Tips and tricks in gynaecological robotic surgery.

It was the dawn of a new era for robotic surgery when the Food and Drug Administration (FDA) approved da Vinci robotic surgical system for general laparoscopic procedures in 2000. The surgical practice saw a transformative breakthrough towards minimally invasive approach with the ever-increasing uptake of advanced robots proven to benefit patients and surgeons in various ways. However, these innovative machines only complement and enhance a surgeon's operating skills, and with such privilege come responsibilities and new challenges. Heavy reliance on such advanced devices while operating on humans necessitates thorough training and supervision to ensure safe and efficient applications. It is the surgeon's responsibility to direct the procedure constantly and lead other team members who assist during the surgery. In this chapter, we provide miscellaneous tips and tricks that can help beginners navigate through robotic surgery with more confidence and enthusiasm.

Immunohistochemical profiling of the tumour microenvironment in borderline and malignant ovarian tumours in young women.

Ovarian cancer is a major cause of cancer-related deaths in women. Our previous study highlighted the interaction between cancer cells and the host immune response in solid cancers. The present study aimed to analyse the proportion, density and distribution of T and B lymphocytes within the tumour and surrounding stroma, and their prognostic significance in young women with borderline and malignant ovarian surface epithelial tumours. Full clinicopathological and outcome data were collected for 57 women aged <50 years diagnosed between January 2010 and December 2015. Representative tumour sections were stained for CD3 (T cells) and CD20 (B cells) and tumour-infiltrating lymphocytes (TILs) were scored following the TILs Working Group Recommendations and described as stromal, intra-tumoural, lymphoid aggregates and touching lymphocytes. Data were statistically analysed and the association with clinicopathological variables was assessed. The median age was 41 years and the most common histological type was serous carcinoma (n=21). The risk of malignancy index was a significant predictor of ovarian cancer diagnosis (P<0.05). A total of 15 out of 34 patients with cancer died. There was significantly greater stromal infiltration of CD3 and CD20 TILs (P=0.01 and P=0.03, respectively) and higher intratumoral CD20 expression in ovarian epithelial cancers compared with borderline tumours. The highest CD3 stroma count and density were observed in serous carcinoma, which also exhibited the highest numbers of CD3 and CD20 aggregates. There was no statistically significant difference between touching lymphocytes and tumour histological subtype. There was no significant association between TIL expression and patient survival. The count, distribution and density of T and B lymphocytes in ovarian tumours varied depending on tumour type and invasiveness. Their topographic distribution within the tumour and surrounding stroma did not impact prognosis in young women with ovarian cancer. TIL analysis in an older age group of women with ovarian tumours is ongoing to determine its potential prognostic significance.

Vulval extra-mammary Paget's disease: the master of disguise revealed.

Extra-mammary Paget's disease is a rare cancer affecting the anogenital region and can present with a myriad of symptoms. In women, the diagnosis of Paget's disease can be challenging as it mimics several other vulval conditions. It is important to promptly recognise this disease because of its potential association with synchronous tumours, such as colorectal adenocarcinoma. The mainstay of treatment is with immunomodulating therapies or surgery, but unfortunately the risk of recurrence is high and appears to be independent of treatment choice and tissue margin status. There is growing evidence to move away from traditional surgical excision to using topical therapy, such as imiquimod, as surgery can often be extensive and disfiguring with a prolonged recovery time. There is considerable psychosexual and physical morbidity associated with Paget's disease, largely owing to multiple surgical recurrences. As recurrences can occur several years after the initial presentation, long-term follow up of patients is recommended.

The effect of the measures taken during the coronavirus pandemic on specialty trainees in obstetrics and gynaecology in the United Kingdom: an online questionnaire survey in one region.

