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First the dissection of its attachments, particularly from the splenic flexure of the colon. [...]the vascular supply. [...]both vessels run in different pathways, joining in the tail of the pancreas and making a curvature towards the splenic hilum.

ObjectiveEarly-stage ovarian cancer might represent an ideal disease scenario for sentinel lymph node application. Nevertheless, the published experience seems to be limited. Our objective was to assess the feasibility and safety concerns of sentinel lymph node biopsy in patients with clinical stage I–II ovarian cancer.MethodsWe conducted a prospective cohort study of 20 patients with histologically confirmed ovarian cancer. 99mTc and indocyanine green were injected into both the utero-ovarian and infundibulopelvic ligament stump, if they were present, during surgical staging. An intraoperative gamma probe and near-infrared fluorescence imaging were used to detect the sentinel lymph nodes. Inclusion criteria included: >18 years of age, suspicious adnexal mass (unilateral or bilateral) at ultrasound and CT imaging or confirmed ovarian tumor after previous surgery (unilateral or bilateral salpingo-oophorectomy with or without hysterectomy). Adverse events were recorded through postoperative day 30. The primary trial end point was to report adverse events related to the technique, including the use of 99mTc and ICG intraperitoneally, as well as the feasibility of the technique.ResultsA total of 20 patients were included in the analysis. Sentinel lymph nodes were detected in 14/15 (93%) pelvic and all 20 (100%) para-aortic regions. Five patients did not have utero-ovarian injection because of prior hysterectomy. The mean time from injection to sentinel lymph node resection was 53±15 min (range; 30–80). The mean number of harvested sentinel lymph nodes was 2.2±1.5 (range; 0–5) lymph nodes in the pelvis and 3.3±1.8 (range; 1–7) lymph nodes in the para-aortic region. There were no adverse intraoperative events, nor any within the 30 days of follow-up related with the technique.ConclusionSentinel lymph node mapping in early-stage ovarian cancer is feasible without major intraoperative or < 30 days safety concerns. (NCT03452982).Trial registration numberClinicalTrials.gov, NCT03452982.

Correspondence to Dr Pablo Padilla-Iserte, Department of Gynecology Oncolgy, La Fe University and Polytechnic Hospital, Valencia 46026, Spain; pablo_iserte@hotmail.com The uterine manipulator is a device commonly used in minimally invasive hysterectomy procedures for benign disease to facilitate uterus mobilization during surgery, generate tension on the main supporting elements of the uterus (broad ligament, uterine vessels, and uterosacral ligaments) to improve surgical field exposure, and provide a landmark for the colpotomy. The retrospective SUCCOR trial—an international European cohort observational study comparing minimally invasive surgery versus open abdominal radical hysterectomy in patients with stage IB1 cervical cancer—showed that patients with early stage cervical cancer who underwent minimally invasive surgery using a uterine manipulator had a higher relapse rate than the group undergoing minimally invasive surgery without use of a uterine manipulator, resulting in the same oncological outcomes as patients with open surgery.3 In endometrial cancer, the current evidence derives from retrospective studies with limited sample sizes. A recent multicenter study evaluating uterine manipulator use in early stage endometrial cancer by minimally invasive surgery found a higher recurrence rate with a worse oncologic outcome in patients with uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics (FIGO) I-II), which questions the safety of the uterine manipulator in endometrial cancer.4 We present a video detailing the interaction between a tumor and the uterine device.

BackgroundFistula repair in the perineal region represents a major challenge for surgeons. It is important for the medical community to facilitate and disclose these techniques.ObjectiveThe aim of this article was to show a stepwise approach for a direct repair and use of a Martius flap for a vesicovaginal fistula.MethodsWe show a single case performed in a patient who presented with a vesicovaginal fistula diagnosed after surgery, which did not respond to conservative management. The procedure consists of the following steps: intraoperative cystoscopy, anatomical direct repair of the fistulous tract between the bladder and vagina, and modified Martius flap.ConclusionsMartius flap is a repair technique used for complex fistula in the perineal region. It is a simple, safe, and reproducible procedure with good long-term functional and esthetic results.

Correspondence to Dr Pablo Padilla-Iserte, Department of Gynecology Oncolgy, La Fe University and Polytechnic Hospital, 46026 València, Spain; pablo_iserte@hotmail.com Female sexuality is a complex phenomenon with important repercussions on patients' quality of life. In certain cases, the anatomical defect should be restored, so reconstructive surgery may be necessary.1 The role of reconstructive surgery in sexual function improvement has already been evaluated in previous studies with promising results.2 Similar outcomes were obtained in patients with vaginal aplasia with the use of Creatsas modification of Williams vaginoplasty, with a great improvement in sex life after reconstruction.3 We present a patient with vaginal stenosis after chemoradiotherapy for locally advanced cervical cancer, in which we have used this procedure to restore the anatomical defect (Video 1). Literature review of vaginal stenosis and dilator use in radiation oncology.

