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IntroductionIn this surgical film, we present a robot-assisted upper vaginectomy and partial cystectomy for resection of endometrial cancer recurrence at the vaginal cuff involving the bladder. We highlight the use of indocyanine green dye guidance to avoid ureteral injury and review techniques to prevent fistula formation.DescriptionThe patient was taken to the operating room for robot-assisted resection of vaginal cuff tumor. Cystoscopy was performed and revealed no mucosal invasion of the bladder. Bilateral ureteral stents were placed without difficulty and injected with indocyanine green dye for identification of the ureters during dissection. Exploratory laparoscopy revealed no gross carcinomatosis or distant metastasis. The vaginal cuff tumor was noted to be invading into the bladder muscularis posteriorly and partial cystectomy was performed to resect the mass margins in this area. Once the tumor was completely mobilized off the bladder anteriorly and rectum posteriorly, upper vaginectomy was performed with adequate margins. The cystotomy was repaired with a running 3.0 absorbable barbed suture horizontally and the vagina was closed with a running absorbable barbed suture vertically to avoid parallel friction with the cystotomy repair for prevention of fistula formation. A piece of omentum was mobilized and sutured over the vaginal closure as an additional step to prevent future fistula formation.Conclusion/ImplicationsLocally recurrent vaginal cuff tumors can be safely resected with adequate margins robotically under indocyanine green dye guidance to avoid ureteral injury. Techniques to prevent future fistula formation include avoiding parallel suture friction between bladder, vagina or rectum and using omentum as a friction barrier.

IntroductionMesonephric-like adenocarcinoma (MLA) of the uterine corpus is a rare and distinct gynecological malignancy. MLA has a similar appearance to mesonephric adenocarcinoma of the uterine cervix or vagina, which originates from mesonephric remnants. Despite presenting with symptoms and signs similar to more common types of endometrial carcinoma, MLA tends to behave more aggressively, with advanced-stage disease at diagnosis, rapid progression, frequent recurrence, distant metastases, and poor prognosis.DescriptionThis video showcases a case of robotic-assisted tumor debulking in a 60-year-old patient with metastatic mesonephric-like uterine carcinoma. The patient had a past medical history of fibroid uterus and endometriosis and presented with pelvic pain and postmenopausal bleeding. Imaging showed a dominant intramural uterine fibroid that had significantly increased in size, right pelvic sidewall and external iliac lymphadenopathy, and associated peritoneal thickening. CT imaging showed intense hypermetabolic activity in the uterus consistent with malignancy and hypermetabolic pelvic lymph nodes. At the time of the procedure, the patient was found to have extensive peritoneal carcinomatosis, bulky lymph nodes, and a tumor on the ureter, with distorted anatomy due to a large multi-fibroid uterus and dense adhesive disease on the vesico-uterine space. This video aims to review the surgical techniques used in complex minimally invasive debulking procedures. By the end of the procedure, all visible cancer was removed. The procedure was uncomplicated, and the patient was discharged on postoperative day 0.Conclusion/ImplicationsOur video provides valuable insights into the surgical techniques used to achieve complete tumor resection in complex cases with aggressive uterine tumors.

In this review, we aim to evaluate the current literature on reproductive and oncologic outcomes after fertility-sparing surgery for early-stage cervical cancer (stage IA1-IB1). This is a systematic review of the existing literature using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist to report on fertility-sparing surgery and its outcomes in early-stage cervical cancer. Outcomes of interest were subsequent clinical pregnancy rate, reproductive outcomes, and cancer recurrence outcomes. Included in this systematic review were 68 studies encompassing 3,592 patients who underwent fertility-sparing surgery. Of these, reproductive outcomes were reported in 1096 pregnancies. The mean clinical pregnancy rate was 53.2%. Those who underwent vaginal radical trachelectomy had the highest clinical pregnancy rate (67.5%). The mean live birth rate was 67.8% in our study. Twenty-one percent of pregnancies after fertility-sparing surgery required assisted reproductive technology. The mean cancer recurrence rate was 3.2%, and the cancer death rate was 0.6% after a median follow-up period of 40.1 months with no statistically significant difference across surgical approaches. Offering fertility-sparing surgery in early-stage cervical cancer is reasonable. Highest clinical pregnancy rate is associated with vaginal radical trachelectomy. Moreover oncologic outcomes of minimally invasive approaches were comparable with abdominal approaches. We encourage detailed preoperative counseling and multidisciplinary approach to achieve best outcomes.

