Background: Mammary-like gland adenocarcinoma of the vulva is a rare and aggressive form of vulvar cancer with histopathologic resemblance to breast cancer. This rare type of vulvar cancer develops from primary metaplasia of mammary-like anogenital glands, more recently discovered anatomic components of the anogenital region. Case presentation: We present a 77-year-old African-American female with a six-month history of painless, left lower vulvar lesion referred to our cancer center following confirmatory biopsy of invasive mammary type adenocarcinoma. Preoperative PET CT demonstrating focal avidity (SUV 7.8) in the vulvar region with no evidence of metastatic disease. She underwent exam under anesthesia, left radical vulvar excision with primary closure, left inguinal sentinel lymph node mapping and biopsy for a TNM stage of T2N0M0 and vulvar FIGO stage IB grade 2. Somatic testing was significant for a BRCA1 mutation (variant p.S770, c.2309C>G). Conclusion: Mammary-like gland adenocarcinoma of the vulva is a rare but aggressive neoplasm that presents diagnostic challenges due to its resemblance to breast carcinoma. Radical resection and sentinel lymph node assessment is feasible. Melanocytic skin types pose a unique set of differences regarding detection, diagnosis and potential genomic variations such as BRCA1 mutation in our patient. Genetic and genomic assessments should be considered to further guide optimal therapeutic options.

This study was conducted to investigate the techniques and complications of enlarged uterine extraction during minimally invasive surgery for uterine malignancy. The electronic medical record was queried for patients with uterine malignancy and enlarged uterus (≥ 250 g) who underwent primary hysterectomy with laparoscopic or robotic approach. Statistical analysis was performed using Fisher’s exact test for categorical variables and Kruskal–Wallis test for continuous variables. All patients with presumed uterine confined endometrial cancer who underwent upfront surgical management with minimally invasive hysterectomy and had uterine specimen weight ≥ 250 g were included. Seventy-eight patients met inclusion criteria. Mean specimen weight and mean operating time differed by extraction technique: intact vaginal extraction 307 g, 163 min; vaginal removal in specimen bag 337 g, 214 min; incidental vaginal morcellation 321 g, 178 min; vaginal morcellation in specimen bag 361 g, 212 min; and small laparotomy 677 g, 237 min. Specimens that required removal with small laparotomy incisions were larger in weight (p = < .001) and had increased operative time (p = < .001). Adjuvant treatment was given to 52.6

Journal of Gynecologic SurgeryAhead of Print An Unusual Cause of Iatrogenic Ureteral ObstructionBrittany Roberts and Mitchel S. HoffmanBrittany RobertsDepartment of Obstetrics/Gynecology, Albany Medical Center, Albany, New York, USA.Search for more papers by this author and Mitchel S. HoffmanMitchel S. Hoffman, MD, Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, Tampa, FL 3361, USA E-mail Address: [email protected]Department of Gynecologic Oncology, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.Search for more papers by this authorPublished Online:17 Jan 2024https://doi.org/10.1089/gyn.2023.0105AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail View articleFiguresReferencesRelatedDetails Volume 0Issue 0 InformationCopyright 2024, Mary Ann Liebert, Inc., publishersTo cite this article:Brittany Roberts and Mitchel S. Hoffman.An Unusual Cause of Iatrogenic Ureteral Obstruction.Journal of Gynecologic Surgery.ahead of printhttp://doi.org/10.1089/gyn.2023.0105Online Ahead of Print:January 17, 2024 PDF download

Objectives: The surgical training of gynecologic oncology (GO) fellows is critical to providing excellent care to women with gynecologic cancers. We sought to evaluate changes in techniques and surgical volumes over an 18-year period among established GO fellowships across the US. Methods: We emailed surveys to 30 GO programs that had trained fellows for at least 18 years. Surveys requested the number of surgical cases performed by a fellow for seventeen surgical procedures over each of five-time intervals. A One-Way Analysis of Variance was conducted for each procedure, averaged across institutions, to examine whether each procedure significantly changed over the 18-year span. Results: 14 GO programs responded and were included in the analysis using SPSS. We observed a significant increase in the use of minimally invasive (MIS) procedures (robotic hysterectomy (p < .001), MIS pelvic (p = .001) and MIS paraaortic lymphadenectomy (p = .008). There was a concurrent significant decrease in corresponding "open" procedures. There was a significant decrease in all paraaortic lymphadenectomies. Complex procedures (such as bowel resection) remained stable. However, there was a wide variation in the number of cases reported with extremely small numbers for some critical procedures. Conclusions: The experience of GO fellows has shifted toward increased use of MIS. While these trends in care are appropriate, they do not diminish the need in many patients for complex open procedures. These findings should help spur the development of innovative training to maintain the ability to provide these core, specialty-defining procedures safely.

