Single-port versus conventional multiport access prophylactic laparoscopic bilateral salpingo-oophorectomy in high-risk patients for ovarian cancer: a comparison of surgical outcomes

Laparoendoscopic Single-Site Surgery (LESS): A Shift in Gynecological Minimally Invasive Surgery

Laparotomy was once the preferred modality of treatment for various gynecological conditions. However, over the years, with the advancements worldwide, a new technique for surgery, laparoscopy, came into play. Since then, laparoscopy is preferred over laparotomy for diagnostic and therapeutic purposes since it was less invasive than laparotomy. Further advancements include laparoendoscopic single-site surgery (LESS), which is a procedure that, as the name implies, only uses one port. It includes using a single incision near the umbilicus in contrast to laparoscopy, which traditionally includes one main port incision and various other side ports. Through the port, multiple devices can be inserted into the cavity. The use of a single port can reduce post-operative complications and help reduce the duration of hospital stays. A single incision near the umbilicus would not leave a very significant scar, and the wound healing time would be comparatively less, reducing the hospital stay time. This novel technique is, therefore, an amalgamation of traditional surgery and recently surfacing minimally invasive surgery. Other modalities which are being used widely include vaginal natural orifice transluminal endoscopic surgery (vNOTES). Since the ports formed are frequently inconspicuous, these procedures leave patients with "scarless" results.

An analysis of the surgical outcomes of laparoendoscopic single-site myomectomy and multi-port laparoscopic myomectomy

Background

This study sought to compare the surgical results of patients undergoing a laparoendoscopic single-site myomectomy (LESS-M) and a conventional laparoscopic myomectomy (CLM) at our hospital.

Methods

The basic data of 233 patients undergoing LESS-M and 233 patients undergoing CLM at the Obstetrics and Gynecology Hospital Affiliated to Fudan University were collected from January 2018 to January 2020, and the results of the operations were compared by evaluating a number of factors, including operation time, intraoperative bleeding, postoperative fever, and postoperative maximum body temperature.

Results

The operation times of the LESS-M and CLM groups were 83.9±33.4 and 75.2±26.7 min, respectively; the difference between the groups was statistically significant. The surgical blood loss of the LESS-M group was 86.1±76.9 mL, and that of the CLM group was 83.8±79.9 mL (P>0.05). When the diameter of a fibroid was ≥8 cm, a fibroid was located in the posterior wall or the number of fibroids was ≥4, the operation time of the CLM group was shorter than that of the LESS-M group. When the diameter of a fibroid was ≥8 cm, the blood loss of the CLM group was less than that of the LESS-M group.

Conclusions

LESS-M is safe and feasible. If the diameter of a fibroid is ≥8 cm, the fibroid is located in the posterior wall, or the number of fibroids is ≥4, the utility of single-port surgery should be carefully considered.

Comparison of novel two-port and conventional multiport laparoscopic surgery approaches for benign adnexal masses: The Bagli method

AIM

This study primarily aims to describe the safety and efficacy of a novel two-port (5 and 10-mm) laparoscopic surgery (TPLS) approach for benign adnexal masses compared with conventional multiport laparoscopic surgery (CMLS) in excisional procedures such as salpingectomy and oophorectomy.

METHODS

This is a retrospective case-control study. Forty-four patients were divided into two groups: two-port (5 mm and 10 mm) laparoscopic surgery group (n: 22) and conventional multiport (three/four port) laparoscopic surgery group (n: 22), with similar indications. All procedures, except ovarian detorsions, included salpingectomy, oophorectomy or salpingo-ophorectomy. The groups were evaluated using their demographic, clinical, intraoperative and postoperative data, and survey questions that were asked were used for analyzing cosmetic satisfaction, surgical satisfaction and preference rates of the TPLS.

RESULTS

There were no significant differences between the groups on demographic features. All patients were discharged within 24 h after both the procedures without any major (organ injury) or minor complication. Surgical satisfaction range was 8.82 (±1.01) in TPLS group and 7.27 (±1.6) in the CMLS group, and differences were significant (P = 0.002). Satisfaction with cosmesis was 95% in the TPLS group and 77% in the CMLS group, and this difference was not significant (P = 0.11). The preferences rate of TPLS was 68% among the 44 women.