Cesarean scar defect, also known as niche, isthmocele, uteroperitoneal fistula and uterine diverticulum, is a known complication after cesarean delivery. Due to the rising cesarean delivery rates, niche has become more common and can present as irregular bleeding, pelvic pain, infertility, cesarean scar pregnancy and uterine rupture. Treatments for symptomatic cesarean scar defect vary and include hormonal therapy, hysteroscopic resection, vaginal or laparoscopic repair, and hysterectomy. We report on the safety and efficacy of our method of repairing cesarean scar defects in 27 patients without adverse outcomes: two-layer repair where the suture does not enter the uterine cavity. Our method of laparoscopic niche repair improves symptoms in nearly 77% of patients, restores fertility in 73% of patients, and decreases the time to conception.

Bowel endometriosis is a complex condition predominantly impacting women in their reproductive years, which may lead to chronic pain, gastrointestinal symptoms, and infertility. This review highlights current approaches to the diagnosis and management of bowel endometriosis, emphasizing a multidisciplinary strategy. Diagnostic methods include detailed patient history, physical examination, and imaging techniques like transvaginal ultrasound (TVUS) and magnetic resonance imaging (MRI), which aid in preoperative planning. Management options range from hormonal therapies for symptom relief to minimally invasive surgical techniques. Surgical interventions, categorized as shaving excision, disc excision, or segmental resection, depend on factors such as lesion size, location, and depth. Shaving excision is preferred for its minimal invasiveness and lower complication rates, while segmental resection is reserved for severe cases. This review also explores nerve-sparing strategies to reduce surgical morbidity, particularly for deep infiltrative cases close to the rectal bulb, anal verge, and rectosigmoid colon. A structured, evidence-based approach is recommended, prioritizing conservative surgery to avoid complications and preserve fertility as much as possible. Comprehensive management of bowel endometriosis requires expertise from both gynecologic and gastrointestinal specialists, aiming to improve patient outcomes while minimizing long-term morbidity.

Background/Objectives: Endometriosis is a chronic gynecological disorder affecting up to 10% of women of reproductive age. The etiology of endometriosis remains unclear; however, there is growing interest in identifying modifiable risk factors, particularly dietary influences. The present study aims to systematically evaluate the association between fruit consumption and the incidence of endometriosis. Methods: A comprehensive systematic search was conducted across PubMed, Embase, Web of Science, and Google Scholar for studies published from 1 January 1990 to 30 September 2024. Relevant data were extracted and categorized, and the methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) checklists. Additionally, meta-analyses were performed using STATA 18.0 to compare daily and weekly fruit consumption among women with and without endometriosis. Results: The analysis included six studies comprising 3689 women with endometriosis and 1463 controls. The meta-analysis revealed no significant association between daily fruit consumption and the risk of endometriosis (odds ratio (OR): 0.95; 95% confidence interval (CI): 0.90–1.01). Similarly, weekly fruit consumption did not demonstrate a significant link to endometriosis risk (OR 1.03, 95% CI: 0.78–1.35). The assessment of publication bias using Begg’s and Egger’s tests, along with contour-enhanced funnel plots, indicated the absence of publication bias in the data across both analysis groups. Conclusions: This study indicates that fruit consumption does not significantly influence the risk of developing endometriosis. Additional research is necessary to examine preferred dietary interventions for populations affected by this condition.

Uterine fibroid is one of the most common benign uterine diseases, affecting up to 70–80% of females of reproductive age. Whilst abdominal myomectomy has traditionally been a major uterine-sparing surgical intervention for its management, this is not without considerable technical challenges and the potential for multiple complications and morbidity. Since the introduction of video-assisted endoscopic surgery by Dr. Camran Nezhat in the 1980s, the development of minimally invasive approaches to myomectomy has accelerated rapidly worldwide. Whilst this offers numerous benefits for patients, laparoscopic myomectomy still carries implications for necessary expertise in surgical skill, intraoperative hemorrhage control, concern for future reproductive potential and risk of occult uterine malignancy. In this review article, we present the latest data regarding such aspects and offer our opinions on widely raised questions and existing contentions regarding myomectomy. We believe that minimally invasive myomectomy is a safe, efficient and beneficial approach to management in the hands of surgeons empowered with advanced knowledge, experience, and refined surgical skills.