Background: Cervical stump malignancies are an uncommon finding post subtotal hysterectomy. Tumors arise from a primary cervical origin with an incidence of 1 -5%. Other described malignancies can include uterine origin, ovarian origin or as metastases from another primary site. A uterine primary is an extremely rare entity and can result from remnant endometrial tissue at the stump apex. Case: 70yo female with a history of remote supracervical hysterectomy for benign indication who presented with postmenopausal spotting. Endocervical curettage of the endocervical stump revealed a grade 2 endometrioid endometrial adenocarcinoma. She was taken to the operating for a robotic radical stump trachelectomy and sentinel lymph node dissection. Conclusions: The surgical video delineates key surgical steps of robotic radical stump trachelectomy including robotic port placement and injection of ICG dye, adhesiolysis and restoration of normal anatomy, opening of the pelvic spaces and exposure of the retroperitoneum, identification and excision of pelvic sentinel lymph nodes, bladder dissection, ureterolysis and ligation of uterine remnant, ureteric tunnel dissection and mobilization of parametrial wing, delineation of a vaginal margin, colpotomy and specimen removal, and vaginal cuff closure.

Journal of Gynecologic SurgeryVol. 40, No. 1 EditorialFree AccessUterine Myomata: 50 Years of Progress in GynecologyMitchel S. HoffmanMitchel S. Hoffman—Mitchel S. Hoffman, MD, Editor-in-Chief Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA.Search for more papers by this authorPublished Online:16 Feb 2024https://doi.org/10.1089/gyn.2023.0146AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail In 1930, with the creation of the American Board of Obstetrics and Gynecology, our discipline of Obstetrics and Gynecology officially became a medical specialty. Many factors led to the development of gynecology and gynecologic surgery as distinct from general medical care and surgery. Few gynecologic disorders made as substantial an impact on this emerging field as uterine leiomyomata. These tumors were frequently detected and their potential to lead to major clinical problems still continues to play a prominent role in the provision of gynecologic care.Surgery is the dominant method of treating women with symptomatic uterine leiomyomata. For almost 100 years, at least through the 1970s, treatment for women with markedly symptomatic leiomyomata was limited to major surgery and by 1 of 2 routes (vaginal or abdominal hysterectomy or myomectomy).The past 50 years have witnessed a significant increase in management options for women with leiomyomata. Newer medical and minor surgical options have reduced the need for major surgery which, when indicated, can often be performed by minimally invasive routes (laparoscopic or transvaginal/transcervical).Dr. Emad Mikhail (MD) is the director of Minimally Invasive Gynecologic Surgery at the University of South Florida Morsani College of Medicine. There, he has developed a specialized clinical service for women with uterine leiomyomata, which is the subject of the Special Topic in this issue. Dr. Mikhail has recruited an outstanding group of experts on the various management options for these patients, as are described and discussed in their articles.I hope you find the Special Topic and the other excellent articles in this issue informative and of value to your practice.FiguresReferencesRelatedDetails Volume 40Issue 1Feb 2024 InformationCopyright 2024, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.Uterine Myomata: 50 Years of Progress in Gynecology.Journal of Gynecologic Surgery.Feb 2024.1-1.http://doi.org/10.1089/gyn.2023.0146Published in Volume: 40 Issue 1: February 16, 2024 TopicsLymphoscintigraphyUterine fibroids PDF download

A minimally invasive surgery (MIS) is the standard of care for surgical treatment in gynecological oncology. Robotic surgery is increasingly being used in this domain. Anesthetic considerations are related to the specific procedure, robotic approach per se, adjuvant chemotherapy, radiotherapy, and patient-specific concerns. Evidence-based practices encompass a balance of preoperative, intraoperative, and postoperative evidence-based goals. A summary of these key aspects of perioperative care for women undergoing MIS can enhance surgical outcomes in gynecological oncology.

