discharge was (1day [range 1–3] in PSS, 1day [range 1–2] in MiniLPS, 1days [range 1–2] in LESS and 1day [range 1–3] in LPS; p=0.99). Conclusions Data show that the effort to minimize the impact of surgical invasiveness can be feasible and could improve the advantages, not only in terms of aesthetic outcomes, even if the differences among the endoscopic approaches have not a relevant clinical impact. The technology innovations like PSS maintain the same triangulation between instruments as standard LPS with an evident decrease of the invasiveness thanks to reduced instruments size, even if the lack of suitability of bipolar energy, that require a multifunction instrument, remain a limit of these instruments.

This study was designed to compare perioperative outcomes and postoperative pain of standard laparoscopic (S-LPS), minilaparoscopic (M-LPS), and laparoendoscopic single-site (LESS) hysterectomy. A single-institutional, matched, retrospective, cohort study was performed. Between May 2010 and March 2011, 85 consecutive women were submitted to a total laparoscopic hysterectomy by S-LPS, M-LPS, and single-port LESS. Perioperative outcomes of these three techniques were analyzed and compared. Demographics and baseline characteristics of each group were absolutely comparable. The median operative time was longer [105 (range, 75–125) min] in the LESS group compared with the M-LPS group [90 (range, 60–120) min; p

Objective To illustrate the laparoscopic surgical management of a particular localization of extrauterine pregnancy misdiagnosed until 12 weeks gestational age, complicated by hemoperitoneum and abortion. Design Canadian Task Force III on the Periodic Health Examination’s Levels of Evidence. Setting The prevalence of ectopic pregnancy among women presenting to an emergency department with first trimester bleeding, pain, or both ranges from 1% to 16% [1] . The most common localization of ectopic pregnancy is the fallopian tubes, whereas abdominal pregnancy accounts for at least 1% of extrauterine pregnancies. The reported incidence of abdominal pregnancy ranges from 1:10 000 to 1:30 000 pregnancies [2] . Abdominal pregnancy can be localized in the pelvic cul-de-sac, broad ligament, bowel, or pelvic sidewall. This rare type of ectopic pregnancy is often misdiagnosed until later in pregnancy, evolving in hemoperitoneum, abortion, embolism, or rarely, in diagnosed cases, live birth by cesarean section. In the literature, it is recommended that the placenta be left in situ in cases of abdominal pregnancy to avoid hemorrhage and organ injury, even though this approach may be associated with a higher rate of postoperative complications, such as infection, secondary bleeding, and cancer transformation [3] . We present a case of abdominal pregnancy in which the gestational sac was implanted in the broad ligament and resulted in hemoperitoneum at 12 weeks gestational age. Intervention In August 2010, a 35-year-old woman, gravida 3 para 1, presented at the Di Meglio ultrasound diagnostic center in Naples for a noninvasive prenatal ultrasound (bi-test) to confirm gestational age in what to that point had been considered a normal pregnancy at 12 weeks gestation. Ultrasound revealed an ectopic abdominal pregnancy with a live fetus located in the left parauterine side. A suspicious fluid level in the pouch Douglas was also detected, and so the woman was advised to go to an obstetric hospital for a medical evaluation of the clinical situation (starting hemoperitoneum). Later that same day, the woman presented at the Villa dei Platani Hospital in Avellino, where ultrasound confirmed increased fluid in the pouch of Douglas, along with initial signs of hemoperitoneum and loss of the fetal heartbeat. The woman was immediately transferred to the Malzoni Center for Advanced Endoscopic Gynecological Surgery in Avellino, where she underwent operative laparoscopy for removal of the abdominal pregnancy (surgeon, M.M.). Informed consent for the laparoscopic surgery was provided by the patient in accordance with local regulations. The patient also provided informed consent for the use of images and a video of the procedure. Institutional Review Board approval was not required. The procedure involved laparoscopic hemoperitoneum drainage (at least 500 mL of blood), left adnexectomy after transperitoneal identification of the left uretheral pathway, and complete removal of left broad ligament pregnancy abortion with consensual removal of the ectopic placenta. Conclusion The laparoscopic management of abdominal pregnancy and hemoperitoneum resulting from rupture of the gestational chamber and abortion was optimal. With this minimally invasive technique, it was possible to drain the hemoperitoneum completely and then proceed to total removal of the gestational chamber and the fetus. Thanks to the magnification of the image by laparoscopy, it was also possible to completely remove the placenta and the cotyledons from the peritoneal surface, thereby avoiding possible postoperative bleeding, infection, and sepsis resulting from retention of incomplete removal of the placenta. On the first postoperative day, the patient was in excellent clinical condition, with a marked reduction in circulating β-human chorionic gonadotropin. She was discharged on the second postoperative day and currently is in good health.

