Ovarian Transposition Strategy in Patients with Cervical Cancer Who Undergo Pelvic Radiation: Proposal of Ovarian Placement Based on Virtual Simulations

Objective: To establish a proposal for the location for ovarian transposition, considering different irradiation techniques and time to ovarian failure. Methods: Patients with cervical cancer in childbearing age submitted to adjuvant radiotherapy were selected. Delineation of simulated positions of the ovaries and pelvic radiation planning was done in CT, with three techniques: 3D conformal radiotherapy, intensity-modulated radiotherapy, and volumetric modulated arc radiotherapy. In order to correlate the ovaries maximal doses with the time to ovarian failure, the authors have used the one adaptation of Wallace model that predicts oocytes survival rates after radiation exposure. Results: Thirteen patients who were being treated between 2008 and 2017 were studied. When the ovaries were positioned 10 cm cranially from the sacral promontory, the pelvic radiation entails a decrease of 20% in the time to ovarian failure compared with that expected for a female at the same age without irradiation exposition. The placement of the ovaries <5 cm cranially from the sacral promontory results in a decrease >90%. There was no difference in time to ovarian failure between the radiation treatment techniques tested: 3D conformal radiotherapy, intensity-modulated radiotherapy, and volumetric modulated arc radiotherapy (p=0.197). Conclusions: The present study, based on virtual simulations, is the first to use the sacral promontory as a reference for a proposal of ovarian location with transposition. The authors have correlated the position of the ovaries and percentage of decrease in time to ovarian failure. These findings can potentially improve the management and counselling of patients with cervical cancer in childbearing age and deserve clinical validation.

The Effects of Moderate Neuromuscular Blockade Combined with Transverse Abdominal Plane Block on Surgical Space Conditions During Laparoscopic Colorectal Surgery: A Randomised Clinical Study

Background Deep neuromuscular blockade may be beneficial on surgical space conditions during laparoscopic surgery. The effects of moderate neuromuscular blockade combined with transverse abdominal plane block (TAPB) on the surgical space conditions during laparoscopic surgery has not been described. We investigated if moderate neuromuscular blockade combined with TAPB would be associated with similar surgical space conditions compared with deep neuromuscular blockade. Methods Eighty patients undergoing elective laparoscopic surgery for colorectal cancer were randomly divided into two groups. The intervention group was treated with moderate neuromuscular blockade (train-of-four (TOF) count between 1 and 3) combined with TAPB (M group), while the control group was treated with deep neuromuscular blockade (D group), with a TOF count of 0 and a post-tetanic count (PTC) ≥ 1. Both groups received the same anesthesia management. The distance between the sacral promontory and the umbilical skin during the operation was compared between the two groups. The surgeon scored the surgical space conditions according to a five-point ordinal scale. Patients’ pain scores were evaluated eight hours after the operation. Results The 95% confidence intervals of the difference in the distance from the sacral promontory to the umbilical skin between the groups were − 1.45–0.77cm. According to the preset non-inferior standard of 1.5cm, (-1.45, ∞) completely fell within (-1.50, ∞), and the non-inferior effect test was qualified. There was no significant difference in the surgical rating score between the two groups. The dosage of rocuronium in group D was significantly higher than that in group M (P < 0.01). The M group had significantly lower pain scores than the D group eight hours after the operation (P < 0.05). Conclusions In laparoscopic colorectal cancer surgery, moderate neuromuscular blockade combined with TAPB can provide surgical space conditions similar to those of deep neuromuscular blockade, and at the same time, reduces the use of muscle relaxants, relieves postoperative pain within 4 hours after operation, shorten the time to extubation and stay in PACU. Trial registration: chictr.org.cn (ChiCTR2000034621), registered on 12, July, 2020