Journal of Gynecologic SurgeryVol. 39, No. 6 EditorialFree AccessAnesthesiology: Our Colleagues, Our PartnersMitchel S. HoffmanMitchel S. HoffmanDepartment of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, H. Lee Moffitt Cancer Center and Research Institute, Tampa, Florida, USA. Search for more papers by this authorPublished Online:1 Dec 2023https://doi.org/10.1089/gyn.2023.0112AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookXLinked InRedditEmail This year's final issue features a Special Topic on the essential relationship of anesthesia and analgesia to gynecologic surgery and care. Jeffrey Huang, MD, a leader in academic anesthesiology and an H. Lee Moffitt Cancer Center and Research Institute colleague, has assembled a group of expert colleagues who provide an excellent series of articles on anesthesia and analgesia topics. While anesthesiologists have been providing care to gynecologic patients for more than a century, the articles in this Special Topic issue discuss recent updates and advances in this field.As gynecologic surgeons, we are treating an expanding population of women who are elderly, have major comorbidities, may need to be in steep Trendelenburg positioning for extended periods of time, and/or require highly complex procedures. The challenges that the anesthesia team faces with these higher-risk groups of women are often greater than those faced by the surgeon who is performing the operation.Anesthesiologists are our partners and we must work closely with these specialists before, during, and (at times) after surgery to achieve the best results. To collaborate effectively with a team of anesthesiologists we must have a good understanding of the types of care that they provide to our patients. The articles in Dr. Huang's Special Topic issue provide a primer for gynecologic surgeons that will help us fulfill this responsibility and appreciate the more-recent aspects of perioperative care better that we might consider incorporating into practice.In addition to performing surgical procedures, gynecologists will often assume responsibility for the care of women with chronic pelvic pain. Pain may result from a source that can be identified but yet has an elusive etiology, and/or may be very difficult to treat adequately. Several of the articles in this issue's Special Topic inform us about the potential ways our anesthesia colleagues may be able to assist in managing patients with chronic pelvic pain.As a fellow gynecologic surgeon, I encourage you to maintain a close working relationship with your anesthesiology colleagues for the purpose of optimizing perioperative and pain-related patient care. I hope you will benefit from reading these articles and would be interested in your thoughts by way of a Letter to the Editor.—Mitchel S. Hoffman, MDEditor-in-ChiefFiguresReferencesRelatedDetails Volume 39Issue 6Dec 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.Anesthesiology: Our Colleagues, Our Partners.Journal of Gynecologic Surgery.Dec 2023.253-253.http://doi.org/10.1089/gyn.2023.0112Published in Volume: 39 Issue 6: December 1, 2023PDF download

Objective: This article describes the incidence, presentation, management, and outcome of posthysterectomy vaginal cuff evisceration over a 2-year timeperiod at a major cancer center. Materials and Methods: This was a retrospective chart review of patients who developed vaginal cuff evisceration after prior hysterectomy. The denominator of hysterectomies performed by the department between May 1, 2020 and April 30, 2022, was included in the analysis. The cases of vaginal evisceration were well-known to the practice. Results: Three women who had undergone hysterectomy during the 2-year timeperiod developed vaginal cuff evisceration. This incidence was 0.3%. All 3 women underwent surgical repair (1 with bowel resection) without subsequent complications. Conclusions: Vaginal evisceration is a rare complication of hysterectomy at a major cancer center. This report adds to the body of knowledge regarding diagnosis and management of this dramatic and life-threatening event.