The coronavirus pandemic (COVID-19) has had unprecedented effects on healthcare delivery. A 34-question online survey was sent to obstetrics and gynaecology trainees within the West Midlands to assess the impact of the pandemic on training, working practices and well-being. 101 responses were received from obstetrics and gynaecology trainees. Trainees reported a significant reduction in both elective and emergency surgeries as well as outpatient clinics. Over one third of respondents felt additional training time may be required following reduction of clinical opportunities. 44% of trainees felt their workload increased significantly. 55% of trainees felt the pandemic had a significant negative impact on their physical and mental well-being. Obstetrics and gynaecology trainees in the West Midlands have adapted to the challenges of the COVID-19 pandemic despite significant impact on their training, working practices and wellbeing. It is important to tailor training to improve trainees' education and combat lost training time during the pandemic. This should be considered for long-term shaping of the obstetrics and gynaecology training pathway.IMPACT STATEMENTWhat is already known on this subject? Little research is available about the impact of the COVID-19 pandemic on obstetrics and gynaecology trainees. This is the first study of its kind to assess the effect of the pandemic on obstetrics ang gynaecology trainees in the United Kingdom.What do the results of this study add? The results of this study have shown that obstetrics and gynaecology training has been heavily affected during the COVID-19 pandemic. There have been significant impacts on their training, working patterns and physical and mental wellbeing.What are the implications of these findings for clinical practice and/or further research? These findings can be used to mould the obstetrics and gynaecology training pathway based on the feedback given by the trainees during the pandemic. The survey questions can also be utilised as a framework for similar research projects across the United Kingdom Deaneries, among other specialties and around the world.

Antegrade ureteric embolization following transection and ligature in a lateral pelvic wall squamous cell carcinoma: Technique and literature review.

Iatrogenic injuries to the ureter are a rare event in gynecological surgery. They are often managed via stent insertion or nephrostomies. While embolization is commonly utilized for the sealing of vessels, its uses in ureter occlusion have not widely been reported. We describe a case of a 27-year-old patient with a previously stented ureter due to a pelvic side wall tumor causing an obstruction. She underwent a laparotomy and open biopsy. During the procedure, the ureter was injured and later ligated. The ligature slipped postoperatively with an obvious urinary leak inside the abdomen. The ureter was embolized using a nester embolization coil, histoacryl, and lipiodol. This is the first case in which this method was used for iatrogenic transection of the ureter.

Impact of COVID-19 on Gynaecological oncology; a global perspective.

The coronavirus pandemic caused global devastation with over 2 million deaths and put unprecedented pressure on health care facilities world-wide. The response to the pandemic differed globally as countries faced different challenges. Within Gynaecological oncology, a multitude of guidance was published by various countries and organisations which demonstrated major themes. These consisted of implementations aimed at reducing transmission, managing limited resources, treatment prioritisation whilst continuing urgent oncological surgery where possible and the use of alternative therapies in the management of oncology patients to reduce hospital admission. Due to the novelty of this virus and its global effects, published guidance is currently limited to best practice and small-scale trials. This review aims to summarise the global response to coronavirus with respect to Gynaecological oncology and suggests potential interventions to limit the spread of the virus during resurgence or in the event of a future global pandemic. It also discusses the current trials recruiting relevant to the field of Gynaecological oncology to better inform the specialty on the management of cancer patients during COVID-19.

Oral retinoid, acitretin, is effective in the management of resistant recurrent vulval verrucous carcinoma: A case report.

Verrucous carcinomas are a rare variant of squamous cell carcinoma. Vulval verrucous carcinoma comprises only 1% of vulval malignancies. This case report discusses the successful management of aggressive recurrent vulval verrucous carcinoma with acitretin, an oral synthetic retinoid used to manage severe psoriasis, after multiple surgical interventions and radiotherapy had failed. This is the first reported case in which verrucous carcinoma had recurred in a musculocutaneous graft. To manage the recurrence, the patient underwent radiotherapy, which did not resolve the condition. The patient was then administered acitretin 25 mg once daily, which successfully resolved the condition, and the patient has been symptom free for 6 months. This report aims to propose the use of acitretin as a management option for recurrent verrucous carcinomas.