To evaluate the effectiveness of our training method for basic “hands-on” laparoscopic courses. A prospective observational study between September 2008 and December 2010 at Catholic Laparoscopy Advanced Surgery School of the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Sacred Heart-Rome, was conducted. Each course lasted for 3 days, divided into theoretical and practical parts, ending with a live surgery. Gynecologists who attended our ‘hands-on’ laparoscopic courses had no or minimum experience with laparoscopic technique. The teachers were expert laparoscopists of our Division, and every single group of participants had the same tutor for the entire course. Trainees completed self-assessment anonymous questionnaire of laparoscopic knowledge, before and immediately after the course. During the study period, we performed 20 basic courses, enrolling 120 consecutive gynecologists. Among them, 114 (95%) decided to participate. Average age was 41 years (range 35–60 years) and 108 (94.7%) trainees were Italian. The subjective assessment showed an immediate improvement of motor skills. Laparoscopic training course can improve both theoretical knowledge and motor skills. Such courses result in a short-term subjective improvement.

Objective: This study aimed to evaluate the potential advantages of laparoendoscopic single-site surgery (LESS) approach with respect to conventional laparoscopy. Methods: Thirty LESS patients were matched 2:1 with a previous cohort of 58 patients undergoing conventional laparoscopy for the same type of surgery (controls). Results: Median operative time (38.5 vs 54 minutes; P = .09) and estimated blood loss (20 vs 30 mL; P = .008) were more favorable in patients undergoing LESS treatment compared with those undergoing conventional laparoscopy. Rupture of the cyst was observed in 11 out of 30 cases (36.6%) and 26 of 58 controls (44.8%; P = .46). Median length of stay was 1 day in the cases and 2 in the controls ( P = .03). Conclusions: Decreases in operative time, estimated blood loss, or length of stay should not be considered a benefit attributable to LESS; rather it seems there are no differences between these 2 surgical approaches after an adequate selection of patients.

This study aimed to validate the feasibility, efficacy, and safeness of laparoscopic treatment for benign adnexal diseases through a single transumbilical access in a prospective series of patients. A prospective clinical trial including 30 women was conducted in our teaching and research division. Patients underwent different laparoscopic procedures by the laparoendoscopic single-site (LESS) approach using a multiport trocar, conventional laparoscopic instrumentation, and standardized surgical technique, with evaluation of the multiaccess conversion rate. The patients underwent different laparoscopic procedures (10 bilateral adnexectomies; 22 cystectomies, and 3 chromosalpingographies) by the LESS approach using a multiport trocar and conventional laparoscopic instrumentation with standardization of this innovative minimally invasive technique. The laparoscopic procedures were completed through a single access in 28 cases (93.4%). In two cases, at the end of the intervention, hemostasis required one additional sovra-pubic access. No major intra- or postoperative complications were observed. The mean hospital stay was 1.3 days. The results of this study suggest the feasibility of the LESS approach in gynecologic surgery with a low conversion rate for multi-access laparoscopy, a rapid learning curve, limited complications, and good results in terms of cosmesis and postoperative pain. More clinical data are needed to confirm these advantages over standard laparoscopic technique.