Introduction/BackgroundBorderline ovarian tumours (BOTs) have an average age at the diagnosis of 40 years and around 30% of patients have not completed their childbearing. Fertility sparing surgery (FSS) is considered the best treatment without an impact on the overall survival rate. However, the safety of laparoscopy for FSS in BOTs remains limited with short follow-up and ESGO and ESMO guidelines indicate open surgery as the standard approach. We aim to assess the long-term oncological safety of laparoscopy in the FSS treatment of BOTs.MethodologyThis is a retrospective single-centre study including 34 women who underwent laparoscopic FSS for BOTs, between January 2000 and June 2019 at Hospital Clinic of Barcelona. FSS was considered when the uterus and at least part of the ovarian tissue was conserved. Patients were scheduled for transvaginal ultrasound and blood test including CA125 for 10 years or until loss. Chi-square and Fisher’s tests were applied for qualitative variables. Student T-tests or Mann-Whitney tests were applied for continuous variables.ResultsMedian age was 32 years. Unilateral cystectomy was performed in 15 patients (44.1%), bilateral cystectomy in 2 (5.9%), unilateral adnexectomy in 14 (41.1%) and unilateral adnexectomy with contralateral cystectomy in 3 (8.9%). Mean tumour size and CA125 at diagnosis was 8.72 cm and 21, respectively. Twelve patients (35.2%) relapsed with a mean follow-up time of 95 months, being earlier in case of unilateral cystectomy (median 30 months, IQR 29) and bilateral cystectomy (18 months, IQR 0), compared to unilateral adnexectomy (median 78 months, IQR 64). Up to 41% relapses occurred after 45 months. Surgical factors related to laparoscopy and risk of recurrence were studied without finding significant differences.Abstract 2022-RA-1715-ESGO Table 1Univariate analysis of the risk of recurrence after the first surgery Factor Category Odds Ratio (IC 95%) P value Histology Serous 4 (0.6744003 23.72478) 0.10 Mucinous FIGO Stage 2014 IA-IB 0.54 (.1192275 2.311757) 0.394 IC-III Laterality Bilateral 1.21 (.1751372 8.389066) 0.845 Unilateral Type of surgery Cystectomy 1.51 (.3865568 5.950685) 0.550 Adnexectomy Capsular rupture Yes 1.1 (.2602337 4.649666) 0.897 No Endobag use Yes 1.06 (.2736021 4.1802) 0.923 No ConclusionLaparoscopic FSS for BOTs is a safe treatment in patients with reproductive desire without impacting on overall survival. A long-term follow-up is essential to detect late recurrences.

Introduction: Treatment for advanced ovarian cancer (AOC) comprises cytoreductive surgery combined with chemotherapy. Multimodal prehabilitation programmes before surgery have demonstrated efficacy in postoperative outcomes in non-gynaecological surgeries. However, the viability and effects of these programmes on patients with AOC are unknown. We aimed to evaluate the feasibility and postoperative impact of a multimodal prehabilitation programme in AOC patients undergoing surgery. Methods: This single-centre, before-and-after intervention pilot study included 34 patients in two cohorts: the prehabilitation cohort prospectively included 15 patients receiving supervised exercise, nutritional optimisation, and psychological preparation from December 2019 to January 2021; the control cohort included 19 consecutive patients between January 2018 and November 2019. Enhanced Recovery After Surgery guidelines were followed. Results: The overall adherence to the multimodal prehabilitation programme was 80%, with 86.7% adherence to exercise training, 100% adherence to nutritional optimisation, and 80% adherence to psychological preparation. The median hospital stay was shorter in the prehabilitation cohort (5 (IQR, 4–6) vs. 7 days (IQR, 5–9) in the control cohort, p = 0.04). Differences in postoperative complications using the comprehensive complication index (CCI) were not significant (CCI score: 9.3 (SD 12.12) in the prehabilitation cohort vs. 16.61 (SD 16.89) in the control cohort, p = 0.08). The median time to starting chemotherapy was shorter in the prehabilitation cohort (25 (IQR, 23–25) vs. 35 days (IQR, 28–45) in the control cohort, p = 0.03). Conclusions: A multimodal prehabilitation programme before cytoreductive surgery is feasible in AOC patients with no major adverse effects, and results in significantly shorter hospital stays and time to starting chemotherapy.

