Wai Yoong

Two Cases of vNOTES Assisted Vaginal Adnexectomy in Management of Paraneoplastic Anti‐ N ‐Methyl‐ D ‐Aspartate Receptor Encephalitis Secondary to Ovarian Teratoma

ABSTRACT Anti‐ N ‐Methyl‐ D ‐Aspartate receptor encephalitis typically presents with neuropsychiatric symptoms, followed by autonomic dysregulation sometimes necessitating Intensive Care admission. It has a 15% mortality rate and when associated with ovarian teratoma, early surgical excision improves recovery rate by 25%. We describe the first two cases of vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) assisted vaginal adnexectomy for surgical treatment of ovarian teratoma associated anti‐NMDA encephalitis and highlight the advantages of this novel approach. These include low insufflation pressures, shorter duration of surgery, avoidance of abdominal scarring, lower pain scores and more rapid recovery. While the outcomes in these two cases suggest that ovarian teratoma associated anti‐NMDA encephalitis could be surgically managed through the vNOTES route rather than conventional laparoscopy, more randomized data still need to be available before this becomes standard approach.

vNOTES Assisted Vaginal Bilateral Salpingo‐Oophorectomy in Postmenopausal Women With Large Ovarian Fibroma

ABSTRACT The authors describe two cases where women with large ovarian fibromas (6 and 9 cm, respectively) underwent a transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) assisted bilateral salpingo‐oophorectomy. Retrieval was facilitated by transvaginal cold knife morcellation in the Pouch of Douglas under direct vision following vNOTES assistance without abdominal incisions. This is the first time vNOTES has been described for excision of solid ovarian tumors of these dimensions; the authors discuss its advantages compared to conventional laparoscopy, together with challenges of retrieving a solid lesion through a posterior colpotomy incision.

Concurrent vNOTES risk reducing bilateral salpingo-oophorectomy at the time of mastectomy in women with breast cancer and BReast CAncer (BRCA) gene mutation

Women with breast cancer and BRCA gene mutation should be offered bilateral risk reducing salpingo-oophorectomy (RRBSO) due to lifetime ovarian cancer risk. Laparoscopic BSO, either concurrently or following index mastectomy, is benchmark but vaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) gaining traction as an alternative route. We report three novel cases of simultaneous "dual site" surgery in women with breast cancer and BRCA inheritance. vNOTES RRBSO is performed prior to breast surgery during the "dual site" procedure. As recommended by National Comprehensive Cancer Network, salpingectomy was completed to the level of cornu and ovarian pedicle was excised distally to include 2 cm margin. Peritoneal cytology was obtained and bowel, omentum, appendix and pelvic organs were inspected. Data collected included age, BMI, Ca-125 levels, duration of surgery, estimated blood loss, length of stay, 24 hour VAS, peri-operative complications, sexual function (FSFI-6), and recovery status (RI-10). Three women underwent concomitant vNOTES RRBSO and mastectomy. Median operative time and postoperative stay were 45 mins and 26 hours and there were no complications. Sexual function appeared unaffected by the vNOTES approach (FSFI-6 median score 6 vs 4) and normal activity resumed within 23 days. Histology of fallopian tubes and ovaries was benign. Concomitant vNOTES RRBSO and mastectomy avoids a second surgical admission and repeat anaesthesia and does not appear to delay recovery. Findings support adoption of vNOTES as a patient-friendly alternative which can be performed concurrently with mastectomy.

Outcomes and cost-effectiveness of vNOTES vs conventional laparoscopic ovarian cystectomy for ovarian teratoma (dermoid cysts): A comparison of two minimal access routes of surgery

Laparoscopic ovarian cystectomy is the benchmark surgical treatment for ovarian teratoma but vNOTES is emerging as an alternative with avoidance of abdominal scars, less pain and more rapid recovery. This study aimed to compare outcome data and expenditure for two minimally invasive routes in the surgical management of ovarian teratoma. Case control study of vNOTES vs laparoscopic ovarian cystectomy (n = 21 in each group). Data collected included age, BMI, teratoma size, duration of surgery, estimated blood loss, length of stay and peri-operative complications. Expenditure for the procedures were calculated using unit costs verified with NHS England Cost Collection website. Mean age (38.42 vs 39.80 yrs), BMI (29.38 vs 27.90 kg/m Shorter theatre duration and length of stay, better cosmesis, less pain and rapid recovery, allied with lower cost support the adoption of vNOTES as a viable option for minimally invasive adnexectomy for ovarian teratoma.

Unusual presentation of aggressive angiomyxoma arising from the posterior vaginal wall

A multiparous woman presented with a large bulge protruding from the posterior wall of the vagina, initially diagnosed as a rectocele. Imaging revealed a cystic lesion measuring 9 cm × 6 cm × 3.5 cm suspected to be a developmental cyst. The lesion underwent surgical excision with significant improvement in symptoms. Histological analysis reported an aggressive angiomyxoma (AAM); postoperative hormonal therapies were considered and rigorous follow-up initiated. The authors discuss challenges in investigating and managing AAM with proposals made for improving preoperative diagnosis and optimising postoperative management. Correlating tumour size with symptoms, judicious planning of surgery, rigorous postoperative follow-up and involving the patient in all aspects of decision-making will guide clinicians in providing the best care in the rare entity of AAM.