OBJECTIVE:We sought to document current surgical practices among gynecologic oncologists in the United States. METHODS:In March/April 2020, we conducted a cross-sectional survey among members of the Society of Gynecologic Oncology to identify gynecologic oncology practice trends in the United States. The survey collected demographic data and queried participants on types of surgical procedures performed and chemotherapy use. Univariant and multivariant analyses were used to evaluate the association between surgeon practice type, region of practice, working with gynecologic oncology fellows, time in practice, and dominant surgical modality of practice on performance of specific procedures. RESULTS:Among 1199 gynecologic oncology surgeons who were emailed the survey, 724 completed the survey (60.4% response rate). Of these respondents, 170 (23.5%) were within 6 years of fellowship graduation, 368 (50.8%) identified as female; and 479 (66.2%) worked in an academic setting. Surgeons who worked with gynecologic oncology fellows were more likely to perform bowel surgery, upper abdominal surgery, complex upper abdominal surgery, and prescribe chemotherapy. Surgeons who were ≥ 13 years out from fellowship graduation were more likely to perform bowel surgery and complex abdominal surgery and less likely to prescribe chemotherapy and perform sentinel lymph node dissections (P < 0.05). CONCLUSIONS:These findings highlight the variation in surgical procedures performed by gynecologic oncologists in the United States. These data support that there are practice variations that would benefit from further investigation.

Journal of Gynecologic SurgeryVol. 39, No. 5 EditorialFree AccessLearning and Teaching SurgeryMitchel S. HoffmanMitchel S. Hoffman—Mitchel S. Hoffman, MD, Editor-in-Chief Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA.Search for more papers by this authorPublished Online:3 Oct 2023https://doi.org/10.1089/gyn.2023.0087AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail A surgeon must select from among 3 routes for performing a hysterectomy: vaginal; open abdominal; or laparoscopic. In addition, there are variations of these approaches that include robotic and vNOTES [vaginal natural orifice transluminal endoscopic surgery].The first article of this issue has Drs. Kristin N. Taylor and Kenneth H. Kim (MD, MHPE) from the Samuel Oschin Cancer Center at Cedars–Sinai Medical Center (Los Angeles, CA) providing a historical perspective on the use of robotics in gynecologic surgery. Dr. Kim, an internationally renowned expert on the subject, adds thoughts on future directions that this evolving technology might take.As an introduction to this article, I would like to comment on surgical training in robotic surgery. During an open abdominal operation, the attending surgeon can readily demonstrate, observe, control, and correct surgical steps with a trainee. The same is true, although to a lesser extent, for vaginal and laparoscopic surgery. Robotic surgery is unique in this respect. The individual operating at the surgeon console has complete control, at least momentarily, of the operation. The attending surgeon can point, draw a line, control an assisting robotic instrument (dual console), and resume complete control very rapidly.The complete transfer of control of robotic surgery to a trainee highlights 2 important issues. First: Even with only momentary control, a catastrophic complication may occur (such as moving scissors that are out of the field of view and puncturing a major vessel). Second: How do we effectively teach complex gynecologic surgery without being able to continuously demonstrate or redirect the trainee should the need to do so arise during the case? There are no clear answers to these questions, although the development of the teaching console and the ability of the educator to control 1 of 3 instruments have been major advances with respect to teaching robotic surgery. Currently, the major focus of the Taylor and Kim article provides the best answer to balancing surgical safety and education in robotic surgery with the use of a priori simulation-based training.This article presents a very relevant point of view regarding how sophisticated data developed from the robotic simulator will push education beyond practice and basic feedback to practice, leading to very sophisticated feedback, and eventually to achieving proficiency in robotic surgical techniques.As a profession it is important that we approach advances in surgical technology responsibly, especially with regard to training.I invite readers of this journal to communicate their thoughts to me regarding surgical education and the incorporation of new technology for surgical care by submitting Letters to the Editor.FiguresReferencesRelatedDetails Volume 39Issue 5Oct 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.Learning and Teaching Surgery.Journal of Gynecologic Surgery.Oct 2023.203-203.http://doi.org/10.1089/gyn.2023.0087Published in Volume: 39 Issue 5: October 3, 2023PDF download

