Assessment of the role of laparoscopic ovarian biopsy.

Seventy-four patients with either endocrine and/or infertility problems were subjected to laparoscopic ovarian biopsy. The patients were divided into 4 categories: those with primary amenorrhea, secondary amenorrhea, ovarian androgenic hyperfunction, and infertility. The results were critically examined to evaluate the procedure in the investigation and treatment of each of these disorders. It was concluded that laparoscopic ovarian biopsy is most helpful in primary amenorrhea but justified in secondary amenorrhea only if a histologic diagnosis of premature ovarian failure is though to be essential. Patients with ovarian androgenic hyperplasia should not be candidates for the procedure as the laparoscopic appearance of the ovaries offered equally valuable information and the hazards of biopsy in this particular group of patients outweighed its diagnostic and therapeutic usefulness. The ovarian biopsy offered very little benefit for the infertility patients.     

Laparoscopic prophylactic oophorectomy in women with inherited risk of ovarian cancer.

The aim of this study was to specify the surgical procedure most adapted for prophylactic laparoscopic oophorectomy in patients with an inherited risk of ovarian cancer. This prospective study was based on a series of 27 patients who underwent prophylactic bilateral laparoscopic oophorectomy between September 1995 and January 1998. Nine patients underwent an oophorectomy (33%) and 18 patients an adnexectomy (67%). The laparoscopic procedure was converted into a laparotomy in one patient in whom an ovarian adenocarcinoma was detected during the surgical procedure. During final histologic examination of the ovaries, 23 patients were found to have benign atypical histologic alterations, one patient had an ovarian adenocarcinoma and only three patients (11%) had normal ovaries. In women with an inherited risk of ovarian cancer, during the laparoscopic procedure for prophylactic oophorectomy, the abdomino-pelvic cavity should be thoroughly explored with peritoneal cytology and systematic peritoneal biopsies. The laparoscopic procedure could be converted into a laparotomy if an ovarian cancer is discovered.     

Use of laparoscopic support to avoid laparotomy in vaginal ovarian cystectomy

The objective of our study was to evaluate the use of a procedure for vaginal ovarian cystectomy that is supported by the option to convert to laparoscopy. The ovarian cystectomy was initially approached transvaginally, and then if impossible, completed laparoscopically. We applied this operation system to 38 patients with benign ovarian cysts. Preoperative characteristics of patients, outcomes of colpotomy and vaginal ovarian cystectomy, conversion rate from a vaginal approach to a laparoscopic procedure or a laparotomy, completion rate, operating time, blood loss, complications, and postoperative outcomes were examined. Colpotomy was successfully performed in 37 (97%) of 38 cases and vaginal ovarian cystectomy was accomplished in 35 (92%) cases. Three (8%) cases, including 1 case of failed posterior colpotomy and 2 cases of intrapelvic adhesions, were converted from a vaginal approach to a laparoscopic procedure. In all (100%) cases, cystectomy was successful without laparotomy. Support by laparoscopy preserves the minimal invasiveness of vaginal ovarian cystectomy in cases that would normally require conversion to laparotomy. Thus, this operation system is an alternative procedure to an exclusively vaginal ovarian cystectomy.     

Laparoscopic Ovarian Transposition Before Pelvic Cancer Treatment: Ovarian Function and Fertility Preservation

Survivors of pelvic cancer treatment live with the ramifications of pelvic radiation for many years after their cure. Several options are available to preserve ovarian function and fertility in reproductive age women undergoing pelvic radiation. Laparoscopic ovarian transposition is an under-utilized, yet fairly simple surgical procedure to relocate the ovaries away from the radiation field. Although randomized-controlled trials on the outcomes of ovarian transposition are scarce, there is a growing body of evidence on the risks and benefits of this procedure, in terms of prevention of premature ovarian failure, and potentially preserving fertility. In this review, we summarize the available data on the indications, patient selection and outcomes of ovarian transposition, as well as illustrate the technique of the procedure.     