Serendipitous Discovery of a Benign Obturator Nerve Schwannoma

Schwannomas are typically benign tumours of the peripheral nerves. However, they seldom arise from the obturator nerve. Here we report a case of an uncommon swelling (2.5 × 3.5cm) in a 65-year-old male cadaver which was found during the routine dissection for first MBBS students in the department of Anatomy, Kasturba Medical College, Manipal, India in the month ofDecember 2019. It was seen originating from the left obturator nerve in the pelvis at the level of the sacral promontory. Histopathological investigation revealed a schwannoma. The hypocellular tumor was arranged in a sweeping fascicle pattern with patches of myxoid degeneration. Obturator schwannomas, though rarely seen, can exist in the cadaver, as seen in the present case. Hence, it should be considered as a differential diagnosis for clinical cases of pelvic masses and eliminated only after thorough radiological examination. Knowledge about the existence of such schwannomas is, therefore, a must. Keywords: Schwannoma, Obturator nerves, neurilemmoma, nerve sheath neoplasms.

A QUANTITATIVE, CROSS-SECTIONAL STUDY TO MEASURE AORTA SACRAL PROMONTORY DISTANCE AMONG FEMALES REFERRED FOR CONTRAST ENHANCED CT ABDOMEN

Aim: This study was carried out to measure the aorta sacral promontory distance among the females referred for contrast enhanced CT abdomen in a tertiary hospital. Material and methods: A quantitative, cross-sectional study was conducted in the Department of radiology, Indira Gandhi Institute of Medical Science, Patna, Bihar, India from December 2019 to October 2020.Total of 140 patients who underwent Contrast Enhanced CT abdomen. The age, height and weight of the patients were noted. In this study, aorta sacral promontory distance was determined. Results: The mean age was found to be 51.37 years, mean APT distance 4.61±0.80 cm and mean BMI 24.88. Increased in age was correlated with decrease in APT distance but there was no correlation between BMI and APT distance. According to this study, APT distance was decreased in elderly female patients but no significant change in BMI and APT. Conclusion: we conclude that the age increased, APT distance decreased and there was no significant change in relation to BMI. Therefore, during sacral colpopexy, the surgeon should be careful and consider the aorta sacral promontory distance in the elder female patients while performing dissection. Keywords: aorta sacral promontory distance, pelvic organ prolapse, sacral colpopexy.

Laparoscopic monolateral suspension for vaginal vault prolapse: a report of an exit surgical strategy during sacralcolpopexy

Background Vaginal vault prolapse is the most frequent long-term complication in patients undergoing hysterectomy and sacralcolpopexy is considered the gold standard. We report our surgical strategy maintaining single-arm mesh when the sacral promontory is not accessible to fix the mesh for an unknown sacral osteophytosis during a laparoscopic sacralcolpopexy. This is significant because, to our knowledge, the bone variant as a procedure limiting factor has never been described before. This opens new horizons for the sacralcolpopexy surgery, because it becomes necessary to know of a valid surgical alternative with mesh maintenance if this complication occurs again or to perform an assessment of the accessibility of the sacral promontory immediately after its dissection. Case presentation We present a case of a 75-year-old woman with recurrence of vaginal vault prolapse. A laparoscopic sacralcolpopexy was recommended. During surgery, we found that the procedure was not feasible due to the presence of an unknown osteophytosis of the sacrum which prevented the fixing of the mesh to the sacral promontory. We decided to proceed with a single-arm lateral suspension by using a modified approach of the original technique, maintaining the mesh originally shaped for the sacral colpopexy. At follow-up, the vaginal vault is well suspended. Conclusion This exit strategy may represent a valid surgical alternative when laparoscopic sacral colpopexy is not possible for anatomical variants, allowing to keep the laparoscopic approach using mesh. To our knowledge, cases in which the anatomical bone variant prevented access to the sacral promontory have never been described in the literature, as bone evaluation has never been considered a limiting element of this procedure.