CONCLUSION

Novel TPLS is feasible and safe in expert hands. In addition, it provides more surgical satisfaction to patients. However, there were not significant differences in long-term cosmesis results between the TPLS and CMLS groups.

Laparoscopy in the coronavirus disease 2019 (COVID-19) era

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) that emerged in China at the end of 2019 has become a pandemic infection that has now involved 200 countries with 465,915 confirmed cases and 21,031 confirmed deaths. Unfortunately, many data have shown that the high number of undocumented infections could have a major role in the rapid diffusion of the disease. In most of the nations involved, non-urgent, non-cancer procedures have been stopped to reallocate medical and paramedical staff to face the emergency. Moreover, concerns have been raised that minimally invasive surgery could be a procedure that carries the risk of virus diffusion in the operating theater during surgery. This paper reports clinical recommendations and scientific studies to assist clinicians in this field.

Oophorectomy as a Hormonal Ablation Therapy in Metastatic and Recurrent Breast Cancer: Current Indications and Results

Breast cancer is the commonest malignancy affecting females. Hormone-positive cancers carry a better prognosis. Many adjuvant and palliative endocrine therapies are in use, including surgical ablation. We retrospectively studied seventy-four patients who did bilateral salpingo-oophorectomy (BSO)/bilateral oophorectomy (BO) for factors affecting survival and prognosis. BSO was superior in overall and progression-free survival. Incidental ovarian metastasis carried a grave prognosis. Surgical hormonal ablation is a viable option with laparoscopic BSO as the approach of choice.

Trends of Opportunistic Salpingectomy

Background and Objectives:

This study analyzed the trends of opportunistic salpingectomy (OS) accompanied by hysterectomy in a 9-year follow-up period at a single institute.

Methods:

This retrospective cohort study included 1184 women at Hualien Tzu Chi Hospital from 2007 to 2015 who underwent hysterectomy performed with or without OS. Parameters including patient age, operating time, surgical approach, length of hospital stay, and perioperative complications were evaluated.

Results:

There was an increase in the number of hysterectomies with OS (from 8% to 80%; P < .001) over the study period. Minimal additional operating time was necessary for hysterectomy with OS (3.7 and 3.6 minutes in open and laparoscopic surgery, respectively). No significant differences were observed in the risks of hospital readmission or blood transfusions between women who underwent hysterectomy with OS performed with the open approach and those who underwent the procedure using the laparoscopic approach. From 2007 to 2015, the proportion of open hysterectomies decreased from 56% to 6%.

Conclusion:

The results of this 9-year follow-up study revealed that, as a cancer prevention method, OS seems to be feasible and safe, requires minimal extra time, and does not increase the morbidity or long-term sequelae.

Endocrine Therapy in Premenopausal Hormone Receptor Positive/Human Epidermal Growth Receptor 2 Negative Metastatic Breast Cancer: Between Guidelines and Literature

There is growing interest in the endocrine treatment (ET) of premenopausal women with hormone receptor positive (HR+) metastatic breast cancer (MBC). This review summarizes available data on endocrine therapy for this patient subset and aims to define the most appropriate treatment approach. The combination of luteinizing hormone-releasing hormone (LHRH) agonists plus tamoxifen seems effective and safe and is considered as being superior to either approach alone; still, single-agent therapy remains an acceptable treatment option. Due to their mechanism of action, aromatase inhibitors alone are not suitable for the treatment of premenopausal patients, but the combination with LHRH agonists may result in excellent disease control. Fulvestrant, in conjunction with LHRH agonists, also yields interesting results regarding clinical benefit rate and time to progression; currently, other orally available selective estrogen receptor downregulators are under clinical evaluation. Recently, targeted drugs have been added to ET in order to reverse endocrine resistance, but only limited information regarding their activity in premenopausal patients is available. The cyclin dependent kinase 4 and 6 inhibitor palbociclib when combined with fulvestrant and LHRH agonists was shown to prolong progression-free survival over endocrine therapy alone in pretreated patients; similar results were obtained with the addition of abemacicilib or ribociclib to endocrine therapy. Currently, activity of the mammalian target of rapamycin inhibitor everolimus in combination with letrozole and goserelin is under assessment in premenopausal patients after progression on tamoxifen (MIRACLE trial).