Management of the Adnexal Mass

The methods for preoperative diagnosis and evaluation of the woman with a suspected ovarian neoplasm have evolved significantly with little or no impact on the surgical treatment, which remains removal of the abnormal ovary. Although most adnexal masses are benign, the primary goal of the diagnostic evaluation is the exclusion of malignancy. A complete history, physical examination, and ultrasonic imaging are vital in evaluating a suspected ovarian mass. In postmenopausal women, serum CA-125 determinations further improve sensitivity and specificity. Once the presence of an ovarian mass is established, the crucial decision is whether to observe the patient or proceed with surgical removal. If surgical removal is indicated, the proper procedure is important for staging and initiation of effective therapy. While many surgeons are now using the less invasive laparoscopic approach, the standard of care continues to be a laparotomy with either an ovarian cystectomy or oophorectomy. Future clinical research in the management of adnexal masses should focus on decreasing the number of patients undergoing a surgical procedure, and in patients who require surgery, further evaluation of laparoscopy as a safe, cost-effective means of treatment. Improved imaging techniques may allow for nonoperative management of probably benign ovarian neoplasms.     

The use of non-linear analysis for differentiating the biomagnetic activity in ovarian lesions.

In this study we investigated the biomagnetic activity measured with the superconducting quantum interference device (SQUID) in benign and malignant ovarian lesions using non-linear analysis. We used a single channel biomagnetometer SQUID in order to measure the magnetic field emitted from benign and malignant ovarian lesions. We can differentiate such biomagnetic activities using non-linear analysis. Using the application of non-linear analysis in the ovarian lesions together with the use of dimensional calculations we have observed a clear saturation value for the dimension of malignant ovarian lesions and non-saturation for benign ovarian lesions. The biomagnetic measurements with the SQUID and the application of non-linear analysis in benign and malignant ovarian lesions, is a promising procedure in assessing and differentiating ovarian tumours.     

Ultrasound evaluation of pelvic masses: predictors of malignancy for the general gynecologist

Recent data indicate that assessment of sonographically determined tumor volume and morphology is the most accurate means to differentiate benign from malignant ovarian tumors. Doppler flow studies generally have shown a lower impedance to flow in vessels supplying ovarian malignancies than in those associated with benign tumors. However, the overlap in pulsatility index and resistive index values of benign and malignant ovarian tumors, and the cost of this procedure, make its routine use impractical. In a postmenopausal woman with a sonographically confirmed ovarian tumor, a progressively rising serum Ca-125 is highly suspicious for malignancy.     

Association between ovarian endometriosis and malignancy in the peri-menopausal period: report of two cases and review of the literature

The association of endometriosis and ovarian malignancy is about 1%, with a peak incidence in patients over 45 years. The best way of treating peri- and post-menopausal women with endometriosis is still a very controversial issue. We report two cases of peri-menopausal women in which endometriosis was associated to ovarian malignancy. The first case was a 49-year-old woman who underwent laparoscopic oophorectomy for an ovarian endometrioid cyst. Definitive histology showed ovarian endometrioid cyst with endometrioid and clear cell carcinoma. Subsequently, surgical restaging was performed. The other case was a 49-year-old woman who underwent hysterectomy and bilateral oophorectomy for an ovarian mass suggestive of endometriosis and uterine myomas. At frozen section examination, ovarian adenocarcinoma was found and staging procedure was performed. Definitive histology showed carcinosarcoma of the ovary with areas of endometriod adenocarcinoma. Given the non-infrequent association between ovarian endometriosis and cancer, more data are needed to decide for an aggressive or conservative approach to peri-menopausal endometriosis.     

Whole-Ovary Laparoscopic Incisions Improve Hormonal Response and Fertility in Patients with Extremely Poor Ovarian Response

