Ovarian reserve in women with endometriosis under total cystectomy compared to partial cystectomy: A randomized clinical trial

Background: The standard procedure for ovarian endometriosis is laparoscopic excision of ovarian cysts and complete removal of the cyst capsule using the striping technique. Owing to the possibility of reducing ovarian reserve, and in some cases, the premature ovarian failure, the safety remains to be known. Objective: To compare the ovarian reserve in women with endometriosis who underwent total cystectomy with partial cystectomy. Materials and Methods: In this randomized clinical trial, 56 women with endometriosis who were referred to the Research and Clinical Center for Infertility and Shahid Sadoughi Hospital, Yazd, Iran between January and February 2020 were randomly assigned into two groups (n = 25/each); group I (total cystectomy) and group II (partial cystectomy). To assess the ovarian reserves, the anti-Müllerian hormone (AMH) level before and three months after surgery was measured and compared between the two groups. Results: No significant difference was observed in the AMH levels before and after surgery (p = 0.52, p = 0.32, respectively). However, the mean reduction of AMH in total cystectomy group was significantly higher than the partial cystectomy (p = 0.001). Conclusion: Cystectomy in women with endometriosis reduces ovarian reserve and can help maintain some ovarian reserve by performing partial instead of total cystectomy. Key words: Anti-Müllerian hormone, Endometriosis, Cystectomy, Ovarian reserve.

Indocyanine green fluorescence-guided laparoscopic colorectal cancer surgery with prophylactic retrograde transileal conduit ureteral catheter placement after previous total cystectomy: a case report

Background Iatrogenic ureteral injury (UI) is a potentially serious complication of colorectal cancer surgery. Performing perioperative placement of ureteral stents or intraoperative fluorescence navigation surgery for the ureter using indocyanine green (ICG) has been employed as a method of preventing UI. However, transileal conduit stent placement has been considered challenging because it is difficult to identify the ureteral orifice due to the anatomical changes caused by a previous surgery. We report a case in which laparoscopic colectomy was safely performed using a combination of prophylactic transileal conduit ureteral catheter placement and intraoperative ICG fluorescence navigation surgery. Case presentation A 75-year-old man presented to our hospital complaining of vomiting and abdominal distension. He had a history of open total cystectomy and ileal conduit urinary diversion 11 years prior to admission. Computed tomography confirmed colon dilation with fecal impaction from the ascending colon to the sigmoid colon and wall thickening in the sigmoid colon. Colonoscopy during the transanal ileus tube insertion revealed a Borrmann type II tumor with circumferential stenosis 10 cm distal to the junction between the descending colon and the sigmoid colon. The patient was diagnosed with colorectal ileus due to obstructive sigmoid colon cancer and underwent transanal ileus tube insertion. Severe intra-abdominal adhesions were expected due to the previous total cystectomy, and the left ureter was near the sigmoid colon tumor; therefore, prophylactic retrograde transileal conduit ureteral catheter placement was performed one day before the elective surgery. During the operation, 20 ml (5.0 × 10–2 mg/ml) ICG was administered from the transileal conduit ureteral catheter, and ICG fluorescence of the ureter was observed in the retroperitoneum. Laparoscopic Hartmann's operation was successfully performed, confirming ureter fluorescence. The operation time was 231 min, with 5 mL of intraoperative bleeding. The ureteral catheter was removed 3 days after the operation. The patient’s postoperative course was good with no complications, and he was discharged on postoperative day 7. Conclusions Prophylactic transileal conduit ureteral catheter placement and ICG fluorescence navigation surgery were effective in performing laparoscopic colorectal surgery with severe adhesions after urinary diversion.

Management of the Uncommon Bladder Cancers: A Single-Center Experience over 10 Years

Background. Under the name of uncommon bladder cancers are gathered rare histological entities which represent less than 5% of bladder tumors. There is not a clear and consensual therapeutic management for these entities. Purpose. To review a single-institution 10-year experience with rare form of bladder cancers detailing the diagnosis, treatment, and patient outcome. Materials and Methods. We performed a retrospective review of 27 medical records of rare bladder cancer form treated at our center between February 2006 and February 2015. The clinicopathologic features are reported with emphasis on treatment and survival. Results. Mean patient age was 65.5 ± 20 yr and 70% of patients were males. Smoking background was found in 16 cases, chronic bladder irritation factors were found in 12 cases, and past urinary tract infection was found in 11 cases. The main symptom was total hematuria (93%) causing an anemia in 16 cases. The two mean histological forms were epidermoid carcinoma (37%) and adenocarcinoma (22%). 26% of patients were found to have extended invasive tumors (T4) at diagnosis. Metastatic disease was confirmed in 8 cases. Our patients were managed by a wide range of therapeutic modalities as total cystectomy with bilateral lymph node dissection (63%), palliative chemotherapy (30%), or concomitant radiochemotherapy (7%). 55.6% of patients were alive one year after diagnosis. Epidermoid carcinoma has the best prognosis followed by leiomyosarcoma and sarcomatoid carcinoma. Neuroendocrine carcinoma has the worst outcome. The overall 5-year survival rate is 33.3%. Conclusion. The rarity and small size of these tumors justify the absence of clear and consensual therapeutic management. No role of total cystectomy concerning the conclusions could be drawn but elements suggest this may be the treatment of choice. The highly aggressive nature of those lesions justifies an aggressive and fast therapy when feasible which gives the best outcomes.

