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Ceccaroni M, D'Ancona G, Roviglione G, Choi S, Capezzuoli T, Puppo A, Drampyan A, Barra F. Tailoring radicality in diaphragmatic surgery for deep endometriosis: A matter of choice. Best Pract Res Clin Obstet Gynaecol 2024:102499. [PMID: 38710608 DOI: 10.1016/j.bpobgyn.2024.102499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/09/2024] [Accepted: 04/16/2024] [Indexed: 05/08/2024]
Abstract
Diaphragmatic endometriosis (DpE) is a rare disease localization which represents an important clinical challenge. The main criticisms toward the proper DpE management consist of poor consensus on both surgical indications and the choice between different surgical techniques available to treat the disease. Furthermore, only weak recommendations are provided by current guidelines and surgical management is mostly based on surgeon's experience. As consequence, the lack of standardization about the surgical treatment led to the risk of under- or over-treatments in patients suffering from this form of endometriosis. The latest evidence-based data suggest to adopt a lesion-oriented surgical approach serving as a guide in daily surgical activities, in order to ensure a tailored radicality and reduce the rate of surgery-related complications. Diaphragmatic endometriosis surgery should be performed only by expert surgeons with an extensive oncogynecologic expertise since it represents a technically demanding procedure. A multidisciplinary approach is also mandatory in order to adequately select and treat these patients by minimizing the risk of additional morbidity.
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Affiliation(s)
- Marcello Ceccaroni
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Gianmarco D'Ancona
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy.
| | - Giovanni Roviglione
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Sarah Choi
- Sydney Women's Endosurgery Centre, Women's & Children's Health, St. George Hospital, South Eastern Sydney Local Health District, New South Wales, 2217, Australia
| | - Tommaso Capezzuoli
- Department of Obstetrics and Gynecology, Gynecologic Oncology and Minimally Invasive Pelvic Surgery, International School of Surgical Anatomy, IRCCS "Sacro Cuore - Don Calabria" Hospital, Negrar di Valpolicella, Verona, Italy
| | - Andrea Puppo
- Clinic of Obstetrics and Gynecology, Santa Croce e Carle Hospital, Cuneo, Italy
| | - Ashot Drampyan
- Department of Endoscopic Gynecology, Republic Institute of Reproductive Health, Perinatology, Obstetrics and Gynecology, Yerevan, Armenia
| | - Fabio Barra
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, and Maternal and Child Health (DINOGMI), University of Genoa, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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Hebert T. Robotic assisted laparoscopy for deep infiltrating endometriosis. Best Pract Res Clin Obstet Gynaecol 2024; 92:102422. [PMID: 38007964 DOI: 10.1016/j.bpobgyn.2023.102422] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 10/09/2023] [Accepted: 10/22/2023] [Indexed: 11/28/2023]
Abstract
Deep infiltrative endometriosis is a condition affecting up to 15 % of women of childbearing age, defined by extra uterine location of endometrial like tissues. The symptoms of endometriosis range from severe dysmenorrhea to infertility, chronic pelvic pain, bowel dysfunction and urinary tract involvement to name the most common. Endometriosis has an impact on the quality of life of patients, with personal and social consequences. Although medical treatment is indicated in the first instance, surgery may be necessary. Standard laparoscopy has become the gold standard for this surgery. However, surgery for deep infiltrative endometriosis is known to be highly complex, and the significant development of robotic assistance in recent years has had an impact on the evolution of surgical practice. This comprehensive review of the literature provides an overview of the contributions of robotic surgery in the field of endometriosis and gives an insight into the next steps in its development.
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Affiliation(s)
- T Hebert
- Centre Olympe de Gouges, Gynecologic Surgery Department, University Hospital, Tours, France.
