Levonorgestrel intrauterine device with absence of threads: don't take expulsion for granted! A case series of possible errors in ultrasound evaluation, in case of "lost IUDs".

Levonorgestel intrauterine devices are safe contraceptive methods, with even medical indications. However, they may present rare, but severe complications such as perforation and abdominal dislocation. Ultrasound assessment may be limited if a medicate intrauterine device is lost, due to its particular echogenicity. We report cases complicated by loss of intrauterine devices. Based on this experience we believe that ultrasound should always be associated to an X-ray examination to prevent misdiagnosis, especially in case of loss of a levonorgestrel device. Although our conclusions are not innovative and the cases are limited, we believe they can be a reminder in clinical practice to avoid not so infrequent complications and clinical errors. We would also like to recall the limitations of ultrasound in locating levonorgestrel intra uterine devices and stress that one should never take for granted the expulsion of the device in case of lost its threads.

Clinical and Oncologic Outcomes of Robotic Versus Abdominal Radical Hysterectomy for Women With Cervical Cancer: Experience at a Referral Cancer Center.

OBJECTIVES: To compare the clinical and oncologic outcomes of robotic radical hysterectomy (RRH) vs abdominal radical hysterectomy (ARH) in patients with cervical carcinoma. METHODS: A retrospective analysis of women who underwent radical hysterectomy for cervical cancer from December 2006 to December 2014 at European Institute of Oncology was performed. Patients who underwent RRH were compared with women operated on by ARH. The groups were matched by age, body mass index, tumor size, International Federation of Gynecology and Obstetrics stage, comorbidity, previous neoadjuvant chemotherapy, histology type, and tumor grade. RESULTS: A total of 203 and 104 women who underwent RRH and ARH, respectively, were analyzed. Baseline characteristics, stage of disease, histology type, and grade of differentiation were similar between groups. Surgical time was significantly shorter in the ARH group (208 vs 282 minutes, P ≤ 0.001). Robotic radical hysterectomy was associated with significantly less estimated blood loss (219 vs 104 mL, P = 0.001) and with significantly shorter hospital stay (5.2 vs 3.9 days, P ≤ 0.001). Abdominal radical hysterectomy was correlated with a significantly higher number of lymph nodes removed (25.8 vs 22, P = 0.003). None of the robotic procedures required conversion to laparotomy. A significantly higher number of patients in ARH required postoperative transfusion (11 [10.5%] vs 6 [2.9%], P = 0.006). Lower extremity lymphedema was significantly higher in ARH (28 [27.5%] vs 17 [8.3%], P = 0.001). Recurrence rates as well as progression-free survival and overall survival were similar between groups at a median follow-up of 41.64 months. CONCLUSIONS: Robotic radical hysterectomy is safe and feasible and is associated with improved clinical outcomes. Although longer follow-up is needed, early data show equivalent oncologic outcomes compared with other surgical modalities.

Neoadjuvant chemotherapy followed by robotic radical hysterectomy in locally advanced cervical cancer: a multi-institution study.

OBJECTIVE: Minimally invasive surgery has been performed in locally advanced cervical cancer (LACC) without adverse effect in patient's overall prognosis and survival. The aim of this report is to evaluate the feasibility and morbidity of total robotic radical hysterectomy (TRRH) with pelvic lymphadenectomy in patients with LACC after neo-adjuvant chemotherapy (NACT). METHODS: From February 2008 to April 2013 a retrospective data collection of women undergoing TRRH for cervical cancer stage FIGO IB2 to IIB, after neo-adjuvant chemotherapy, was conducted at "Regina Elena" National Cancer Institute of Rome and European Institute of Oncology of Milan. All patients deemed operable underwent TRRH with pelvic lymphadenectomy within 4 weeks from the last chemotherapy cycle. RESULTS: Median operative time was 225 min (range, 105-387 min). The median blood loss was 150 mL (range, 30-700 mL). The median number of removed pelvic lymph nodes was 23 (range, 8-69). Sixteen patients had an optimal response (12 PCR, 4 pPR1) to chemotherapy, 33 patients had a pPR2 and 11 patient showed stable disease. Adjuvant therapy was administrated in 36 patients (60%). We experienced one intra-operative complication and 19 post-operative complications, but no conversions to laparotomy were necessary to manage these complications. Six patients received a blood transfusion. At the time of this report, with a median follow-up of 28.9 months, 50 patients (83%) are free from recurrence. CONCLUSION: This experience demonstrates the feasibility of TRRH pelvic lymphadenectomy after NACT in LACC with good accuracy and safety.

Rectovaginal fistula: a new approach by stapled transanal rectal resection.

Many surgical procedures have been developed to repair rectovaginal fistulas even if no "procedure of choice" is reported. The authors report a case of relatively uncommon, complex, medium-high post-obstetric rectovaginal fistula without sphincteral lesions and treated with a novel tailored technique. Our innovative surgical management consisted of preparing the neck of the fistula inside the vagina and folding it into the rectum so as to enclose the fistula within two semicontinuous sutures (stapled transanal rectal resection); no fecal diversion was performed. Postoperative follow-up at 9 months showed no recurrence of the fistula.