Recent Advances in the Surgical Management of Cervical Cancer

The Wertheim hysterectomy: Development, modifications, and impact in the present day

Ernst Wertheim was a pioneer in the history of the surgical treatment of cervical cancer. His English-language manuscript "The extended abdominal operation for carcinoma uteri (based on 500 operative cases)," which was published in 1912, detailed his standardization of the radical hysterectomy and formed the basis of the current treatment for early stage cervical cancer. We contextualize the Wertheim hysterectomy, emphasizing medical advances that allowed for its development and subsequent modification. We then discuss modifications to the originally proposed procedure, including a maximally extended parametrical resection pioneered by Takayama, and the addition of the Taussig en bloc lymph node dissection by Meigs, both of which afforded an improved mortality profile due to decreased disease recurrence. Finally, we discuss progress that has been made in the present day, such as the development of nerve-sparing and fertility-sparing surgeries, as well as the introduction of the robotic platform. In this way, we hope to provide a historical background for the Wertheim hysterectomy-a cornerstone of gynecologic oncology.

[Study of surplus cost of robotic assistance for radical hysterectomy, versus laparotomy and standard laparoscopy]

OBJECTIVES

The study purpose was to compare the costs among robotic, laparoscopic and open radical hysterectomy for cervical cancer.

PATIENTS AND METHODS

Thirty-seven patients underwent robotic radical hysterectomy for cervical cancer. Cases were performed by three surgeons, at two institutions, and were retrospectively reviewed to perform a cost comparison between all three modalities. We included costs for edible materials in anesthesia and surgery, but costs for staff and indirect financial expenses were excluded. Those data are compared to open and laparoscopic radical hysterectomy data.

RESULTS

The average cost for robotic assistance presented a surplus of 1796 euros compare to laparotomy and 1313 euros compare to standard laparoscopy in 2008, and 1320 and 837 euros respectively.

DISCUSSION AND CONCLUSION

The average cost for radical hysterectomy was highest for robotic, followed by standard laparoscopy, and least for laparotomy. However, over only 2 years of use, this difference tends to decrease. Medico-economic impact is the main restraint for robotic assistance development, and needs to be assessed permanently.

Clinical observation on the acupuncture treatment in patients with urinary retention after radical hysterectomy

OBJECTIVE

To observe the acupuncture therapy effect on the urinary retention after radical: hysterectomy. METHODS METHODS: Eighty cases of urinary retention after radical hysterectomy were randomly assigned to: the treatment group and control group according to the random number table method, 40 cases in each group. From the 15th day post operation, the patients in the two groups started to be treated and 7 days as a course with 5 days treatment and 2 days interval. The treatment group applied acupuncture with modalities of common needling on Zusanli (ST36) bilaterally, electroacupuncture on Sanyinjiao (SP6), Shuidao (ST28), and Scalp Reproduction Area bilaterally, moxibustion on Shenque (CV8). The control group applied acupoint injection with vitamin B B12 12, and Sanyinjiao and Zusanli were selected. Take turns on both sides. The courses for the recovery, of bladder function and residual urine volume for those who had voluntary micturition more than 200 mL after the first and second course of treatment were compared between the two groups.

RESULTS

Within 1 course and 2: courses of treatment, the patients with bladder function recovery in the treatment group were 21 (21/40) and 36 (36/40), and those in the control group were 12 (12/40) and 29 (29/40), both with a significant difference (P<0.05). After the first course and second course, residual urine volume for those who had voluntary micturition more than 200 mL in the treatment group was 91.7 ± 17.5 mL and 93.5 ± 15.5 mL, in the control group 102.4 ± 13.7 mL and 102.5 ± 15.7 mL, both with a significant difference (P<0.05).

CONCLUSIONS

Combination of acupuncture: modalities was better than acupoint injection for the recovery of bladder function in urinary retention after radical hysterectomy. It would shorten the course of treatment and get a better recovery, decrease urinary retention cases of refractoriness, and extending the treatment could raise the healing rate of urinary retention.