Utility of ICG fluorescence imaging with vessel clamp for ileocecal resection while preserving ileal conduit constructed after previous total cystectomy

Background Indocyanine green (ICG) is useful for evaluating the intestinal perfusion of anastomosis. Especially for patients with prior surgeries, ICG imaging enables surgeons in visualizing the anatomical field. Here, we reported the positive and negative staining techniques of ICG fluorescence with vessel clamp for determining the optimal resection area of vessels and mesentery. Case presentation An 80-year-old man, who had an ileal conduit constructed after a prior total cystectomy, was diagnosed with ascending colon cancer. Although the tumor-feeding vessel was primarily the ileocecal artery, there was no detailed information about the blood running through the ileal conduit. At first, the ascending colon and the marginal vessels were transected at distal side of the tumor. Next, both, the ileocecal artery and the marginal artery of oral side of the ileal anastomotic site were clamped. Finally, we injected ICG intravenously to assess the blood flow. As a result, the blood flow between the ileal anastomotic site and transected ascending colon was not identified (negative staining). Therefore, we cut the root of the ileocecal artery, and dissected the peripheral mesocolon including the ileal anastomotic site. After the ileo-ascending colon anastomosis, we injected ICG intravenously again. The blood flow to the ileal conduit was preserved (positive staining). Conclusion ICG fluorescence imaging with vessel clamp can clearly visualize the demarcation line between ischemic and non-ischemic intestinal tract. In colorectal surgeries, this technique is useful to assess the anastomotic perfusion and determine optimal dissection area of vessels and mesentery in secondary intestinal surgery.

Diagnostic and Predictive Values of Inflammatory Factors in Pathology and Survival of Patients Undergoing Total Cystectomy

Background. Inflammation and tumorigenesis are related. We conducted this study to evaluate whether inflammatory factors (IFs) have a diagnostic value for pathology and a predictive value for survival and recurrence in bladder cancer patients undergoing total cystectomy. Methods. The patients who were diagnosed with bladder cancer and underwent total cystectomy in our center from 2014 to 2020 were enrolled. The values of neutrophil to lymphocyte ratio (NLR), derived neutrophil to lymphocyte ratio (dNLR), platelet to lymphocyte ratio (PLR), lymphocyte to monocyte ratio (LMR), and systemic immune-inflammation index (SII) were calculated by blood routine test results before operation. The AUC of ROC was calculated to judge the diagnostic value of the IFs in pathology and their corresponding cut-off values. For overall survival (OS) and recurrence-free survival (RFS), the above IFs were grouped according to the cut-off value. The differences between different groups were analyzed by the Kaplan-Meier curves, and the predictive value of these IFs was determined by the Cox proportional hazards regression model. Results. A total of 79 patients were enrolled. All IFs had no diagnostic value for the pathological grade, tumor T stage, and systemic metastasis. Only NLR (AUC=0.706, cut‐off value=3.12, sensitivity=75.00%, specificity=70.00%, P=0.014), dNLR (AUC=0.700, cut‐off value=2.49, sensitivity=66.67%, specificity=76.67%, P=0.015), and SII (AUC=0.704, cut‐off value=463.56, sensitivity=100.00%, specificity=40.00%, P=0.004) had a diagnostic value for lymph node metastasis. The median follow-up time was 31 months, and there was no significant difference in OS between the two groups for all IFs. For RFS, Kaplan-Meier suggested PLR might be predictive when the cut-off value was 266.70 (P=0.044), but the subsequent Cox proportional hazards regression analysis showed that all IFs had no predictive value for OS and RFS. Conclusions. We found that in patients undergoing total cystectomy preoperative NLR, dNLR and SII had a diagnostic value for lymph node metastasis, while all these five IFs had no predictive value for OS and RFS. However, this conclusion needs to be further verified by large-scale studies in the future.