Ultrasonographic and Radiographic Assessment of Prostate Gland in Perineal Hernia Dogs

Background: Prostate gland affections are considered as common cause for perineal hernia in intact male dogs. Normal prostate gland is usually less distinct, radiographically; however, when enlarged it alters the anatomical position of rectum and urinary bladder and can be distinguished for its objective assessment. Radiography fails to differentiate the parenchymal abnormalities of prostate however, ultrasonography can. Therefore, this study was aimed to assess the involvement of prostate gland using radiography and ultrasonography in perineal hernia affected dogs. Methods: Thirty-eight intact male dogs, suffering from perineal hernia and presented during the entire year of 2018, were investigated. Both radiographic (subjective and objective) and ultrasonographic modalities were applied to assess the enlargement of prostate gland. The subjective assessment parameters on radiography (n=38) included the lifting/displacement of rectum from normal position and cranial displacement of urinary bladder. The objective parameters (n=29) included the prostate length and depth measured using inbuilt calliper of computerized radiography system and ultrasonography and comparing it with 70% of the pubic brim to sacral promontory distance. Results: The mean prostatic length was significantly more than the prostate depth on both radiography and ultrasonography. There was a significant positive correlation between the radiographic pubic brim to sacral promontory distance and the prostate length and depth measured on both the diagnostic modalities. The subjective assessment of prostate over emphasized the prostate depth and under estimated the prostate length compared to objective measurements on radiography. There was a significant correlation between the prostate lengths measured on radiography and ultrasonography and the lengths were not significantly different on two diagnostic modalities. Objective analysis on radiography revealed the prostate length and or/depth of 54.72% perineal hernia dogs (15/29) to be more than 70% of pubic brim to sacral promontory distance. In conclusion, the prostate affections may not always be the primary aetiology in dogs suffering from perineal hernia and prior investigation of prostate is recommended as a deciding factor for whether castration should be done a few weeks prior to or simultaneously with the perineal herniorrhaphy. The increased length of the prostate is a better indicator of prostatomegaly than the depth.

Iatrogenic endometriosis following apical pelvic organ prolapse surgery: a case report

Background Iatrogenic endometriosis is the presence of endometrial glands and stroma out of the uterus following certain surgical interventions. The rate of iatrogenic endometriosis after gynecologic surgeries due to benign uterine disease is 1–2%. Laparoscopic supracervical hysterectomy is also a part of frequently used surgical treatment of apical pelvic organ prolapse, which is followed by sacrocervicopexy. However, there are no data about iatrogenic endometriosis after apical prolapse surgery in the current literature. Herein, we present a case report of a patient diagnosed with de novo endometriosis 1 year after laparoscopic supracervical hysterectomy and sacrocervicopexy. Case presentation A 46-year-old parous Slavic woman who underwent laparoscopic supracervical hysterectomy and sacrocervicopexy secondary to grade 3 symptomatic apical prolapse 1 year earlier was admitted to the same clinic with pelvic pain that had started 6 months following surgery. Deep vaginal palpation was painful. Transvaginal ultrasonography revealed an area with hypervascularization on the sacral promontory. She was scheduled for diagnostic laparoscopy. A 2 × 2-cm solid, wine-colored, hypervascular hemorrhagic lesion was seen on the sacral promontory. The lesion and the peritoneal layer behind it were totally excised. The patient was discharged on the first postoperative day, without any complications. Pathologic examination revealed foci of endometriosis comprising endometrial glands and stroma within the connective tissue, along with hemosiderin-laden macrophages. The symptoms of the patient resolved after the surgery, and no further adjuvant treatment was needed. Conclusion Although the rate of iatrogenic endometriosis is low after laparoscopic supracervical hysterectomy and sacrocervicopexy, the possibility of the occurrence of iatrogenic endometriosis should be discussed with patients who are diagnosed with apical prolapse to determine the type of surgical intervention. Iatrogenic endometriosis should be kept in mind for differential diagnosis in case of pain after laparoscopic supracervical hysterectomy and sacrocervicopexy.