Hypertrophic Herpes Simplex With Subsequent Development of Plasma Cell Vulvitis: A Potential Diagnostic Pitfall.

A 37-yr-old patient previously diagnosed with human immunodeficiency virus initially presented with a genital lesion which upon histologic assessment was diagnosed as a pseudotumor associated with herpes simplex virus infection. The pseudotumor responded to initial treatment with Acyclovir, however, the lesion recurred 2 yr later and was diagnosed as plasma cell vulvitis. We discuss the clinical presentation, diagnostic work up and treatment options of such a rare lesion.

A 5-year follow-up of vulval swelling due to extraskeletal myxoid chondrosarcoma: A rare case report.

Vulval extraskeletal myxoid chondrosarcoma (EMC) is a rare cause of vulval swelling, reported <10 times in the literature to date. EMC in this location is frequently misdiagnosed due to its rarity, and patients may incur delays in diagnosis and treatment. We herein present the diagnosis and management of the case of vulval EMC in a 42-year-old Caucasian female patient who presented in 2011 with a swelling on the right labium majus. The tumour was initially misdiagnosed as a Bartholin's cyst and managed conservatively. The tumour was ultimately diagnosed as EMC and treated by radical surgical excision and adjuvant radiotherapy. The aim of the present study was to report the results after a long-term follow-up period and review the available relevant literature.

Recurrent urachal mucinous adenocarcinoma presenting as bilateral ovarian tumors on cesarean delivery.

Secondary ovarian cancers, Krukenberg tumors, are a distinctive subset of metastatic tumors arising from the gastrointestinal tract (stomach, colon, and appendix), the biliary system, the breast, or other genital organs. These tumors account for 5% of all ovarian malignancies. Such metastases could mimic primary mucinous ovarian adenocarcinomas. Metastases from the urinary tract are uncommon. Primary adenocarcinoma of the bladder accounts for less than 1% of all bladder malignancies; one third of these tumors are urachal in origin. Urachal cancers are rare and tend to occur in older men (mean age, 50-60 years); however, it was described previously in a 15-year-old girl. Symptoms include hematuria, dysuria, frequency, urgency, and recurrent urinary tract infections. These tumors have a predilection to locally spread to the surrounding organs. Ovarian metastasis is a rare event and is infrequently reported in literature.

Differential expression of cyclin-dependent kinase inhibitors and apoptosis-related proteins in endocervical lesions.

The development of neoplasia is associated with abnormalities of cell cycle control and apoptosis. In this study, a panel of cyclin-dependent kinase inhibitors (CDKIs) and apoptosis-related proteins (p16, p21, p53, Bcl2 and hsp27) was analysed by immunohistochemistry in 91 glandular cervical lesions. A significant increase in p21 and p53 expression occurred from normal cervix (n=11) through endometriosis/tubo-endometrioid metaplasia (TEM) (n=19) and cervical glandular intraepithelial neoplasia (CGIN)/adenocarcinoma in situ (AIS) (n=33) to invasive adenocarcinoma (n=28). p16 showed diffuse strong expression in CGIN/AIS and invasive adenocarcinoma compared with focal expression in some TEM/endometriosis lesions and no expression in normal cervix. Bcl2 was highly expressed in TEM/endometriosis compared with CGIN/AIS and adenocarcinoma. p16 immunostaining discriminated accurately between neoplastic and non-neoplastic cervical lesions, provided that diffuse strong positivity was present. Similarly, diffuse expression of Bcl2 distinguished endometriosis/TEM from CGIN/AIS. These data demonstrate that analysis of CDKIs and apoptosis-related proteins provides useful information in the diagnostic assessment of glandular lesions of the cervix.

Pregnancy after TVT-O: case report and literature review.