This randomized clinical trial (Canadian Task Force classification I) aimed to compare 2-dimension (2-D) versus 3-dimensional (3-D) laparoscopic hysterectomy and pelvic lymphadenectomy in endometrial and cervical cancer patients. Between December 2014 and March 2015, 90 patients were enrolled: 29 (32.2%) with early or locally advanced cervical cancer after neoadjuvant treatment and 61 (67.8%) with early-stage endometrial cancer. Patients were randomly assigned to undergo 2-D (Group A, n = 48 [53.3%]) or 3-D (Group B, n = 42 [46.7%)]) laparoscopy. Baseline characteristics were superimposable in the 2 groups. Median operative time was similar in the 2 groups. Median estimated blood loss during lymphadenectomy was significantly lower in Group B than in Group A (38 mL [range, 0-450] vs 65 mL [range, 0-200]; p = .033). In cervical cancer patients operative time of pelvic lymphadenectomy performed by "novice" surgeons (those with

Objective The evolution of minimally invasive surgery has moved beyond reduction of surgical trauma while maintaining adequate efficacy and safety standards. Percuvance™ Percutaneous Surgical System (PSS) instruments represents the last novelty in this panorama. Consisting of less than 3 mm laparoscopic shaft introduced percutaneously with an interchangeable 5 mm tool installed in place of the needle tip, they combine micro-invasiveness and operative performance. Study design We prospectively collected and retrospectively analyzed data of 10 cases of laparoscopic total hysterectomy with Percuvance™ PSS for benign or early malignant gynecological diseases in order to assess the capability and safety of this new device. Data were recorded in a prospectively designed clinical database including patient demographics characteristics, operative data, intra- and postoperative complications, conversion rate, length of hospital stay and cosmetic outcome. Results The reported series consisted of 10 patients undergoing total laparoscopic hysterectomy with a median age of 51.5 years (range 44–72 years) and a median BMI (body mass index) of 25.3 (range 19.7–30.4). All patients had bilateral salpingo-oophorectomy or bilateral salpingectomy and two of them underwent pelvic lymphadenectomy. A median operative time of 67 min (range 45–180 min) and a median estimated blood loss (EBL) of 50 ml (range 10–100 ml) were registered. Median PSS introduction time was 5 min (range 3–10 min). No conversions to standard laparoscopy or laparotomy were required and no intraoperative complications occurred. Discharge was on day 1 in 4 cases, on day 2 in the other 6 cases. All patients conveyed complete satisfaction with the cosmetic result and postoperative pain control. No complications were registered within 30 days after surgery. Conclusions PSS total laparoscopic hysterectomy is safe and feasible with good results in terms of operative time, cosmesis, postoperative pain, recovery and short hospitalization. Further studies are needed to compare PSS total hysterectomy to conventional multi-access laparoscopic and other mini-invasive approaches.

Objective: In the last decade robotic surgery has acquired a more important role in gynecologic surgery [1]. Recently, the new robotic platform Telelap ALF-X (TRANSENTERIX Inc., USA) has been proposed as an alternative system to bridge the gap between robotic and laparoscopic features. This new robotic device provides a novel approach to endoscopy thanks to remote 3D vision with an eye-tracking camera control system, an incorporated haptic interaction and high configuration versatility due to total robotic arms independency. These technical characteristics, combined with fully reusable instruments and conventional 5-mm ports.The aim is to show the new surgical approach in treatment of early stage endometrial cancer using new robotic platform ALF-X.Methods: The patient was 70 years old women affected by endometrioid endometrial carcinoma stage IA (FIGO 2009) diagnosed by endometrial biopsy and radiologic examinations. She had no past medical history and the body mass index was 29.14 kg/m(2). We performed laparoscopic Class A Querleu-Morrow total Hysterectomy [2] and bilateral salpingo-oophorectomy using Telelap ALF-X [3].Results: Total operative time was 98 min and 9 min for docking time. The estimated blood loss was 50 mL. The patient was discharged home on postoperative day 2 and no complications were noted according to Dindo classification [4].Conclusions: Despite the absence of articulated instrument, total hysterectomy performed using Telelap ALF-X is technically feasible and the use of this novel robotic platform allowed to maintain the standard laparoscopic setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach.