Journal of Gynecologic SurgeryVol. 39, No. 2 EditorialA Disease, a Syndrome, or Both?Mitchel S. HoffmanMitchel S. Hoffman—Mitchel S. Hoffman, MD, Editor-in-Chief Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA.Search for more papers by this authorPublished Online:12 Apr 2023https://doi.org/10.1089/gyn.2023.0025AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"A Disease, a Syndrome, or Both?." Journal of Gynecologic Surgery, 39(2), p. 59FiguresReferencesRelatedDetails Volume 39Issue 2Apr 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.A Disease, a Syndrome, or Both?.Journal of Gynecologic Surgery.Apr 2023.59-59.http://doi.org/10.1089/gyn.2023.0025Published in Volume: 39 Issue 2: April 12, 2023PDF download

Journal of Gynecologic SurgeryVol. 39, No. 4 EditorialFree AccessUnintended ConsequencesMitchel S. HoffmanMitchel S. HoffmanDepartment of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA.Search for more papers by this authorPublished Online:26 Jul 2023https://doi.org/10.1089/gyn.2023.0049AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail Journal articles on complications always attract my attention, and so it is with this issue. As a busy gynecologic surgeon whose practice is filled with complex cases, I have had my share of surgical complications.Two aspects of the article by Sarkar et al.—“Adverse Events When Using Advanced Sealing Devices During Vaginal Hysterectomy: An Analysis of the Manufacturer and User Facility Device Experience (MAUDE) Database” (pp. 158–161)—attracted my attention. First was the subject of surgical complications in general and, second, was complications related to the application of new technology to surgical procedures.The pelvis is a confined space that is characterized by the intimate relationship of portions of the urinary, genital, and intestinal tracts. Surrounding these organ systems is an extensive neural network and the major vascular supply to the pelvic organs and lower extremities. Maintaining the integrity of these structures is a major challenge of pelvic surgery. All surgeons who perform pelvic operations must have a clear understanding of the complications that may arise as well as their prevention, recognition, and management.Being surgeons carry great responsibilities to our patients. They trust that we know what we are doing and will always do our best. Despite our skill and best efforts, complications will occur and, as surgeons, we must be committed to constantly enhancing our knowledge, skills, and dedication to prevent or manage these potential adverse outcomes.Technological advances in gynecologic surgery are, so far, a mixed blessing. On the positive side, they have improved the efficiency, precision, and ergonomics of some procedures. On the negative side, these advances may drive up the costs of surgical care, sometimes without proven benefit over more-conventional methods. New surgical technology often becomes available to surgeons before it has been fully vetted. This may influence the likelihood of a surgical complication, either as a result of incomplete understanding of the technology or the technology itself. As surgeons, we must be cautious about incorporating new technologies, and be responsible about adapting them to maximize patient benefit while minimizing the chance of harm.I invite you, the readers of this journal, to communicate your thoughts regarding surgical complications and the incorporation of new technology to surgical care. The best format for doing this would be a “Letter to the Editor.”—Mitchel S. Hoffman, MDEditor-in-ChiefFiguresReferencesRelatedDetails Volume 39Issue 4Aug 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.Unintended Consequences.Journal of Gynecologic Surgery.Aug 2023.150-150.http://doi.org/10.1089/gyn.2023.0049Published in Volume: 39 Issue 4: July 26, 2023PDF download

Journal of Gynecologic SurgeryVol. 39, No. 3 EditorialThe Pelvic SurgeonMitchel S. HoffmanMitchel S. Hoffman—Mitchel S. Hoffman, MD, Editor-in-Chief Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA.MCC GYN Program, Moffitt Cancer Center, Tampa, Florida, USA.Search for more papers by this authorPublished Online:1 Jun 2023https://doi.org/10.1089/gyn.2023.0035AboutSectionsView articleView Full TextPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail View article"The Pelvic Surgeon." Journal of Gynecologic Surgery, 39(3), p. 107FiguresReferencesRelatedDetails Volume 39Issue 3Jun 2023 InformationCopyright 2023, Mary Ann Liebert, Inc., publishersTo cite this article:Mitchel S. Hoffman.The Pelvic Surgeon.Journal of Gynecologic Surgery.Jun 2023.107-107.http://doi.org/10.1089/gyn.2023.0035Published in Volume: 39 Issue 3: June 1, 2023PDF download