Study ObjectiveRecent findings have shown mechanical fragmentation of ovarian cortex and ovarian drilling could promote follicle growth in patients with premature ovarian insufficiency and polycystic ovarian syndrome, respectively. A common element shared by these treatments is the mechanical disturbance of ovarian extracellular matrix tissues. We thus hypothesized a simplified whole-ovary laparoscopic incision (WOLI) procedure may provide the intrinsic stimuli needed to activate resting follicles in patients with an extremely poor ovarian response (EPOR) who had negligible chance of becoming pregnant with their own oocytes via modern in vitro fertilization practice.DesignRetrospective pilot study.SettingThe study was conducted in a research medical center in Taiwan.PatientsWomen who had multiple canceled ovarian stimulation cycles due to the lack of follicle growth were recruited. A total of 6 patients with EPOR received the WOLI procedure, which covers the whole surface of ovaries, in 2015 to 2017.InterventionsAfter receiving an outpatient WOLI procedure, ovarian response and follicle growth were monitored for 90 days with or without gonadotropin stimulation. Embryo quality and clinical outcomes were analyzed.Measurements and Main ResultsAfter the WOLI treatment, 5 of 6 patients had significant increases in serum estradiol level and improved follicle growth (p = .001). Multiple oocytes were retrieved from each of these patients, and it led to thawed embryo transfer (ET) cycles in 4 patients (p = .010). On average, the duration from the WOLI procedure to the first ovum pickup was 24 days (11 to 58 days). After ET, 2 patients became pregnant and delivered healthy babies. Two other patients received ET, and 1 led to a chemical pregnancy. One patient had cryopreserved embryos with pending transfer.ConclusionThe standardizable WOLI procedure restored hormonal responses in a majority of patients with EPOR. Further validation of this novel and yet simple laparoscopic procedure, which requires only 1 laparoscopic surgery, may provide a practical option to reactivate the aging ovarian environment in patients with EPOR and premature ovarian insufficiency.     

Laparoscopic treatment of ovarian granulosa cells tumor developed in the pelvic anterior preperitoneal space 20 years after laparotomic salpingo-oophorectomy: case report and review of literature

Abstract

Granulosa cells (GC) tumors are rare tumors which account for approximately 2–3% of all ovarian malignancies with a favorable prognosis. We report a case of a 54-year-old postmenopausal woman who developed an ovarian GC tumor in the pelvic anterior preperitoneal space 20?years after laparotomic salpingo-oophorectomy due to small part of the cyst could drop or remain entrapped into the abdominal wound during the closure of laparotomy 20 years before. Then, the patient underwent a second laparoscopic procedure with peritoneal washing, a type A radical hysterectomy, omentectomy, appendectomy, and pelvic and para-aortic lymphadenectomy. This rare case of ovarian GC tumor developing in the site of previous laparotomy demonstrates the importance of a correct and clean surgical procedure to avoid the risk of leaving even small portions of the cyst exposing the patients to either the risk of malignancy or additional surgical procedures.

Precis: This rare case of ovarian granulosa cells tumor developed from residual ovarian tissue intrapped into the abdominal wound 20 years after laparotomic ovariectomy.     

The scope and limitations of laparoscopic ovarian biopsy in the diagnosis of secondary amenorrhea.

Laparoscopically directed ovarian biopsy has been evaluated in 39 cases of secondary amenorrhea. The definite diagnosis was achieved in 29 cases. In 10 cases, ovarian histopathology alone was insufficient, and the estimations of gonadotropins were essential for the final diagnosis. The scope and limitations of this procedure for the differential diagnosis of premature ovarian failure and hypothalamic-pituitary lesions are discussed.     

Adequacy of oophorectomy at the time of gynecologic surgery.

OBJECTIVES: To determine the incidence of incomplete ovarian removal during gynecologic surgery and correlate the risk of inadequate removal with the procedure chosen. METHODS: This is a prospective observational study. Ovaries received during a 4-month period in the participating institutions were independently histologically evaluated. Gross inspection of the ovarian capsule, infundibulopelvic ligament, hilum and utero-ovarian ligament was assessed. Grossly close margins were confirmed histopathologically. Any margin with histologically confirmed ovarian tissue at the margin was interpreted as incompletely removed. Details of each surgical procedure were recorded for comparison. RESULTS: Ovaries (n=174) from 94 patients were collected and 155 were evaluable. The overall incidence of incomplete ovarian removal was 6.5%. Of the 125 ovaries removed abdominally, 23 were laparoscopically assisted and 7 were vaginal; inadequate removal was documented in 5%, 9% and 29%, respectively (P=0.04). There was no relationship of inadequate resection by underlying pathologic diagnosis (P=0.25) or by institution (4.6% university hospital vs. 8.8% community hospital; P=0.29). CONCLUSIONS: Incomplete ovarian removal occurs and is related to surgical approach. A larger study is warranted to evaluate the role of pelvic pathology or surgeon experience as a risk for incomplete oophorectomy.     

An immunomagnetic-based method for the purification of ovarian cancer cells from patient-derived ascites.