IMPLICATIONS FOR PRACTICE

This review provides clinicians with an overview on the available data regarding endocrine treatment of hormone receptor positive (HR+) metastatic breast cancer (MBC) in premenopausal women and summarizes the treatment options available in routine clinical practice. Knowledge of an up-to-date therapeutic approach in women with premenopausal HR+ MBC will lead to better disease management, thereby improving disease control and quality of life while minimizing side effects.

A Laparoendoscopic Single-site Surgical Approach to Laparoscopic Salpingectomy

STUDY OBJECTIVE

To demonstrate a laparoendoscopic single-site (LESS) surgical approach to salpingectomy.

DESIGN

A technical video showing step-by-step a LESS surgical approach to salpingectomy (Canadian Task Force classification level III). Institutional review board approval was not required for this study.

SETTING

Of all gynecologic cancer types, ovarian cancer has the highest mortality rate and is the fifth leading cause of cancer deaths among women [1,2]. The leading theory of epithelial ovarian carcinogenesis indicates that serous, endometrioid, and clear cell ovarian carcinomas originated from the fallopian tube and endometrium and not directly from the ovary itself [1-10]. This has led to the use of prophylactic salpingectomy as a theoretical form of ovarian cancer risk reduction at the time of hysterectomy or as a means of tubal sterilization. Prophylactic salpingectomy does not appear to increase the risk of complications and appears to be safe [2]. Ovarian function does not seem to be compromised by salpingectomy based on serum markers or response rates with in vitro fertilization [11-16]. A LESS approach may reduce the morbidity associated with the placement of multiple ports and can improve cosmetic outcomes. Prophylactic LESS bilateral salpingo-oohorectomy was shown to be feasible and safe for high-risk patients for ovarian cancer [17].

INTERVENTIONS

Laparoscopic salpingectomy at the time of hysterectomy or as a means of tubal sterilization using the LESS technique.

CONCLUSION

This is a simple and reproducible technique for preventing major complications associated with LESS salpingectomy. This approach permits easier specimen retrieval because of the large solitary incision that is made. There is a significant improvement in cosmetic satisfaction when compared with a traditional laparoscopic approach in the setting of prophylactic risk reduction surgery [18].

Bilateral Salpingo-oophorectomy Compared to Gonadotropin-Releasing Hormone Agonists in Premenopausal Hormone Receptor-Positive Metastatic Breast Cancer Patients Treated with Aromatase Inhibitors

Purpose

Although combining aromatase inhibitors (AI) with gonadotropin-releasing hormone agonists (GnRHa) is becoming more common, it is still not clear if GnRHa is as effective as bilateral salpingo-oophorectomy (BSO).

Materials and Methods

We retrospectively analyzed data of 66 premenopausal patients with hormone receptor– positive, human epidermal growth factor receptor 2–negative recurrent and metastatic breast cancer who had been treated with AIs in combination with GnRHa or BSO between 2002 and 2015.

Results

The median patient age was 44 years. Overall, 24 (36%) received BSO and 42 (64%) received GnRHa. The clinical benefit rate was higher in the BSO group than in the GnRHa group (88% vs. 69%, p=0.092). Median progression-free survival (PFS) was longer in the BSO group, although statistical significance was not reached (17.2 months vs. 13.3 months, p=0.245). When propensity score matching was performed, the median PFS was 17.2 months for the BSO group and 8.2 months for the GnRHa group (p=0.137). Multivariate analyses revealed that the luminal B subtype (hazard ratio, 1.67; 95% confidence interval [CI], 1.08 to 2.60; p=0.022) and later-line treatment (≥ third line vs. first line; hazard ratio, 3.24; 95% CI, 1.59 to 6.59; p=0.001) were independent predictive factors for a shorter PFS. Incomplete ovarian suppression was observed in a subset of GnRHa-treated patients whose disease showed progression, with E2 levels higher than 21 pg/mL.