A 37-year-old woman previously treated with TVT-O developed recurrent symptoms of stress urinary incontinence during pregnancy. Symptoms started to develop later in the second trimester and progressed gradually to affect her quality of life at the end of pregnancy. In the event she had a very quick spontaneous vaginal delivery at 40 weeks' gestation. Postnatal physiotherapy successfully controlled the incontinence symptoms and urodynamic studies demonstrated no incontinence with a stable bladder and a normal flow rate. The patient remains well 2 years following delivery with no further treatment.

Overexpression of cyclins A and B as markers of neoplastic glandular lesions of the cervix.

INTRODUCTION: Cyclins are a family of regulatory proteins that play a pivotal role in controlling the cell cycle. While there is evidence of their altered expression in cervical squamous lesions, their precise role in glandular neoplasia is yet to be elucidated. OBJECTIVES: To investigate the role of cyclins as markers of early cervical glandular neoplasia by comparing their expression in lesions of different histological type. METHODS: Through a cross-sectional analytical study, paraffin wax sections of normal cervix (n = 11), endometriosis/tubo-endometrioid metaplasia (TEM) (n = 19), cervical glandular intraepithelial neoplasia (CGIN) (n = 33), and invasive adenocarcinoma (n = 28) were studied using monoclonal antibodies for cyclins A, B, D, and E with heat pretreatment for antigen unmasking. A quantitative assessment was employed for the analysis of percentage expression of each marker. Statistical analysis of data was performed using SPSS. RESULTS: A progressive significant increase in cyclin A expression occurred from normal cervix (median: 0, IQ: 0-0), through endometriosis/TEM (median: 1, IQ: 0-15) and CGIN (median: 15, IQ: 0-30) to invasive adenocarcinoma (median: 40, IQ: 21.25-60). Cyclin B exhibited a similar pattern (median: 0, IQ: 0-0, median: 0, IQ: 0-0.5, median: 8, IQ: 0.75-15, and median: 30, IQ: 15-45, respectively). Statistically higher expression of cyclin B was found in CGIN than in TEM/endometriosis (P < 0.001). Invasive adenocarcinomas expressed higher levels of cyclins A and B than CGIN (P < 0.001). There was significantly greater cyclin E expression in TEM/endometriosis than in normal cervix (P = 0.03) with a nonsignificant further increase in CGIN and invasive adenocarcinoma. The expression of cyclin D was not significantly different among all groups. CONCLUSIONS: Our data indicate that up-regulation of cyclin A and B expression occurs in neoplastic lesions of the cervix. Cyclin B expression was significantly more widespread in CGIN lesions than in TEM/endometriosis indicating that further assessment of the value of this marker in the diagnosis of cervical glandular neoplasia is warranted.

The human sperm head: a key for successful fertilization.

In order to examine the predictive value of determining the sperm head shape, the acrosomal size, the presence of acrosomal vacuoles, and the challenged acrosome reaction (AR) on the outcome of a standard in vitro fertilization (IVF) program, a prospective study was conducted that included 75 couples undergoing IVF treatment. An assessment of sperm morphology was performed using the Hobson Sperm Tracker (Hobson Tracker Limited, Sheffield, United Kingdom). The assessment of the AR was performed before and after adding pooled undiluted human follicular fluid (FF). The outcome measure was an IVF rate of inseminated oocytes. A positive correlation was found between the fertilization rate (FR%) and the proportion of the sperm with a normal (oval) head shape (P <.001), the sperm exhibiting acrosomal vacuoles (P <.003), the sperm with a normal acrosomal size (40%-70% of total head area, P <.025), and the sperm undergoing AR after adding FF (P <.001). Multiple logistic regression analysis revealed that by incorporating the above 4 parameters, the sensitivity of prediction of IVF FR% values was 79%, and the specificity was 93%, with a positive predictive value of 96%. This study shows that the multiparametric assessment of the sperm head is useful in predicting the FR% values of a standard IVF treatment. The automated analysis used in this study is shown to maintain a level of precision and accuracy acceptable for application in a routine semen analysis situation.