Objectives: To determine the association between ovarian endometriomas and stage of endometriosis. Methods: A total of 222 women aged 18–55 years old, who underwent minimally invasive surgery between January 2016 and December 2021 for treatment of endometriosis were included in the study. Patients underwent laparoscopic and/or robotic treatment of endometriosis by a single surgeon (FRN) and were staged using the ASRM revised classification of endometriosis. Pre-operative imaging studies, and operative and pathology reports were reviewed for the presence of endometriomas and the final stage of endometriosis. Using univariate analyses for categorical variables and the two-sample t-test or Mann–Whitney test for continuous data, association between endometriomas, stage of endometriosis, type of endometrioma, and other patient parameters such as age, gravidity, parity, laterality of endometriomas, prior medical treatment, and indication for surgery was analyzed. Results: Of the 222 patients included in the study, 86 patients had endometrioma(s) and were found to have stage III–IV disease. All 36 patients with bilateral endometriomas and 70% of patients with unilateral endometriomas had stage IV disease. Conclusions: The presence of ovarian endometrioma(s) indicates a higher stage of disease, correlating most often with stage IV endometriosis. Understanding the association between endometriomas and anticipated stage of disease can aid in appropriate pre-operative planning and patient counseling.

Endometriosis is a frequent, estrogen-dependent, chronic disease, characterized by the presence of endometrial glands and stroma outside of the uterine cavity. Although it is not considered a precursor of cancer, endometriosis is associated with ovarian cancer. In this review, we summarized the evidence that clear-cell and endometrioid ovarian carcinomas (endometriosis-associated ovarian carcinoma—EAOC) may arise in endometriosis. The most frequent genomic alterations in these carcinomas are mutations in the AT-rich interaction domain containing protein 1A (ARID1A) gene, a subunit of the SWI/SNF chromatin remodeling complex, and alterations in phosphatidylinositol 3-kinase (PI3K) which frequently coexist. Recent studies have also suggested the simultaneous role of the PTEN tumor-suppressor gene in the early malignant transformation of endometriosis and the contribution of deficient MMR (mismatch repair) protein status in the pathogenesis of EAOC. In addition to activating and inactivating mutations in cancer driver genes, the complex pathogenesis of EAOC involves multiple other mechanisms such as the modulation of cancer driver genes via the transcriptional and post-translational (miRNA) modulation of cancer driver genes and the interplay with the inflammatory tissue microenvironment. This knowledge is being translated into the clinical management of endometriosis and EAOC. This includes the identification of the new biomarkers predictive of the risk of endometriosis and cancer, and it will shape the precision oncology treatment of EAOC.

Background/Objectives: Endometriosis is a chronic, inflammatory, estrogen-dependent disease that has historically been underdiagnosed, especially in patients with unexplained infertility. On average, diagnosis is delayed by 11 years, underscoring the need for precision medicine to improve outcomes. To compare disease severity and anatomical distribution of endometriosis between patients with unexplained infertility who underwent noninvasive Receptiva BCL6 testing before surgery and those who did not. Methods: A cross-sectional analysis was conducted on 195 women with unexplained infertility and histologically confirmed endometriosis following diagnostic video laparoscopy, with or without robotic assistance. Disease severity was staged using updated guidelines. Anatomical sites of endometriosis were documented. Patients were grouped based on whether they had undergone the Receptiva BCL6 overexpression test prior to surgery. Results: Of the 195 patients, 43 underwent Receptiva testing; 41 of them tested positive and were confirmed to have endometriosis during surgery. These patients had fewer affected anatomical regions (3.14 ± 2.09) compared to those without testing (3.93 ± 2.26; p = 0.04). The No Receptiva group also had more high-stage cases (70.39% vs. 65.12%, p-value: 0.038). In both groups, endometriosis most frequently involved the periureteral region, rectovaginal septum, and ovaries, though ovarian tissue was rarely excised to preserve fertility. Conclusions: Among patients with unexplained infertility and confirmed endometriosis, those who had preoperative Receptiva testing showed lower disease burden and severity. These findings support the potential utility of noninvasive testing to enrich diagnostic accuracy and guide earlier, more targeted intervention.