The technique of robotic assisted laparoscopic surgery in gynaecology, its introduction into the clinical routine of a gynaecological department and the analysis of the perioperative courses - a German experience

OBJECTIVE

Robotic assisted surgery is an advancement on conventional laparoscopy. The first and single FDA-approved device is the da-Vinci™ system, which provides means to overcome the limitations of conventional laparoscopy. In Germany the use of the robotic system in gynaecology is at the threshold of a promising development. There is a wide spectrum of indications, such as simple and radical hysterectomies, including pelvic and paraaortic lymph node dissection. The introduction of the robotic system into the clinical routine is demonstrated.

MATERIAL AND METHODS

Robotic assisted laparoscopic interventions have been performed in the reporting hospital since April 2008. In the course of treatment of 172 cases, an increasing rise of complexity of surgical procedure has been achieved. The daVinci™ system is well adaptable in clinical routine. Hitherto, the clinical outcome has been favourable, higher-grade specific complications occurred very rarely. The short time advantages are a decrease of postoperative length of stay, a reduction of postinterventional need of analgetics and an overall accelerated period of recovery has been demonstrated compared to conventional abdominal procedures. It also shows that a drastic decrease of open conventional abdominal procedures concerning uterine pathologies appeared in the reporting department.

RESULTS

Perioperative advantages of robotic assisted laparoscopic interventions are, above all, the decrease of morbidity (concerning blood loss, need of analgetics, length of stay, etc.). Surgical advantages are the more complex applicability, improved precision, dexterity and vision (3D), a greater autonomy of the surgeon, a smaller learning curve and an increase of preparation consistent with the anatomical structures. In contrast, disadvantages concern an initial greater time investment, the potentially different management of complications, the limited applicability in multiquadrant surgery and the difficulty regarding cost coverage respective to recovery.

CONCLUSIONS

In conclusion, robotic assisted minimal invasive surgery has an enormous potential in gynaecology; by simplifying the essential surgical procedure. The advantages of this technique will be approachability for a majority of gynaecological patients. The feasibility of a multitude of gynaecological surgical interventions has already been approved partially in a small number of cases. The upcoming challenge now is to verify the short and long term advantages of robotic surgery in prospective trials, especially concerning gynaecological oncology.

The twenty-first century role of Piver-Rutledge type III radical hysterectomy and FIGO stage IA, IB1, and IB2 cervical cancer in the era of robotic surgery: a personal perspective

Type III radical hysterectomy reported in 1974 by Piver, Rutledge, and Smith is considered worldwide by many as the standard surgical therapy for invasive cervical carcinoma stage IB and IIA. With the increasing number of robotic surgeries being performed for early stage cervical cancer worldwide, the purpose of the paper is to present our personal perspective of the 21st century role of Piver-Rutledge type III radical hysterectomy for stage IB cervical cancer in the era of robotic surgery using the da Vinci robot.

Asian society of gynecologic oncology workshop 2010

This workshop was held on July 31-August 1, 2010 and was organized to promote the academic environment and to enhance the communication among Asian countries prior to the 2nd biennial meeting of Australian Society of Gynaecologic Oncologists (ASGO), which will be held on November 3-5, 2011. We summarized the whole contents presented at the workshop. Regarding cervical cancer screening in Asia, particularly in low resource settings, and an update on human papillomavirus (HPV) vaccination was described for prevention and radical surgery overview, fertility sparing and less radical surgery, nerve sparing radical surgery and primary chemoradiotherapy in locally advanced cervical cancer, were discussed for management. As to surgical techniques, nerve sparing radical hysterectomy, optimal staging in early ovarian cancer, laparoscopic radical hysterectomy, one-port surgery and robotic surgery were introduced. After three topics of endometrial cancer, laparoscopic surgery versus open surgery, role of lymphadenectomy and fertility sparing treatment, there was a special additional time for clinical trials in Asia. Finally, chemotherapy including neo-adjuvant chemotherapy, optimal surgical management, and the basis of targeted therapy in ovarian cancer were presented.