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Pagano F, Schwander A, Vaineau C, Laura K, Nirgianakis K, Imboden S, Mueller MD. True Prevalence of Diaphragmatic Endometriosis and Its Association with Severe Endometriosis: A Call for Awareness and Investigation. J Minim Invasive Gynecol 2023; 30:329-334. [PMID: 36669679 DOI: 10.1016/j.jmig.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 01/11/2023] [Accepted: 01/12/2023] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE To identify characteristics indicating preoperatively the presence of diaphragmatic endometriosis (DE). DESIGN Comparison of characteristics of patients with diaphragmatic endometriosis (DE) with characteristics of patients with abdominal endometriosis without diaphragmatic involvement, in a prospective cohort study. SETTING Tertiary referral center; endometriosis center. PATIENTS A total of 1372 patients with histologically proven endometriosis. INTERVENTIONS Surgery performed laparoscopically under general anesthesia. All patients with suspected endometriosis underwent a complete bilateral inspection of the diaphragm. MEASUREMENTS AND MAIN RESULTS Demographic and clinical pathologic characteristics were evaluated using basic descriptive statistics (comparison of the groups using the χ2 test and the Mann-Whitney t test). A logistic regression analysis was performed to evaluate the relationship (hazard ratio) between symptoms and the presence of DE. DE was diagnosed in 4.7% of the patients (65 of 1372). There was no significant difference between the 2 groups (patients with abdominal endometriosis with or without DE) with regard to typical endometriosis pain (dysmenorrhea, dyschezia, dysuria, and/or dyspareunia). However, in the DE group, diaphragmatic pain was present significantly more often preoperatively (27.7% vs 1.8%, p <.001). Four DE patients (6.1 %) were asymptomatic (with infertility the indication for surgery). In the DE group, 78.4 % had advanced stages of endometriosis (revised American Fertility Society III° or IV°); the left lower pelvis was affected in more patients (73.8%). In cases of ovarian endometriosis, patients with DE showed a significantly higher prevalence of left ovaries involvement (left 63% vs right 35.7%, p <.001). Patients with DE had a significantly higher rate of infertility (49.2% vs 28.7%, p <.05). CONCLUSION Patients with shoulder pain, infertility, and/or endometriosis in the left pelvis have a significant higher risk of DE and therefore need specific preoperative counseling and if indicated surgical treatment.
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Affiliation(s)
- Flavia Pagano
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Adriana Schwander
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Cloé Vaineau
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Knabben Laura
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Konstantinos Nirgianakis
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Sara Imboden
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors)
| | - Michael D Mueller
- Department of Gynecology and Obstetrics, Bern University Hospital and University of Bern, Bern, Switzerland (all authors).
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Moawad G, Youssef Y, Ayoubi JM, Feki A, De Ziegler D, Roman H. Diaphragmatic endometriosis: robotic approaches and techniques. Fertil Steril 2022; 118:1194-5. [PMID: 36369182 DOI: 10.1016/j.fertnstert.2022.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 09/02/2022] [Accepted: 09/16/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To present different approaches used in the surgical management of diaphragmatic endometriosis using the Davinci Robotic system. DESIGN A video article presenting patient positioning, port placement, and surgical techniques used in robotic excision of diaphragmatic endometriosis with concomitant pelvic disease. SETTING Endometriosis center. PATIENT(S) Patients undergoing excision of diaphragmatic endometriosis. INTERVENTION(S) Systematic robotic approach to excise diaphragmatic lesions depending on the depth of invasion. MAIN OUTCOME MEASURES(S) The advantages and disadvantages of the lithotomy and the lateral decubitus approach were reviewed. Ports placements are illustrated according to the chosen approach. Diaphragmatic peritoneal stripping, diaphragmatic shaving, and diaphragmatic excision are different techniques used according to the depth of invasion. RESULTS(S) N/A. CONCLUSION(S) The choice of approach between the lithotomy position and the left lateral decubitus position depend on the extent of the diaphragmatic disease and the presence of concomitant pelvic lesions. Despite the lack of high-quality evidence, the advantages of the robotic system may improve the outcomes in such difficult cases in comparison with conventional laparoscopy.