Conclusion

Both BSO and GnRHa were found to be effective in our AI-treated premenopausal metastatic breast cancer patient cohort. However, further studies in larger populations are needed to determine if BSO is superior to GnRHa.

A Novel System for Single-Port Laparoscopic Surgery: Preliminary Experience

AIMS

To present preliminary data of single-access laparoscopic surgery with a new device for the treatment of benign adnexal pathologies.

METHODS

Ten women with benign adnexal pathologies underwent salpingectomy (n = 4) and ovarian/para-ovarian cyst enucleation (n = 6) using a laparo-endoscopic single-port approach with an innovative advanced multiport reusable trocar inserted transumbilically through a small wound retractor. Trocar introduction time, operative time, estimated blood loss, conversion to standard laparoscopy, peri- and postoperative complications, hospital stay and Visual Analog Scale score (as assessment of pain and cosmesis) were analyzed.

RESULTS

Port placement was successful in all patients. Mean trocar introduction time was 4.4 min (range 3.4-5.3 min) and no intra or postoperative complication occurred. The mean operating time was 50.0 ± 9.2 min and mean blood loss was 28.5 ± 8.8 ml. The mean hospital stay following surgery was 1.6 ± 0.5 days and convalescence was complete in 1 week. Neither scores for postoperative incisional pain nor cosmesis side effects have been observed in any subjects.

CONCLUSION

We concluded that adnexal single-port surgery performed with this innovative advanced surgical instrumentation is a feasible, safe, and effective technique that drastically reduces postoperative pain and does not compromise cosmetic appearance. The isolation of the operative field by means of the drape prevents the contamination of the port site that occurs frequently, and mainly in adnexal pathologies of uncertain etiology. In addition, the ease of insertion and the conformation of the new port access also make the procedure feasible in obese patients.

Advanced Mesodermal (Müllerian) Adenosarcoma of the Ovary: Metastases to the Lungs, Mouth, and Brain

Background. A malignant mixed Müllerian tumor (MMMT) is a malignant neoplasm found in the uterus, the ovaries, the fallopian tubes, and other parts of the body that contains both carcinomatous (epithelial tissue) and sarcomatous (connective tissue) components. Outcome of MMMTs is determined primarily by depth of invasion and stage. The metastatic background of these lesions is controversial and unknown. Case Report. A 75-year-old woman was admitted to the hospital with anorexia, weakness, and persistent coughing. The imaging exams revealed a solid, promiscuous lesion of 16 × 14 cm in dimensions located into the small pelvis, surrounding the uterus and the ovaries. The patient underwent exploratory laparotomy. The mass was removed and the histological examination of the specimen revealed an advanced mesodermal adenocarcinoma of the ovary (MMMT). Nine days after the operation the patient presented with metastatic lesions in the mouth as well as the lungs. Within a month after the discharge from the hospital metastatic lesions of the MMMT were also depicted in the CT brain scan. Conclusion. Despite the fact that sarcomas have a long-term metastatic potential, to our knowledge this is the first case of Müllerian adenosarcoma presenting with such extraperitoneal metastases.

Safe endobag morcellation in a single-port laparoscopy subtotal hysterectomy

Recently, the American Food and Drug Administration (FDA) published an alert about the risks of uterine tissue morcellation during laparoscopic procedures. In particular, the possible risk of spreading an undiagnosed malignant tumor was emphasized. From then on, a fervent debate in the media has led major scientific societies to express their position on the matter. We present a safe endobag abdominal morcellation in a single port-access laparoscopy subtotal hysterectomy. The endobag abdominal morcellation is feasible and safe; consequently, the development of devices dedicated to intracavitary morcellation in a closed system has been encouraged.