Robotic Surgery a Step Forward in Standardization of Hysterectomy in Patients with Deep Infiltrating Endometriosis.

Introduction: Hysterectomy in cases with deep infiltrating endometriosis (DIE) poses a particular challenge represented by the lack of standardization, causing technical difficulties or incomplete resection of the deep endometriosis lesions. AIM: This article attempts to use the concept of lateral and antero-posterior virtual compartments in the standardization of robotic hysterectomy (RH) in cases of deep parametrial lesions according to ENZIAN classification. MATERIAL AND METHOD: We collected data from 81 patients who underwent total hysterectomy and en bloc excision of the endometriotic lesions by robotic surgery. Results: Excision was realized by the technique of retroperitoneal hysterectomy, its standardization depending on the ENZIAN classification being described step by step. Tailored robotic hysterectomy always included the en-block removal of uterus, adnexa, and posterior and anterior parametria, which included endometriotic lesions and the upper one-third of the vagina with all endometriotic lesions of posterior and lateral vaginal mucosa. Discussion: The hysterectomy and parametrial dissection must be done according to the size and location of the endometriotic nodule. The goal of hysterectomy for DIE is to release the uterus and the endometriotic tissue without risks of complication. CONCLUSION: "En-bloc" hysterectomy together with endometriotic nodules, where the parametrial resection is tailored according to the lesions, is an optimum method, because the blood loss, operative time, and intraoperative complications are reduced comparing with other methods.

A biomechanically based concept for a stronger obstetric anal sphincter repair.

INTRODUCTION AND HYPOTHESIS: This study emanates from the ISPP OASIS and fecal incontinence study group at the 2018 annual meeting of the International Society for Pelviperineology (ISPP) in Bucharest, Romania. The aim was to analyze the biomechanical factors leading to the breakdown of anal sphincter repair and to suggest a more robust technique for external anal sphincter (EAS) repair. METHODS: Our starting point was what happens to the EAS wound repair site during defecation following EAS repair, with special reference to the process of wound healing. RESULTS: We concluded that a graft no more than 1 × 1.5 cm sutured across the EAS tear line would mechanically support the tear line, vastly reduce the internal centrifugal forces acting on it during defecation, thereby giving the wound time to heal. Three different grafts were discussed, autologous, biological, and mesh. Also analyzed were the effects on EAS muscle contractility of overly tight repair and overly loose sphincter repair, the latter occasioned by the tearing out of sutures and repair by secondary intention. CONCLUSIONS: We have analyzed causes of sphincter repair failure, introduced a graft method, preferably autologous, for the prevention thereof and supported ultrasound assessment, rather than the absence of fecal incontinence as the criterion for success of EAS repair. Although based on well-established biomechanical principles, our proposal at this stage remains unproven. Our hope is that these concepts will be challenged, clarified, and tested, preferably in a randomized controlled trial.

Diagnosis of endometriotic lesions by sonovaginography with ultrasound gel.

AIMS: The aim of the study was to evaluate the diagnostic ability of sonovaginography (SVG) with ultrasound gel in patients with endometriosis. MATERIAL AND METHODS: We conducted a multicentre prospective study, which included 193 patients with symptoms highly suggestive for endometriosis. All patients were investigated by transvaginal sonography and SVG with gel and afterwards underwent laparoscopic surgery. For each category of endometriotic lesions investigated, we calculated and compared the sensitivity, specificity,  positive predictive value and negative predictive value of the imagisticinvestigations used. RESULTS: In the case of endometriotic lesions of the uterosacral ligaments, SVG with gel had a sensitivity of 78.5% and a specificity of 96% (p=ns). The lesions of the vagina and rectovaginal septum were diagnosed with a sensitivity of 79%, respectively 94% (p=ns), obtaining a specificity of 99%, respectively of 97% (p=0.007). The lesions of the Douglas pouch were identified with a sensitivity of 81% (p=0.015), and those of the rectosigmoid with a 94% sensitivity (p=0.010). We obtained lower sensitivity (67%) in detecting the lesions of the urinary bladder (p=ns). CONCLUSIONS: SGV with ultrasound gel represents a useful investigation tool for the evaluation of endometriotic lesions in the posterior pelvic compartment.