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Piccus R, Mann C, Sutcliffe RP. Diagnosis and treatment of diaphragmatic endometriosis: results of an international patient survey. Eur J Obstet Gynecol Reprod Biol 2021; 260:48-51. [PMID: 33740695 DOI: 10.1016/j.ejogrb.2021.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 03/02/2021] [Accepted: 03/06/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To quantify the delays associated with the diagnosis and treatment of diaphragmatic endometriosis (DE), and to evaluate patient-reported postoperative outcomes. STUDY DESIGN An anonymous survey was designed to collect data regarding demographics, duration and nature of DE symptoms, type of surgery and postoperative outcomes. Members of endometriosis patient associations in 14 countries were invited to complete the survey if they had been diagnosed with DE. Factors associated with postoperative outcomes were analyzed using Mann-Whitney U and Fisher's exact tests. RESULTS Data was available from 136 respondents (median age 34 years). 98 % of respondents were from Europe, North America or Oceania. The most frequently reported symptoms of DE were moderate-severe pain in the upper abdomen (68 %), chest (64 %) and shoulder (54 %). Pain was right-sided in 54 %, left-sided in 11 % and bilateral in 35 %. Of 122 respondents who initially consulted a primary care physician, a gynaecology referral occurred after a median of five consultations (range 1-100). The median time between first primary care consultation and diagnosis of DE was two years (range 0-23). 31 % were diagnosed >1 year after their first gynaecology consultation (range 1-13 years), and 30 % required two or more laparoscopies before diagnosis. 116 respondents underwent surgical treatment. Postoperative data was available for 113 respondents, and 65 % reported either a significant improvement or complete resolution of symptoms. There was no significant difference in age (P = 0.19), timing of diagnosis (P = 0.59) or type of procedure (excision or ablation) (P = 0.13) between respondents who did and did not experience symptomatic relief after surgery. 61 % reported long-lasting symptomatic relief after a median of 1 year, whilst 39 % reported ongoing moderate-severe pain or have undergone further surgery for recurrent symptoms. CONCLUSION The diagnosis and treatment of diaphragmatic endometriosis is often delayed, due to lack of awareness by patients and healthcare professionals. The diagnosis of DE requires a high index of suspicion and involvement of surgeons trained in laparoscopic liver mobilization. Recurrent symptoms are common following surgical treatment, and international collaborative studies are required to determine the long-term outcomes of this condition.
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Benelmir S, Lallemant M, Manfredelli S, Ramanah R. [How do I perform … a laparoscopic diaphragmatic endometriosis resection]. ACTA ACUST UNITED AC 2021; 49:792-794. [PMID: 33516937 DOI: 10.1016/j.gofs.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Indexed: 11/28/2022]
Affiliation(s)
- S Benelmir
- Pôle mère-femme, service de gynécologie-obstétrique, centre hospitalier universitaire Besançon, 3 Boulevard Alexandre Fleming, 25000Besançon, France
| | - M Lallemant
- Pôle mère-femme, service de gynécologie-obstétrique, centre hospitalier universitaire Besançon, 3 Boulevard Alexandre Fleming, 25000Besançon, France; Laboratoire de nanomédecine, imagerie et thérapeutiques, INSERM EA 4662, Université de Franche-Comté, 19, rue Ambroise Paré, 25000 Besançon, France
| | - S Manfredelli
- Service de chirurgie digestive, centre hospitalier universitaire Besançon, 3, boulevard Alexandre Fleming, 25000 Besançon, France
| | - R Ramanah
- Pôle mère-femme, service de gynécologie-obstétrique, centre hospitalier universitaire Besançon, 3 Boulevard Alexandre Fleming, 25000Besançon, France; Laboratoire de nanomédecine, imagerie et thérapeutiques, INSERM EA 4662, Université de Franche-Comté, 19, rue Ambroise Paré, 25000 Besançon, France.
