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Objective(s) Cervical incompetence is an important cause of recurrent pregnancy loss, typically presenting in the second trimester with silent cervical dilation and premature delivery of the fetus. We aimed to evaluate the conception rate and time to conception or failure to conceive after preconceptional laparoscopic abdominal cerclage (LAC). Study Design We conducted this retrospective observational cohort study at a tertiary referral center. Patients who underwent LAC in the nonpregnant state for a second-trimester pregnancy loss between June 2012 and February 2020 were included. Results The subjects were 40 patients with a history of one or more second-trimester pregnancy losses despite the placement of vaginal cerclage, who had undergone LAC before contemplating a future pregnancy. The mean number of second-trimester pregnancy losses before LAC was two per woman. The ages of the women at the time of cerclage ranged from 21 to 42 years. The time to pregnancy, which was the primary outcome of the study, was determined as the number of menstrual cycles before the patient became pregnant after LAC and the number of cycles needed for the patient to achieve her latest pregnancy before LAC. Of the 40 women, 22.5 % were noted during the LAC operation to have a pelvic peritoneal pathology that might have affected fertility, and all such pathologies were treated concomitantly during the procedure. Spontaneous pregnancy rates before and after LAC were 96.4 % and 89.3 % (p = 0.299), and times to pregnancy before and after LAC were 6.3 ± 8.4 and 6.6 ± 8.1 cycles (p = 0.897). Neither difference was statistically significant. In more than 84 % of patients who became pregnant after LAC, pregnancy was sustained to the stage of viability. Conclusion(s) In patients with cervical incompetence, LAC is a very effective intervention to sustain pregnancy to the stage of viability. If placed during the preconceptional period, it does not delay achieving pregnancy and does not have a negative impact on the chances of conception. This may be reassuring to women undergoing this procedure before they achieve a pregnancy.

Plasmacytoid urothelial carcinomas (PUC) of the bladder are rare variants known for diffuse and infiltrative spread, however their magnetic resonance imaging (MRI) features are not well established. We aimed to evaluate MRI features of PUC of the bladder and their association with survival.This retrospective single-center study included 41 patients with pathologically-proven bladder PUC of the bladder that underwent pre-treatment MRI between January 2000 and March 2020. Two radiologists reviewed MRIs independently followed by consensus with a third radiologist. On MRI, tumor extent, size, Vesical Imaging-Reporting and Data System (VI-RADS) scores (≥4, muscle-invasive; 5, extravesical extension [EVE]), pelvic peritoneal spread (PPS), hydronephrosis, pelvic adenopathy and clinicopathological factors of age, gender, pathological stage, and treatment type were extracted. Kaplan-Meier curves and Cox proportional-hazards models were used to evaluate association with survival.Thirty-two men and 9 women (median age 70 years, IQR 64-76) were included. Most were muscle-invasive (n = 30 [73.2%]). On MRI, most tumors were diffuse (n = 28 [68.3%]),5 cm (n = 30 [73.2%]), VI-RADS 4 to 5 (n = 36 [87.8%]) with features of EVE and (n = 31 [75.6%]) and PPS (n = 25 [61.0%]). Variables associated with survival were: Larger tumors (5 cm; hazard ratio [HR] = 5.0; 95% confidence interval [CI] 1.6-15.5; P0.01), diffuse extent (HR = 4.0; 95% CI 1.4-11.2; P = 0.01), EVE (HR = 4.5; 95% CI 1.5-13.6; P0.01), PPS (HR = 3.0; 95% CI 1.2-7.4; P = 0.01), hydronephrosis (HR = 13.7; 95% CI 3.1-60.9; P0.01), pathologic stage (≥pT3 vs. pT1; HR = 5.6; 95% CI 1.3-22.0; P = 0.02), and margin positivity (HR = 4.4 [95% CI 1.2-16.4], P = 0.03).PUCs of the bladder are commonly large, diffuse VI-RADS score 4 to 5 tumors with MRI features of EVE and PPS. These features and pathological stage were associated with survival.