OBJECTIVE: Primary ovarian cancer cells obtained from fresh tumor have many advantages over established cell lines. Therefore, a procedure for the specific and efficient purification of such neoplastic cells is critical. We report an effective immunomagnetic method for the isolation of tumor cells from the ascitic fluid of patients diagnosed with ovarian adenocarcinoma. METHODS: This procedure incorporates the use of monoclonal antibody (mAb) CC49, which recognizes the tumor-associated glycoprotein 72 (TAG-72). TAG-72 is highly expressed on ovarian tumor cell surfaces with little or no reactivity with normal tissues. Also used in this protocol are immunomagnetic beads, which bind to the CC49 mAb via a secondary antibody. When ovarian cancer cells adhere to the magnetic beads, a magnetic field is used to separate the tumor cells from all other cellular components. RESULTS: Using ascitic fluid from five patients, we found that preparations before purification contained between 38 and 52% neoplastic cells. Using our method, we produced preparations that were between 63 and 96% pure for cancer cells, thus obtaining an average increase in tumor cell enrichment of 86%. CONCLUSION: We, therefore, believe this method is preferable for producing high yields of pure ovarian neoplastic cells. We are now employing this technique in our laboratory to provide a stringent and pure template for our studies on gene transfer to primary ovarian cancer cells.     

Prophylactic oophorectomy

Because of the lack of effective alternatives and the simplicity of the procedure, prophylactic oophorectomy is viewed as the best available tool for reducing the individual risk of ovarian cancer. The genetics of hereditary ovarian cancer are described in this chapter and a careful risk-versus-benefit assessment is provided with respect to two populations of patients that appear suitable candidates for this procedure. These include patients with increased risk of developing ovarian cancer due to hereditary genetic predisposition, in which the lifetime risk of ovarian cancer may be as high as 16-65%, depending on the penetrance of the germ-line mutation. Additionally, routine salpingo-oophorectomy in patients over 40 years undergoing scheduled gynaecological surgery or colorectal surgery might reduce the overall incidence of ovarian cancer by as much as 5% in the general population.     

A Way to Reduce the Occurrence of Intraoperative Capsule Rupture in Presumed Clinically Early-stage Ovarian Cancer with Adhesions to the Abdominal Wall

Study ObjectiveTo present a procedure to reduce the occurrence of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall.DesignStepwise presentation of the procedure with narrated video footage.SettingThe occurrence of intraoperative capsule rupture exerts a negative effect on the prognosis of early-stage ovarian cancer [1,2]. Thus, it is important to reduce intraoperative capsule rupture to improve the oncologic outcome of such patients. In this video we describe a laparoscopic procedure to minimize the risk of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. A 52-year-old woman was referred from a local clinic for a 6 × 6 × 4-cm left ovarian mass and a 7 × 6 × 6-cm right ovarian mass. Her serum cancer antigen 125 level was 214.4U/mL. Pelvic magnetic resonance imaging and positron emission tomographic/computed tomographic imaging showed no evidence of metastatic diseases or lymph node involvement. A diagnosis of ovarian malignancy was suspected.InterventionsLaparoscopic evaluation suggested that the right adnexa was adhered to the right abdominal wall and there was no evidence of tumor seeding in the peritoneal cavity. We collected the peritoneal lavage fluid. Since pelvic adhesiolysis between the right adnexa and the abdominal wall may increase the occurrence of intraoperative capsule rupture of the ovarian tumor, leading to a worse clinical outcome, we decided to remove both the right adnexa as well as the adhered peritoneum. The key steps of the procedure are summarized as follows. First, the utero-ovarian ligament and tubal isthmus were coagulated and excised. Second, the pelvic peritoneum was excised, and the infundibulo-pelvic ligament and ureter were identified and mobilized. Third, the infundibulo-pelvic ligament was coagulated and excised. Fourth, the pelvic peritoneum which was adhered to the right adnexa was dissected off the ureter and excised. Then, the resected right adnexa as well as the adhered peritoneum were collected in a disposable pocket and removed to avoid further contamination. Adenocarcinoma was diagnosed by frozen section evaluation. So, surgical staging was performed laparoscopically, and consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, and random peritoneal biopsies from the pelvis, paracolic gutters, and undersurfaces of the diaphragm. Final pathologic reports showed ovarian clear cell carcinoma with involvement of both ovaries and the adhered peritoneum.ConclusionOur method is effective for intact removal of the involved adnexa without rupture and the adhered pelvic peritoneum with potential for tumor seeding.     