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Vigueras Smith A, Cabrera R, Kondo W, Ferreira H. Diaphragmatic endometriosis minimally invasive treatment: a feasible and effective approach. J OBSTET GYNAECOL 2020; 41:176-186. [PMID: 32053018 DOI: 10.1080/01443615.2019.1702934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The present review aims to analyse the current data available on the feasibility, safety and effectiveness of the minimally invasive surgical (MIS) treatment of diaphragmatic endometriosis (DE). Through the use of PubMed and Google Scholar database, we conducted a literature review of all available research related to diagnosis and treatment of DE, focussed on the minimally invasive techniques. The studies were selected independently by two authors according to the aim of this review. DE is an under-diagnosed disease affecting between 0.1% and 1.5% of fertile women. It is predominantly multiple, asymptomatic and highly associated with pelvic disease in about 50-90%. MIS techniques seems to be safe, effective and feasible in tertiary advanced endometriosis centre, offering definitive advantages in terms of hospital stay, post-operative pain and return to normal activity by using several surgical techniques as hydro-dissection plus resection, laser CO2 vaporisation, electrical fulguration, Sugarbaker peritonectomy, partial (shaving) and full-thickness diaphragmatic resection. Symptoms control range from 85% to 100%, with less than 3% of conversion, peri-operative complications and recurrence rate. All cases must be performed by multidisciplinary teams including at least a gynaecologist, thoracic surgeon and anaesthetist. The lack of prospective evaluation of DE interferes with the understanding about the natural history of disease and treatment results. Therefore, the development of adequate evidence-based recommendations about diagnosis, management and follow-up is difficult at this moment.
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Affiliation(s)
- Andres Vigueras Smith
- Department of Minimally Invasive Surgery Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ramiro Cabrera
- Department of Gynaecology and Minimally Invasive Unit, Vita Batel Hospital, Curitiba, Brazil
| | - William Kondo
- Department of Gynaecology and Minimally Invasive Unit, Vita Batel Hospital, Curitiba, Brazil
| | - Helder Ferreira
- Department of Minimally Invasive Surgery Unit, Centro Hospitalar Universitário do Porto, Porto, Portugal
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Bourdel N, Fava V, Budianu MA, Chauvet P, Canis M, Chadeyras JB. Laparoscopic Resection of Diaphragmatic Endometriosis in 10 Steps. J Minim Invasive Gynecol 2019; 26:1224-1225. [PMID: 30980992 DOI: 10.1016/j.jmig.2019.04.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 03/26/2019] [Accepted: 04/03/2019] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Laparoscopic resection of diaphragmatic endometriosis has the advantages of a minimally invasive approach [1]. The standardization and description of the technique are the main objectives of this video. We described the procedure in 10 steps to make it easier and safer. DESIGN A step-by-step video demonstration of the technique (Video 1). SETTING A French university tertiary care hospital. PATIENTS Patients with diaphragmatic endometriosis confirmed by magnetic resonance imaging [2]. The local institutional review board ruled that approval was not required for this video article because the video describes a technique and does not report a clinical case. INTERVENTION There are no guidelines on the surgical treatment of diaphragmatic endometriosis [3]. We propose a laparoscopic approach using a right lateral access with the patient in the left lateral decubitus position [4]. MEASUREMENTS AND MAIN RESULTS This video presents the procedure divided into the following 10 steps: step 1, set up; step 2, patient position; step 3, installation of the trocars; step 4, releasing the liver; step 5, exposure of the diaphragmatic endometriosis; step 6, making a diaphragmatic defect; step 7, exploring the thoracic cavity; step 8, resection of diaphragmatic endometriosis; step 9, inserting the suction catheter; and step 10, closing the diaphragmatic defect. CONCLUSION Standardization of laparoscopic resection of diaphragmatic endometriosis could make this procedure easier and safer to perform. The left lateral decubitus position helps to have complete exposure of the right diaphragmatic muscle and endometriosis. We presented 10 steps to help perform each part of the surgery in logical sequence, making the procedure ergonomic and easier to adopt and learn [5]. Standardization of laparoscopic techniques could help to reduce the learning curve.