Objective: Carcinosarcomas also known as malignant mixed mullerian tumors (MMMTs) contain both carcinomatous and sarcomatous elements. Most MMMTs are arising from female genital tract, including ovaries, uterus and fallopian tubes. Extragenital carcinosarcomas are extremely rare, with an estimation less than 40 cases so far. Case report: We report two cases of primary peritoneal carcinosarcomas. An 81-year-old woman with pelvic peritoneal carcinosarcoma, heterologous type, was treated with incomplete surgery without further chemotherapy, and died of disease soon. The other one was a 76 year-old woman with abdominal peritoneal carcinosarcoma, homologous type. After optimal debulking surgery and subsequent 6 cycles of combination of paclitaxel and carboplatin chemotherapy, the patient is free of tumor half of year. Conclusion: Active therapy, including complete cytoreduction surgery and carboplatin-paclitaxel chemotherapy might offer a chance of disease control for these unusual primary peritoneal carcinosarcomas. Keywords: Carcinosarcoma, Malignant mixed mullerian tumor, Primary peritoneal carcinosarcoma, Case report

Vaginoplasty is the most commonly performed genital surgery for gender affirmation. Male-to-female (MTF) patients are roughly four times more likely to undergo genital surgery than female-to-male (FTM) patients. Penile inversion vaginoplasty is the most common technique used today, although there are also lesser used alternative methods including visceral interposition and pelvic peritoneal vaginoplasty. In general, outcomes are excellent, and many of the complications are self-limited. Most surgeons performing genital surgery for gender dysphoria adhere to the World Professional Association for Transgender Health (WPATH) guidelines for determining who is a candidate for surgery. Currently, there are no absolute contraindications to vaginoplasty in a patient who is of the age of majority in their country, only relative contraindications which include active smoking and morbid obesity. Important complications include flap necrosis, rectal and urethral injuries, rectal fistula, vaginal stenosis, and urethral fistula. When performed correctly in excellent surgical candidates by skilled surgeons, vaginoplasty can be a rewarding surgical endeavor for the patient and surgeon.

Rectal prolapse is a pelvic floor disorder characterised by the protrusion of the rectum through the anal canal. Although its definite treatment is via surgery, an ideal surgical technique has not yet been introduced. Laparoscopic mesh rectopexy has been reported to provide a low recurrence rate and better functional outcomes. This technique can be performed with both the anterior or posterior fixation of the mesh. Herein, we present a video demonstrating the procedure of laparoscopic dorsal rectopexy and peritoneal sac excision in a 62-year-old male with RP.

Introduction: Plasmacytoid urothelial carcinoma (PUC) is a highgrade variant of conventional urothelial cell carcinoma. This study is the first to describe the imaging findings of PUC, which are previously unreported, using clinical and histopathological correlation. Methods: With internal review board approval, we identified 22 consecutive patients with PUC from 2007‒2014. Clinical parameters, including age, gender, therapy, surgical margins, and longterm outcome, were recorded. Baseline imaging was reviewed by an abdominal radiologist who evaluated for tumour detectability/ location/morphology, local staging, and presence/location of metastases. Pelvic peritoneal spread of tumour (defined as >5mm thick soft tissue spreading along fascial planes) was also evaluated. Followup imaging was reviewed for presence of local recurrence or metastases.Results: Median age at presentation was 74 years (range 51‒86), with only three female patients. Imaging features of the primary tumour in this study were not unique for PUC. Muscle-invasive disease was present on pathology in 19/22 (86%) of tumours, with distant metastases in 2/22 (9%) at baseline imaging. Pelvic peritoneal spread of tumour was radiologically present in 4/20 (20%) at baseline. During followup, recurrent/residual tumour was documented in 16/22 (73%) patients and 7/16 (44%) patients eventually developed distant metastases. Median time to disease recurrence in patients who underwent curative surgery was three months (range 0‒19).Conclusions: PUC is an aggressive variant of urothelial carcinoma with poor prognosis. Pelvic peritoneal spread of tumour as thick sheets extending along fascial planes may represent a characteristic imaging finding of locally advanced PUC.

Objective: Gynecologic surgery often necessitates mobilization of the cecum and terminal ileum for adequate operative exposure. The objective of this study was to document the individual variations in peritoneal attachments of the ileocecum in adult female patients without a history of abdominal surgeries. Study Design: This was a prospective observational study from January 1, 2013 to June 30, 2013. All patients undergoing laparotomy or minimally invasive gynecologic surgery were eligible. Patients who had undergone prior pelvic surgery (except tubal sterilization), had apparent evidence of a concurrent or prior pelvic inflammatory process, or had extensive pelvic peritoneal disease (advanced ovarian cancer, severe endometriosis) were excluded. Results: Seventy-one patients were accrued. The most common preoperative diagnosis was uterine cancer (n=34). A minimally invasive approach was employed in the majority of procedures (71.8%). Forty-five patients were noted to have natural or congenital pe...

Lymphatic network of the uterus can be visualized by intracorporal injection of indocyanine green (ICG) as guide in compartmental surgery (Kimmig et al., 2016a; Kimmig et al., 2016b). Compartmental surgery may be able to effectively control for locoregional tumour recurrence and reducing perioperative complications at the same time by resecting the tumour within the borders of the corresponding morphogenetic fields (Höckel, 2015; Höckel et al., 2009; Santiago et al., 2016). There is first evidence, that this may hold true also for endometrial cancer in intermediate/high risk endometrial cancer (Kimmig et al., 2015). However, the systematic lymphadenectomy increases morbidity; as a consequence diagnostic sentinel node biopsy was investigated; there is evidence that the accuracy of detection of positive nodes is excellent with a very low false negative rate also with respect to paraaortic disease (Zahl Eriksson et al., 2016; Darin et al., 2016; Sinno et al., 2016; Tschernichovsky et al., 2016; Ruscito et al., 2016). Thus, performing a resection of the tumour bearing compartment “en bloc” together with the lymphatic network including the sentinel nodes, it may be suggested that this surgery may be able to control for locoregional recurrence in the pelvis up to the pelvic nodes resected (therapeutically) comparable to (Kimmig et al., 2015) and indicates further need of treatment downstream to these nodes in node positive disease (diagnostically). The video defines the technique of “en bloc” resection of the uterus together with its corresponding embryonal compartment (pelvic PMMR) and part for the first draining lymph compartments containing the sentinel nodes (TCL). This will be basis for an international multicenter study under consideration to evaluate the locoregional control of this procedure without additional adjuvant irradiation; systematic pelvic and paraaortic lymphadenectomy will be added in case of node positive disease. OA gold

Surgery for suspected ovarian torsion sometimes reveals unexpected sources of pelvic pain, such as internal hernias, adhesions, or anatomic defects. A 23-year-old nulligravida with Alagille syndrome was taken to the operating room with suspected ovarian torsion. Intraoperatively, the right adnexa bulged out of a right-sided, posterior peritoneal cleft that incarcerated most of the enlarged ovary. No ovarian torsion was identified. The left adnexa appeared to be normal; however, it dwelled within a left-sided posterior peritoneal cleft. The bilateral posterior peritoneal defects that housed the adnexa were likely of congenital etiology. Although adnexal incarceration is a rare finding at surgery for suspected ovarian torsion, it should be part of the differential diagnosis when evaluating acute pelvic pain.

Pelvic pain is a common symptom in women of reproductive age. Acute pelvic pain with rapid onset demands prompt diagnosis and treatment. We report the case of a patient with ovarian incarceration of acute onset. To our knowledge, this is the first report of ovarian incarceration into the pelvic peritoneal sac in a woman of reproductive age. In the present case, laparoscopy was useful in establishing the cause of pelvic pain. The patient reported severe lower right quadrant abdominal pain of sudden onset. At laparoscopic examination, the right fallopian tube was normal; however, the right ovary was not initially visible at the normal site. After the swollen right ovarian ligament was pulled aside using nontraumatic laparoscopic forceps, we were able to detect incarceration of the right ovary into the peritoneal sac in the medial to right uterosacral ligament. This case is unique because of ovarian incarceration into the peritoneal fenestration. We believe this condition was congenital because there was no other cause such as previous surgery, severe endometriosis, or pelvic inflammatory diseases.

Transvaginal ultrasonography was performed on 113 women prior to laparoscopic sterilization. The amount and character of the peritoneal fluid present in the pelvis was assessed at the end of the operative procedure. Sonographically, free pelvic peritoneal fluid was seen in 42.5% of the patients. Laparoscopically, the average amount of fluid present was 11.2 ml with an average of 16.5 ml present in patients with FPPF and 7.2 ml present in patients without FPPF (P < 0.0001). Sonographic measurement of fluid volume was found to significantly underestimate the amount of fluid present at laparoscopy (P < 0.0001). Endometriosis and pelvic adhesions significantly changed the sonographic findings.

Objective To prove the safety and feasibility of evaluating pelvic anatomy with a new imaging technique called saline intraperitoneal sonogram (SIPS). Design Prospective clinical case series. Setting Outpatient fertility clinic. Patient(s) Ten women with unexplained infertility and normal hysterosalpingograms (HSG). Five women with no known risk factors and five women with known risk factors for adhesive disease were enrolled. Intervention(s) Step 1 required performing a sonohysterogram. Step 2 involved directing a 17-g oocyte retrieval needle into a pocket of peritoneal fluid under ultrasound guidance and infusing normal saline. The pelvic anatomy was evaluated with the three-dimensional and four-dimensional mode on pelvic ultrasound. Main Outcome Measure(s) Technical feasibility, safety, time, fluid infusion, and deficit volumes. Result(s) All 10 patients successfully completed the protocol. One of the five women with no risk factors for adhesive disease and a normal HSG was discovered to have a unilateral hydrosalpinx and filmy adhesive disease on SIPS. Both findings were confirmed on laparoscopy. Three out of the five women with known risk factors had abnormal SIPS imaging and were confirmed on laparoscopy to have significant adhesive disease. The average procedure time was 45 minutes (±15 minutes). Conclusion(s) This study demonstrates that SIPS is a safe, quick, and potentially cost-effective method for evaluating pelvic adhesive disease in an outpatient facility in women with unexplained infertility and a normal HSG.

Ten women had endometriosis and pelvic peritoneal defects of the posterior leaf of the broad ligament, with the consistent finding of medial displacement of the ureter toward the uterosacral ligament. Ureterolysis at the time of surgery revealed the underlying course of the ureter and its proximity to the uterosacral ligament, making it susceptible to surgical injury. It is important for surgeons to be aware of this anatomic alteration associated with these specific peritoneal defects.

A case of angiosarcoma of the large bowel is presented. The tumor occurred in a 16-year-old girl who presented with lower abdominal pain and rectal bleeding. A sigmoid colectomy was performed. Although macroscopic omental and pelvic peritoneal metastases were noted at operation, she did not receive adjuvant therapy and was alive and well more than three years after surgery. The literature on colonic angiosarcoma is also reviewed.

We performed this study to assess the feasibility and effectiveness of ultrasound-guided drainage and ethanol instillation for the treatment of pelvic peritoneal cysts. Six women had pelvic peritoneal cysts after previous pelvic surgery; when the cysts recurred after simple drainage, the patients underwent transvaginal ultrasound-guided drainage and instillation of 20-30 mL of ethanol into the cyst cavity. All patients except one presented with abdominal pain. All cysts had clinical and ultrasonic benign characteristics. Drainage and ethanol instillation were performed successfully in all patients without severe side effects or complications. After a mean follow-up time of 13.6 months, a recurrence was found in only one patient, who was successfully retreated. These preliminary results indicate that transvaginal ultrasound-guided fluid drainage and ethanol instillation is an effective treatment for pelvic peritoneal cysts.

201 Background: The Federation of Gynecology and Obstetrics (FIGO) staging system and the National Comprehensive Cancer Network (NCCN) guidelines for endometrial cancer recommend performing pelvic peritoneal cytology to look for the presence of cancer cells in the peritoneal cavity in patients who are undergoing surgical staging of apparent non-metastatic disease. About 10% of cases have positive cytology and this information is used in formulating plans for adjuvant therapy. However, adherence to the guidelines recommending that cytology be performed is not universal. In this study, we sought to identify factors associated with failure to perform pelvic peritoneal cytology at the time of endometrial cancer staging surgery. Methods: We performed a retrospective study of women with FIGO stage I/II endometrial adenocarcinoma who underwent endometrial cancer staging surgery at our institution from 1993-2007. Predictors of failure to perform cytology that were investigated included: surgeon, presence of adhesions, intraoperative blood loss and conversion from laparoscopy to laparotomy. Results: Among 1,112 cases, peritoneal cytology was not performed in 76 (6.8%). In 30 cases cytology was not performed for valid reasons including 15 in which the surgery was performed vaginally, 10 in which the diagnosis of endometrial cancer was not known prior to surgery and 5 in which gross evidence of stage III/IV disease was found at surgery. Of the remaining 46 cases, 11 (23.9%) had surgery that was converted from laparoscopy to laparotomy, 16 (34.8%) had dense pelvic adhesions and 40 (87.0%) had an estimated blood loss greater than 100 ml. The frequency of these and other risk factors will be compared to that seen in a matched cohort of patients who did have pelvic peritoneal cytology performed. Conclusions: Our analysis will investigate predictors of failure to perform pelvic peritoneal cytology. Increased awareness of these factors has the potential to improve compliance with this accepted procedure that plays a role in planning adjuvant therapy for early stage endometrial cancer.

Resection of liver metastases from gynaecological tumours is uncommon. Endometrial stromal sarcomas (ESS) are low incidence gynecological tumours which can originate in previous sites of endometriosis or following metaplasia of the pelvic peritoneal wall, and which are exceptionally associated with liver metastasis. We present a 68-year-old woman with a ESS and metachronic liver metastasis treated by liver resection. There is very little literature on clinical management about liver metastasis from ESS, but extrapolating the data obtained with liver metastasis from sarcomas and uterine tumours, we should recommend resection as this is considered a resectable extrauterine metastasis. In cases with more sites of extrauterine disease, liver resection should also be performed if the other sites are resectable.

A single dose of clindamycin, cefoxitin, or metronidazole was administered to each of 30 women. The mean concentration of cefoxitin in pelvic fluid at 1 h exceeded those of the other two drugs (P less than 0.007). Cefoxitin concentrations were inferior to those of the other drugs when compared with the published MIC for 90% of Bacteroides fragilis strains.

The peritoneum covering the pelvic viscera is usually smooth and glistening. Defects in the pelvic peritoneum are usually presumed to be acquired. Allen and Masters described such a clinical syndrome, the anatomic cornerstone of which was laceration(s) of uterine supports with resultant defect(s) in the broad and/or uterosacral ligaments. This diagnosis has been made more often recently on the basis of laparoscopic findings alone. Twenty-five cases of pelvic peritoneal defects were documented in a series of 635 consecutive diagnostic laparoscopies done primarily for pelvic pain. None fit the criteria of the Allen-Masters syndrome. Sixty-eight percent had associated endometriosis. It is suggested that pelvic peritoneal defects may be causally related to endometriosis, the disease either attacking presumably previously altered peritoneal surfaces or causing peritoneal scarring, duplication, and reduplication secondary to the cyclic insults of the ectopic endometrium and thereby producing the appearance of traumatic lacerations. Further, it is suggested that when such defects are noted at laparoscopy, the presence of other associated pathologic abnormalities, including endometriosis, should be investigated.