Study Objective To compare the surgical and clinical outcomes of patients affected by early-stage endometrial cancer treated using the Telelap ALF-X platform versus conventional laparoscopic surgery. Design Single institution retrospective cohort study (Canadian Task Force classification II-2). Setting Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy. Patients The study involved 89 patients affected by early-stage endometrial cancer who underwent elective surgical staging between October 2013 and September 2014. Among them, 43 (48.3%) underwent Telelap ALF-X staging (ALF-X group), and 46 (51.7%) underwent conventional laparoscopic staging (laparoscopic group). Interventions All selected patients underwent laparoscopic staging with radical hysterectomy (class A sec Querleu-Morrow), bilateral salpingo-oophorectomy, and pelvic lymphadenectomy if required. The 2 surgical groups were further divided into patients who did not require pelvic lymphadenectomy (subgroup 1) and those who underwent pelvic lymphadenectomy (subgroup 2). Measurements and Main Results In the ALF-X group, the median operative time was 128 minutes (range, 69–260 minutes) for subgroup 1 and 193 minutes (range, 129–290 minutes) for subgroup 2. In the laparoscopic group, the median operative time was 82 minutes (range, 25–180 minutes) in subgroup 1 and 104 minutes (range, 36–160 minutes) in subgroup 2. The difference in operative time between subgroups was statistically significant in both the ALF-X and laparoscopic groups (p = .000). In subgroup 1 of the ALF-X group, there was 1 conversion to standard laparoscopy (2.3%) and 2 conversions to laparotomy (4.7%) (p = .234). No conversions to laparotomy occurred in the laparoscopic group. Postoperative complications included 1 case of pelvic hematoma (2.3%) in subgroup 1 of the ALF-X group and 1 case of subocclusion and 1 case of pulmonary edema (4.3%) in subgroup 1 of the laparoscopic group. Conclusion Based on operative outcomes and complication rates, our results suggest that the Telelap ALF-X approach is feasible and safe for endometrial cancer staging; however, further studies are needed to definitively assess the role of Telelap ALF-X early-stage endometrial cancer staging.

STUDY OBJECTIVE: To show the safety, feasibility, and perioperative outcomes of total TELELAP ALF-X hysterectomy (SOFAR S.p.A., ALF-X Surgical Robotics Department, Trezzano Rosa, Milan, Italy). DESIGN: Phase II study (Canadian Task Force II-2). SETTING: Catholic University of the Sacred Heart, Rome, Italy. PATIENTS: From October 2013 to May 2014, 80 women underwent total TELELAP ALF-X hysterectomy. The study population was divided into 2 groups according to surgical procedures: total hysterectomy ± bilateral salpingo-oophorectomy (group 1) and endometrial cancer patients staged with pelvic lymphadenectomy (group 2). INTERVENTIONS: Total TELELAP ALF-X hysterectomy ± bilateral salpingo-oophorectomy with or without pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: The median age was 51 years (range, 48-79), and the median body mass index was 24 kg/m(2) (range, 17.3-34.2). Forty-five patients (56.2%) had previous surgery. The median operative time was 140 minutes (range, 58-320) in group 1 and 197 minutes (range, 129-290) in group 2 (p < .001). The median docking time was 8 minutes (range, 3-25). During the study period, a significant trend in operative time reduction was observed. Procedures were successfully performed without conversion in 93.7% of cases. We observed 2 (2.5%) intraoperative complications, 3 (3.7%) conversions to standard laparoscopy, and 2 (2.5%) to laparotomy. The median time to discharge was 2 days (range, 1-5). One patient (1.2%) was readmitted in the early postoperative period. CONCLUSION: As new technology evolves, critical appraisal of patient-related outcomes, use, cost, and access to minimally invasive hysterectomy must remain a priority. Despite the relative small number of our series, we showed the feasibility and safety of total TELELAP ALF-X hysterectomy for benign and malignant disease.

We performed laparoscopic myomectomy for treatment of a large, twisted, subserous myoma at 25 weeks of pregnancy in a woman with acute abdominal pain that did not respond to analgesic therapy. There are few reports in literature about laparoscopic management of uterine leiomyoma during the first half of pregnancy that demonstrate its feasibility in selected cases. Laparoscopic myomectomy can be considered a minimally invasive alternative to the traditional laparotomy when myomectomy is necessary during the second half of pregnancy, resulting in less postoperative pain and shorter recovery time.

Single-port or laparoendoscopic single-site surgery (LESS) is an advanced minimally invasive procedure that utilizes a single, small incision within the umbilicus. The feasibility and advantages of this type of surgery in benign gynecologic conditions indicate a promising surgical innovation for gynecologic or gynecologic-oncologic patients.

Study Objective To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors. Design Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I). Setting Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy. Patients Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA 2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B). Intervention Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed. Measurements and Main Results Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02). Conclusion TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer.