3D Patient-Specific Virtual Models for Presurgical Planning in Patients with Recto-Sigmoid Endometriosis Nodules: A Pilot Study

Background and Objective: In recent years, 3D printing has been used to support surgical planning or to guide intraoperative procedures in various surgical specialties. An improvement in surgical planning for recto-sigmoid endometriosis (RSE) excision might reduce the high complication rate related to this challenging surgery. The aim of this study was to build novel presurgical 3D models of RSE nodules from magnetic resonance imaging (MRI) and compare them with intraoperative findings. Materials and Methods: A single-center, observational, prospective, cohort, pilot study was performed by enrolling consecutive symptomatic women scheduled for minimally invasive surgery for RSE between November 2019 and June 2020 at our institution. Preoperative MRI were used for building 3D models of RSE nodules and surrounding pelvic organs. 3D models were examined during multi-disciplinary preoperative planning, focusing especially on three domains: degree of bowel stenosis, nodule’s circumferential extension, and bowel angulation induced by the RSE nodule. After surgery, the surgeon was asked to subjectively evaluate the correlation of the 3D model with the intra-operative findings and to express his evaluation as “no correlation”, “low correlation”, or “high correlation” referring to the three described domains. Results: seven women were enrolled and 3D anatomical virtual models of RSE nodules and surrounding pelvic organs were generated. In all cases, surgeons reported a subjective “high correlation” with the surgical findings. Conclusion: Presurgical 3D models could be a feasible and useful tool to support surgical planning in women with recto-sigmoidal endometriotic involvement, appearing closely related to intraoperative findings.

The Role of Selected Chemokines in the Peritoneal Fluid of Women with Endometriosis—Participation in the Pathogenesis of the Disease

Endometriosis is a disorder characterized by the presence of endometrial tissue outside the uterine cavity, primarily into the peritoneal cavity. It is known as a complex, chronic inflammatory disease and it is strongly associated with immune dysregulation. Various soluble mediators of the immune and inflammatory responses, including chemokines, play an important role in these processes. The aim of the study was to understand the role of the chemokines MCP-1, MCP-2, MCP-3, MCP-4, MIP-1 α, MIP-1β, eotaxin 2, eotaxin 3, ENA-78, and fractalkine in the development of endometriosis through their assessment in the peritoneal fluid of women with endometriosis. The study group included 58 women with endometriosis who were diagnosed during laparoscopy and then confirmed by histopathology. In 15 women from the reference group, laparoscopic examination demonstrated a normal status of the pelvic organs without any evidence of endometriosis nor inflammation in the peritoneal cavity. The peritoneal fluid of women with endometriosis and of women from the reference group were examined. To determine the concentration of the studied chemokines, enzyme immunoassays for Luminex® platforms were used. In the peritoneal fluid of women with endometriosis, a statistically significant increase in the concentration of MIP-1β, eotaxin 2, eotaxin 3, ENA-78, and fractalkine and a decrease in the concentration of MCP-1, MCP-2, MCP-3, MCP-4, and MIP-1α were observed compared to the reference group. The concentration of these cytokines depended on the severity of the disease. Changes in the concentration of the studied chemokines in the peritoneal fluid of women with endometriosis suggest their participation in the pathogenesis of the disease. The differences in chemokines concentration observed in different stages of endometriosis may be associated with the presence of inflammation in the peritoneal cavity at each step of disease development.

Tubo-Ovarian Inguinal Hernia with Ruptured Bleeding Follicle: A Case Report

Introduction: Hernias are abnormal protrusions of any abdominal-pelvic or fat organ, which are produced by a defect in the abdominal wall, the most frequent are inguinal hernias and their content is generally of the omentum or intestinal loops, the presence of pelvic organs is very infrequent and the majority of cases described are in children under five years of age. Objective: To analyze the entity in connection with a case of a patient with a tubo-ovarian inguinal hernia. Clinical case: The case of a 34-year-old female patient is presented, who was under follow-up by the gynecology service due to the presence of a left ovarian cyst, with symptoms of pain in the left iliac fossa for more than 6 months of evolution. which is performed an ultrasound, which reports left inguinal hernia for what is electively scheduled by the general surgery service, when performing the herniorrhaphy incarcerated hernia with left ovary with bleeding follicle and fallopian tube is evidenced. Conclusions: These types of findings are infrequent, documented in the literature with a global incidence of Tubo-ovarian inguinal hernias ranging from 0-8-4.4%, however it is worth clarifying that these studies are in infant patients, so its presentation in adults associated with a hemorrhagic follicle is anecdotal as in this case.

TREATMENT OF AORTA MESENTERIC COMPRESSION: CURRENT PROBLEMS AND PROSPECTS

Left renal vein compression between the aorta and the superior mesenteric artery at an acute angle of the origin of the latter (“the nutcracker syndrome”) often leads to phlebohypertension in the left renal vein causing a combination of structural and functional changes in the kidneys and pelvic organs, different clinical manifestations such as left-sided varicocele, hematuria, pelvic venous congestion syndrome, the development of renal failure. The objective of the research: to determine indications for surgical and conservative treatment of aorta mesenteric compression. Materials and methods. The study included 210 patients (142 men and 68 women) with suspected “nutcracker syndrome” who were referred to vascular surgeons for a consultation by urologists and gynecologists during the period from 1999 to 2020, mainly from the western regions of Ukraine (about 11 million population). The age of the patients ranged from 12 to 52. All patients were interviewed for specific complaints: pain in the left lumbar region and left half of abdomen, inability to eat large amounts of food, hematuria, proteinuria, hemospermia, erectile dysfunction, left sided varicocele in men, and left sided pudendal varicosity and dysmenorrhea in women. All referred patients with suspected “nutcracker syndrome” underwent color Doppler ultrasound to determine the presence of pathological reflux in the left renal and gonadal veins by measuring peak systolic velocities in order to confirm or exclude that pathology. The patients with confirmed left renal vein stenosis underwent CT angiography. Results. According to color Doppler ultrasound, different degree of aorta mesenteric compression was confirmed in 138 (65.7%) patients (83 men and 55 women), critical left renal vein stenosis was observed in 35 of them. Two patients were diagnosed with the retroaortic left renal vein (“posterior nutcracker”). According to observations, clinical manifestations of AMC syndrome severe forms occurred in case of an increase in the diameter of the distal part of the LRV compared to its proximal segment by 3-6 times as well as in case of an increase in peak systolic velocity in the stenosed proximal segment by 6-14 times (by 8.7 times on average) compared to the left renal vein distal segment. Conclusions. Color Doppler ultrasound with determination of peak systolic velocities and diameters of the left renal and gonadal veins, pathological reflux in them must be the obligatory diagnostic stage in the patients with suspected AMC. The choice of treatment approach should be made taking into account clinical and laboratory indices, as well as the assessment of AMC severity according to instrumental data (ultrasound, CT angiography, MRA, etc.). The severity of pathomorphological changes in the pelvic organs and their consequences proves the need to eliminate phlebohypertension in the left renal and gonadal veins. LRV transposition proves its effectiveness in the remote postoperative period.

EP.FRI.90 Should laparoscopy be performed before or after appendicectomy in females of reproductive age with a clinical diagnosis of appendicitis?

Introduction Females of reproductive age with a clinical diagnosis of appendicitis may undergo laparoscopy prior to appendicectomy. This paper advocates laparoscopy after appendicectomy only if the appendix is macroscopically normal in this patient group. Method A cohort of patients under the care of a single general surgeon is reported. If the appendix was macroscopically normal a laparoscopic port was inserted through the right iliac fossa incision. This single port was used for laparoscopic assessment of the pelvic organs. Results Fourteen females of reproductive age underwent laparoscopy following a macroscopically normal open appendicectomy. No additional laparoscopic ports were required. A benign dermoid ovarian cyst was identified in a 14 year-old which was electively excised following further investigation by a gynaecologist. Two ruptured simple ovarian cysts were also identified. There were no complications reported in this patient group. Conclusions Laparoscopy following a macroscopically normal open appendicectomy allows assessment of the pelvic organs in females of reproductive age and reduces the number of ports required during surgery.

Evaluation of mycational and sexual complaints inwomen practicing physical activity

The pelvic floor has the function of supporting the pelvic organs. In women,changes in the pelvic musculature can result in urinary incontinence, pelvicorgan prolapses and other disorders, which may include sexual disorders. Theaim of this study was to assess sexual and voiding dysfunctions among womenwho practice physical activity. A cross-sectional observational study was carriedout, with 31 female patients, aged between 20 and 35 years (26.0 ± 4.2),divided into group G1 with 18 women practicing physical activity with practicetime less than 3 years and the G2 group with 13 women practicing physicalactivity for more than 3 years. As evaluation instruments were used: TheInternational Consultation on Incontinence Questionnaire (ICIQ –SF) and theICIQ-VS questionnaire. The results showed a greater severity of voidingsymptoms in women in group G2, with a severity score of 6.0 and group G1 hada severity score of 3.1, chi-square=5.19 and p=0.07. Regarding vaginalsymptoms, G2 showed a prevalence of 61.5%, which may be indicative of POP.In the present study, a high prevalence of UI symptoms was observed inwomen who practice physical activity, when related to the time of practice, therewas the presence of mild UI in Group G1 andmoderate in Group G2 (p=0.07),presenting a higher impairment of the quality of life of the G2 group (p=0.01).

Electromyographic features of the perineum and pelvic floor in patients with an artificial bladder

Aim – to assess the electromyographic features of the pelvic floor muscles and the sphincter apparatus in patients who underwent radical cystprostatectomy with the formation of an artificial bladder.The main study group consisted of 57 patients with muscle invasive bladder cancer who underwent a standard radical cystprostatectomy with ileocystoplasty. The study of the pelvic floor muscular bioelectric activity with computed electromyography (EMG) of the sphincter apparatus of the pelvic organs was carried out on a 2-channel computer electromyograph "NeuroTrac ™ MyoPlus4". The obtained results of the study of the bioelectric activity of the pelvic floor muscles showed a decrease in the amplitude of contractions in the Work Average mode by 42.1% (p≤0.001) for the perineal electrode, and by 35.7% (p≤0.05) for the rectal electrode, compared with the control group, which indicates a low contractility of the muscular diaphragm of the pelvis and may cause incontinence in patients with an artificial bladder. The average deviation over the entire duration of the session in Work mode in the group of patients with neobladder in channels A and B was 2.3 (p≤0.05) and 1.9 (p≤0.05) times higher, respectively, compared with control group. These data indicate an imbalance in the muscle tone of the pelvic floor in patients after extensive reconstructive intervention on the pelvic organs and can potentiate urodynamic disorders in the study group of patients. The average amplitude (Rest Average) of the activity of biopotentials in the resting state of the pelvic floor muscles along channels A and B is higher by 42.4% and 47.6% (p≤0.05), in comparison with the control group, which indicates insufficient relaxation and rest of striated muscles and sphincter. Despite the change in bioelectric potentials from the rectal electrode in the study group of patients, there were no signs of functional insufficiency of the anal sphincter, in contrast to the severity of urinary incontinence, which correlated and corresponded to the results of bioelectrical changes obtained through channels A and B, up to oscillations and loss of complete control. The EMG analysis of the pelvic floor muscles revealed characteristic changes in the biopotentials of the pelvic sphincters and indicated their relationship with the clinical features of the rehabilitation of this group of patients and the prospect of including the biofeedback method. It is a derivative form of the electromyographic signal in the treatment of incontinence in patients with neobladder.

Immunocompetent cells in the tissue of adhesives of patients with adhesion process in the small pelvis

Objective: To study the morphological features and subpopulation composition of immunocompetent cells of adhesion tissue in women with adhesions of the pelvic organs.Materials and Methods: Th e study was carried out using surgical material obtained from 70 women aged 23 to 40 years. Of these, 50 tissue samples of peritoneal adhesions from patients with adhesions of organs in the small pelvis of I – II degree who underwent adhesiolysis and 20 samples of parietal peritoneum from healthy women who underwent endoscopic sterilization for contraception or completion of generative function. Th e authors used histological, immunohistochemical, and morphometric research methods.Results: Immunological changes in adhesion tissue were characterized by the activation of the T-cell link of immunity. It was confi rmed by a signifi cant increase in the content of CD4+ (p <0.001), CD8+ (p <0.001), a shift in the balance of immunoregulatory subpopulations towards CD8+, a lower indicator of the immunoregulatory index (p = 0.015), and insuffi ciency of the humoral link of immunity, namely, the absence of CD20+ content against the background of a slight increase in the CD138+ pool.Conclusion: To prevent the postoperative adhesion process in the small pelvis in patients of reproductive age, it is necessary to apply immunomodulatory therapy in the early postoperative period, which will improve the results of surgical treatment and is pathogenetically justifi ed.

Postradiation genitourinary fistulae: retrospective study

Introduction. Radiation therapy of the pelvic organs, used to treat malignant neoplasms, is the main cause of urogenital fistula formation (UGF). The widespread use of radiation therapy in the treatment of malignant neoplasms of the pelvic organs has led to an increase in the number of patients with radiation injuries. The study of the prevalence, characteristics and long-term results of surgical treatment of fistulas are of great interest. Materials and methods. There are 76 patients with postradial fistulae received treatment in our Clinic Department of Urology of A.E. Evdokimov Moscow State University of Medicine and Dentistry for the last 6 years from 2012 – through 2018; 49 patients (64.5%) were operated on. The majority of the patients were suffering from vesicovaginal fistula 48.7% (37 people). Transvaginal approach was used in 35 cases (71.4%); abdominal approach was in 7 cases (14.3%); laparoscopic approach was in 3 cases (6.1%); robotic approach took place in 2 cases (4.1%); combined – one case (2%), percutaneous puncture nephrostomy – 1 case (2%). The various flaps technique took place in 40.8% of cases (20/49). Results. In total, radiation indced fistula closed in 35 out of 49 patients successfully. As a result, overall efficiency was 71%. The presented data has included our experience over the past 6 years, which is limited by the standardization of treatment and the lack of some data. Conclusions. Closing the fistula can be performed in several stages: by reducing the size of the fistula and giving patients more time to recover.