In a randomized prospective clinical trial one layer and two layer techniques have been compared in 92 patients undergoing colorectal anastomosis. The results were assessed radiologically by barium studies on the tenth postoperative day. There was no significant difference in the incidence of anastomotic breakdown with either technique when the anastomosis was performed above the pelvic peritoneal reflection. When the anastomosis was situated below the pelvic peritoneum the incidence of dehiscence was significantly greater when a two layer technique was used.

Summary 1. A series of 6 cases subjected to abdominoperineal excision of the rectum and com-, plicated in the immediate post-operative period by herniation of a knuckle of small intestine through the pelvic peritoneal suture line is recorded. 2. The complication is due to a defect appearing immediately after operation because symptoms appeared on the first or second post-operative day. 3. The most important symptom was pain on the second post-operative day. This was often associated with a rise in temperature which was misleading. 4. The complication is likely to be overlooked because symptoms are not typical of obstruction until relatively late. 5. The complication can be prevented by attention to suturing of the pelvic peritoneum. A continuous interlocking suture reinforced with interrupted sutures is recommended.

Summary Two patients with a primary pelvic peritoneal ectopic pregnancy are reported. Both had been fitted with an intrauterine contraceptive device.

Congenital or acquired defects in the mesentery are rare, and defects of the supporting structures and in the peritoneum of the pelvis are even more uncommon. Such pelvic peritoneal defects have been associated with endometriosis; however, the extent of this association has been unclear. In the present study, 309 patients had a diagnostic laparoscopy performed for pelvic pain in a prospective manner over a 2-year period. A total of 53 patients were found to have pelvic peritoneal defects. Seventy-nine percent of this group with peritoneal defects had associated endometriosis. Of the 309 patients undergoing laparoscopy, 148 patients were diagnosed as having endometriosis. Twenty-eight percent of this group with endometriosis had pelvic peritoneal defects. We conclude that when such defects are found at laparoscopy, the presence of endometriosis should be investigated thoroughly.

Summary A patient is reported who had pelvic peiitoneal oxyuriasis which came to light while investigating symptoms and signs which were not regarded as being primarily due to the parasite.

In four women pelvic peritoneal inclusion cysts were diagnosed with ultrasound or computed tomography. Three patients had a history of multiple surgical procedures, whereas the fourth had prior severe abdominal trauma. Imaging studies showed large cystic structures contiguous with the adnexa. The normal ovarian appearance was distorted in two women. Pathologic confirmation was obtained in all cases. When large adnexal cystic structures are identified in young women with a history of surgery or trauma, the diagnosis of peritoneal inclusion cysts should be entertained. Recognition should result in conservative therapy rather than salpingo-oophorectomy.

Between 1955 and 1981, 323 pelvic exenterations were performed at the Mayo Clinic. Fifty-nine (18%) were considered retrospectively to be palliative because of pelvic or aortic nodal metastasis, pelvic peritoneal involvement, pelvic wall involvement, bone involvement, or, in two cases, distant metastasis. The survivals were 47% at 2 years and 17% at 5 years. When metastasic nodal disease was found after irradiated pelvic recurrence, the 2- and 5-year survivals were 46% and 23%, respectively. Although exenteration procedures are designed to be curative, the palliative benefits obtained in this group of patients appear to be worthwhile and comparable to those achieved in advanced epithelial ovarian carcinoma for which aggressive surgical management is now strongly advocated.

A technic of rectal resection for benign diseases has been described, in which the cleavage plane between the rectal submucosa and muscularis is used. Dissection within the muscularis without mobilization or eversion of the rectum protects pararectal viscera. Pelvic peritoneal closure is facilitated and sexual function in the male is not impaired. This operative technic has been used successfully in two male patients. These encouraging results suggest further clinical trial when proctectomy for benign disease is indicated.