妇科腹腔镜手术中卵巢功能的保护问题

妇科腹腔镜手术中如何保护卵巢功能问题是健康发展该项技术的关键点之一。在妇科腹腔镜手术中要正确认识和利用电外科器械,将电外科器械对卵巢组织的损伤减少到最小。腹腔镜下卵巢囊肿剥除术,卵巢打孔术,子宫切除术和输卵管手术等要注意卵巢功能的保护,严格掌握手术方式和手术适应证。同时要对卵巢功能进行密切的监测。     

Transvaginal biopsy in the diagnosis of ovarian cancer

Laparotomy and debulking surgery followed by chemotherapy have been the treatment of choice in late stage ovarian carcinoma. Developments in the chemotherapeutic management of ovarian cancer have resulted in a change in opinion as to the optimal management of this disease. Many patients are now receiving initial chemotherapy and trials are in place to compare up front and adjuvant surgery. Tissue diagnosis is required prior to commencing chemotherapy. This article describes one method for accurately obtaining a tumour biopsy. A retrospective case note review of 14 women with a provisional diagnosis of ovarian carcinoma who underwent transvaginal biopsy of their pelvic disease is described. Only 7/12 cases with a positive biopsy had a definite diagnosis of ovarian cancer. The procedure was found to be safe and well tolerated.     

Technique for locating the start of the ovarian cycle in women who have no uterus

A technique was required to identify the start of the ovarian cycle in hysterectomized women. Daily observations of the excretion of pregnanediol relative to creatinine by menstruant women during the course of 15 ovulatory cycles have been used to establish (a) that the centre of the pregnanediol peak can be located from as few as two pregnanediol measurements per week and (b) that this centre precedes the start of menstruation by 7.14 +/- 0.07 days (mean +/- SEM). With this information the onset of menstrual bleeding in an ovulatory cycle can be predicted. Comparison of the prediction with the observation of menstrual onset in 50 cycles gave a mean deviation of 0.276 +/- 0.109 days with a maximum deviation of 1.9 days. In three women observed before and after hysterectomy there was no significant change in the length of the ovarian cycle. It is concluded that this procedure provides a way of identifying the start of a new ovarian cycle in women who have no uterus. The procedure is only applicable to ovulatory cycles.     

Ovulation induction in sterile females with the polycystic ovary syndrome

The outcomes of ovulation induction in 34 infertile women with polycystic gonads were presented. The ovulation was inducted by the ovarian wedge resection or conservative treatment with either clomiphen alone or in association with human chorionic gonadotropin (HCG). The procedure of choice of specific method of management was dependent on the results of laparoscopy, while an ovarian biopsy was performed and histopathological evaluation of segments. In patients with insignificantly enlarged ovarian tunica albuginea conservative treatment with hormones was carried out, in patients with either marked enlarged tunica albuginea or thecal cells in stroma ovarian wedge resection was performed. The presented method of management caused the ovulatory cycles in 85.2% of cases and pregnancies in 61.7% of cases.     

Surgical treatment of recurrent ovarian cancer: report of 21 cases and a review of the literature.

AIM: To evaluate the role of secondary cytoreductive surgery in patients with recurrent ovarian cancer. PATIENTS AND METHODS: A retrospective chart review was conducted on 21 patients submitted to secondary cytoreductive surgery for apparently isolated and resectable recurrence of ovarian cancer, after a disease-free interval of at least 12 months. RESULTS: Fifteen patients (71%) had complete surgical debulking with no macroscopic tumor at the completion of the surgical procedure. Eight patients (38%) required an intestinal resection but no colostomy was performed. Eleven complications were recorded in nine patients, but no operative death occurred. The median survival time for all patients after diagnosis of recurrent disease was 29 months (range 6-96 months). Survival time after diagnosis of recurrence was not significantly related either to known prognostic factors of ovarian cancer or to the length of the clinical remission time. The absence of residual disease after salvage surgery was the only factory associated with prolonged survival. CONCLUSION: Secondary cytoreductive surgery is a safe procedure which should be offered to recurrent ovarian cancer patients with apparently isolated and resectable disease, and without ascitis.