Introduction/BackgroundPrimary vaginal malignant melanoma is an extremely rare and very aggressive tumor with a 5-year survival rate of 5%-25%. The approach to this disease is a challenge, since staging and treatment data is limited, and the prognosis is poor. Lymph node status and mitotic rate should be assessed as they are the most important predictors of survival.MethodologyWe report the case of a 53-year-old woman, subtotal hysterectomized, diagnosed with a primary malignant melanoma of the vagina. On physical examination we can see a hard, cerebroid, non-melanic, pedicled tumour of about 5 cm that depends on the external third of the right lateral face of the vagina.MRI and PET-CT were performed to plan the surgery.There was no evidence of extension of the disease to adjacent or distant structures by imaging tests.A total colpectomy was proposed, and we combined a laparoscopic and vaginal approach to completely remove the tumourFirst, a sentinel lymph node biopsy was performed using a hybrid tracer with ICG and Tc99 to detect one inguinal sentinel node bilaterally.Next, laparoscopic surgery was performed to remove the cervical remanent and to dissect the upper two thirds of the vagina.Afterwards, the approach to the lower third of the vagina was finished vaginally. We dissected the vagina at the level of the introitus and closure of both sides with Chrobak forceps. Paracolpos was cut and the piece was extracted through the vagina.Finally, we closed the perineal muscles by planes and performed vaginal cleisis.ResultsDespite total vaginectomy, one of the inguinal lymph nodes was affected, which is why the patient has been proposed to complete treatment with immunotherapy. However, the expected outcomes are poor.ConclusionThis video shows the feasibility of performing a complete vaginectomy with a minimally invasive technique by combining a laparoscopic and vaginal approach.DisclosuresThere is no standardized therapy for primary melanoma of the vagina but surgical excision either by local wide excision or radical surgery with colpectomy with/without exenteration is the mainstay of treatment.

Introduction/BackgroundSystematic pelvic and para-aortic lymphadenectomy is part of the staging surgery in early-stage ovarian cancer (EOC) to determine the prognosis and indicate adjuvant treatment. However, this procedure is associated with potential severe morbidity. The Mapping Sentinel Lymph Node In early-Stage Ovarian Cancer (MELISA) trial aims to evaluate the sentinel lymph node (SLN) detection and diagnostic accuracy of SLN technique in patients who underwent complete pelvic and paraortic lymphadenectomy in early-stage EOC.MethodologyPatients with ovarian masses suspected of malignancy or re-staging surgery after confirmed malignancy were included. Before the removal of the adnexal tumor, a radiotracer was injected to the infundibulo-pelvic and utero-ovarian ligament. Subsequently, intraoperative images were acquired with a portable gammacamera. After 15 minutes, the adnexal tumor was removed and sent for frozen section assessment. Once malignancy was confirmed, indocyanine green (ICG) was injected to the infundibulo-pelvic and utero-ovarian ligament stumps. The SLN detection was guided by the gammadetector probe, gammacamera and near Infra-red camera. Ultrastaging of the SLN was performed.ResultsSixty-two patients were considered eligible between January-2021 and April-2022. Finally, 30 patients with EOC were analyzed. No statistical differences were found in the baseline and surgical characteristics when categorized according to SLN detection outcomes. In 90% (27/30 patients) at least one SLN was detected, being 88.89% (16/18) in primary surgery and 91.67% (11/12) in re-staging surgeries (p > 0.999). In 96.30% (26/27), 48.15% (13/27) and 44.44% (12/27) the SLN was detected in the aortic, pelvic or both regions, respectively. SLN metastases were found in 18.52% (5/27) with false negative rate of 0% (95% CI 0 – 43.4) and negative predictive value(NVP) of 100% (95% CI 85.1 – 100). Only low volume SLN metastasis were found.Abstract #491 Figure 1Intraoperative and pathlogical images of an ovarian cancer sentinel lymph node[Figure omitted. See PDF]ConclusionThe SLN detection rate in EOC has a high overall detection rate with a NPV of 100% when injecting both radiotracer and ICGDisclosures.

Correspondence to Dr Victor Lago, University Hospital La Fe, Valencia 46026, Spain; victor.lago.leal@hotmail.com In apparent early stage ovarian cancer, complete surgical staging surgery including systematic lymphadenectomy is recommended at the time of diagnosis. Guided by the acoustic signal of the gamma probe and a near-infrared camera, we performed a minimum dissection looking for the sentinel lymph node or nodes in the pelvic and para-aortic region. Between 2017 and 2019, this procedure was performed in 30 patients, in the context of our pilot experience4 and the clinical trial SENTOV (NCT03452982).