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Affiliation(s)
- Nicolas Bourdel
- Department of Gynecological Surgery, CHU Estaing, EnCoV, IP, UMR 6 6602 CNRS, University Clermont Auvergne, Clermont-Ferrand, France (Drs. Bourdel, Fava, Chauvet, and Canis).
| | - Valentina Fava
- Department of Gynecological Surgery, CHU Estaing, EnCoV, IP, UMR 6 6602 CNRS, University Clermont Auvergne, Clermont-Ferrand, France (Drs. Bourdel, Fava, Chauvet, and Canis); Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy (Dr. Fava)
| | - Mihaela-Alexandra Budianu
- Department of Obstetrics and Gynecology, University Emergency Hospital of Târgu Mureș, University of Medicine and Pharmacy of Târgu Mureș, Târgu Mureș, Romania (Dr. Budianu)
| | - Pauline Chauvet
- Department of Gynecological Surgery, CHU Estaing, EnCoV, IP, UMR 6 6602 CNRS, University Clermont Auvergne, Clermont-Ferrand, France (Drs. Bourdel, Fava, Chauvet, and Canis)
| | - Michel Canis
- Department of Gynecological Surgery, CHU Estaing, EnCoV, IP, UMR 6 6602 CNRS, University Clermont Auvergne, Clermont-Ferrand, France (Drs. Bourdel, Fava, Chauvet, and Canis)
| | - Jean-Baptiste Chadeyras
- Department of Thoracic Surgery, Jean Perrin Comprehensive Cancer Center, Clermont-Ferrand, France (Dr. Chadeyras)
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Seidler S, Shabanov S, Andres A, Karenovics W, Wenger JM, Pluchino N. Diaphragmatic Endometriosis: Multidisciplinary Treatment. J Minim Invasive Gynecol 2018; 26:404. [PMID: 30031207 DOI: 10.1016/j.jmig.2018.07.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2018] [Revised: 05/31/2018] [Accepted: 07/06/2018] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To demonstrate a safe laparoscopic procedure for diaphragmatic infiltrative endometriosis. DESIGN Video case SETTING: Teaching hospital (Canadian Task Force classification III). PATIENTS One patient presenting deep and severe diaphragmatic endometriosis. INTERVENTION Laparoscopic cure of diaphragmatic endometriosis. MEASUREMENTS AND MAIN RESULTS Throughout this video, which was approved by the institutional board review, we demonstrate safe and complete surgical treatment of a patient suffering severe pelvic and diaphragmatic endometriosis. The patient complained of menstrual dyspnea and shoulder pain persisting despite hormonal treatment, associated with persistent dyspareunia and pelvic pain despite a previous laparoscopic surgery. Patient positioning and anesthesia were adapted to the special requirements of the surgical technique and the expected risks. The operation consisted of the exposure of the right diaphragm by mobilization of the liver, CO2 laser vaporization of left and right diaphragmatic lesions, nerve-sparing excision of infiltrating nodules, and pleural exploration. Finally, we performed an excision of pelvic endometriosis. Participation of 3 surgical teams to this procedure allowed a safe and complete laparoscopic treatment with resolution of pain symptoms at a 1- and 3-month follow-up. CONCLUSION Laparoscopic treatment allows a safe and complete treatment of diaphragmatic endometriosis.
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Affiliation(s)
- Stephanie Seidler
- Departments of Obstetrics and Gynecology (Drs. Seidler, Shabanov, Wenger, and Pluchino) and
| | - Stas Shabanov
- Departments of Obstetrics and Gynecology (Drs. Seidler, Shabanov, Wenger, and Pluchino) and
| | - Axel Andres
- Surgery (Drs. Andres and Karenovics), University Hospital of Geneva, Geneva, Switzerland
| | - Wolfram Karenovics
- Surgery (Drs. Andres and Karenovics), University Hospital of Geneva, Geneva, Switzerland
| | - Jean-Marie Wenger
- Departments of Obstetrics and Gynecology (Drs. Seidler, Shabanov, Wenger, and Pluchino) and
| | - Nicola Pluchino
- Departments of Obstetrics and Gynecology (Drs. Seidler, Shabanov, Wenger, and Pluchino) and.
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