Objective: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an emerging surgical procedure that combines the advantages of the vaginal approach with laparoscopic vision and instrumentation [1]. Shorter hospitalization and lower postoperative pain associated to vNOTES [2] may be explained by the advantages of this innovative surgical approach (such as absence of abdominal incisions, shorter operating time, lower insufflation pressure) [2;3]. Ovarian tissue cryopreservation allows to preserve reproductive and endocrine functions in young women with oncological disease at risk of premature ovarian insufficiency (POI) caused by gonadotoxic treatments [4]. Ovarian tissue biopsy for cryopreservation consists of a large biopsy of one or both ovaries [4] that is usually performed by laparoscopy. Then, the removed ovarian tissue is cryopreserved for the future transplant after cancer remission. Volume of ovarian biopsy ranges from 50% of the ovary for women at moderate risk of POI to 70 % or whole ovary for women at high risk [5]. Inclusion criteria for ovarian tissue cryopreservation are women aged less than 35 who cannot delay start of oncological treatments for follicles cryopreservation, with a moderate or high risk of POI and good chance of 5-year survival [6]. Ovarian tissue cryopreservation cannot be performed if tumor treatments include uterine irradiation or for tumors at risk of ovarian metastases (as in case of ovarian cancer, leukemia, neuroblastoma, Burkitt lymphoma) [7]. Despite widespread adoption of vNOTES in gynecology, ovarian biopsy for cryopreservation has never been performed using this route.
Design: Step-by-step explanation of the procedure with descriptive text and narrated video footage.
Setting: Tertiary level referral academic center.
Patient(s): A 27-years-old patient recently diagnosed with low grade follicular non-hodgkin lymphoma was referred to our center for ovarian tissue cryopreservation before chemotherapy. The patient included in this study gave informed consent for publication of the video and posting of the video online including social media, the journal website, scientific literature websites (such as PubMed, ScienceDirect, Scopus, etc.) and other applicable sites. Due to the nature of the study, IRB approval was not required.
Intervention(s): Access to peritoneal cavity was created by a 3 cm posterior colpotomy. Peritoneum was then opened using cold scissors and temporarily fixed to the posterior vaginal wall. The Gelpoint Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA, USA), with one 10 mm and two 5 mm trocars, was used as vNOTES port. The inner Alexis ring of the Gelpoint was inserted through the colpotomy into the pouch of Douglas. An hysterometer was placed into the uterine cavity to keep the uterus anteverted during the surgery. A pneumoperitoneum was created to a pressure of 8 mmHg and the operating table was tilted to 20° Trendelenburg position. A 10-mm rigid 30° camera was inserted in the inferior and larger trocar and both the ovaries were visualized. 70 % of the left ovary was removed with cold scissors, in order to minimize trauma on the surgical specimen. After removal of the Gelpoint cap, ovarian biopsy was immediately picked-up by the biologist of our fertility center. The ovary was coagulated with bipolar instrument. Hysterometer was then replaced by a uterine manipulator to perform tubal patency test and blue dye passage through both the salpinges was observed. Finally, the Alexis retractor and the stich on the posterior peritoneum were removed and the vagina was sutured using interrupted stiches. Total operative time was 25 minutes.
Main outcomes measure(s): Ovarian tissue biopsy for cryopreservation by vNOTES.
Results(s): No intraoperative and postoperative complications were reported and the patient was discharged after 24 hours from surgery.
Conclusion(s): VNOTES may be a feasible alternative approach to laparoscopy for ovarian tissue cryopreservation: it allows an easy access to the ovaries and removal of different tissue volumes. Patients undergoing ovarian cryopreservation may benefit of vNOTES approach since a rapid post-operative recovery is crucial to start chemotherapy in a short time. As for other vNOTES surgical procedures, accurate selection of patients seems to be crucial for a successful ovarian tissue cryopreservation [8]. We think that inclusion and exclusion criteria reported for other gynecologic procedures performed through vNOTES may also be valid for ovarian tissue cryopreservation by vNOTES [9]. Women at high risk of pelvic adhesions (such as coexistent endometriosis, previous pelvic surgery or inflammatory pelvic disease), with elevated Body Mass Index or enlarged uterus as well as women with cervical, vaginal or uterine cancer cannot be considered for this approach since all these factors are associated to failure of vNOTES. On the other hand, women with no history of surgery, endometriosis and large myomas may benefit from vNOTES approach and these women represent most of patients who undergo ovarian tissue cryopreservation.
Keywords: Cryopreservation; Fertility preservation; Ovarian tissue; Vaginal natural orifice transluminal endoscopic surgery (vNOTES); Vaginal surgery.
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