Complications of laparoscopic radical hysterectomy and lymphadenectomy for invasive cervical cancer: experience based on 317 procedures

Intraoperative frozen pathology exam of Common iliac lymph nodes and Para-Aortic lymphadenectomy on the prognosis and quality of life for patients with IB2-IIA2 Cervical Cancer: trial protocol for a randomized controlled trial (C-PACC trial)

BACKGROUND

The impact of para-aortic lymphadenectomy (PALD) on prognosis and quality of life (QoL) for IB2-IIA2 cervical cancer patients remain controversial. And whether intraoperative frozen pathology exam on common iliac lymph nodes could help predict para-aortic lymph node (PALN) metastasis was unanswered with high-level evidence.

METHODS

A multi-center, randomized controlled study is intended to investigate the effect of PALD on the prognosis and QoL in cervical cancer patients and to assess the value of intraoperative frozen pathological evaluation of common iliac nodes metastasis for the prediction of PALN metastasis. After choosing whether to receive intraoperative frozen pathological examination of bilateral common iliac lymph nodes, eligible patients will be randomly assigned (1:1) to receive PALD or not. The primary end point is 2-year progression-free survival (PFS). The secondary end points include 5-year PFS, 2-year overall survival (OS), 5-year OS, adverse events (AEs) caused by PALD, AEs caused by radiotherapy and QoL. A total of 728 patients will be enrolled from 8 hospitals in China within 3-year period and followed up for 5 years.

TRIAL REGISTRATION

Chinese Clinical Trial Register Identifier: ChiCTR2000035668.

Systematic review of urological injury during caesarean section and hysterectomy

INTRODUCTION AND HYPOTHESIS

We aim to review iatrogenic bladder and ureteric injuries sustained during caesarean section and hysterectomy.

METHODS

A search of Cochrane, Embase, Medline and grey literature was performed using methods pre-published on PROSPERO. Eligible studies described iatrogenic bladder or ureter injury rates during caesarean section or hysterectomy. The 15 largest studies were included for each procedure sub-type and meta-analyses performed. The primary outcome was injury incidence. Secondary outcomes were risk factors and preventative measures.

RESULTS

Ninety-six eligible studies were identified, representing 1,741,894 women. Amongst women undergoing caesarean section, weighted pooled rates of bladder or ureteric injury per 100,000 procedures were 267 or 9 events respectively. Injury rates during hysterectomy varied by approach and pathological condition. Weighted pooled mean rates for bladder injury were 212-997 events per 100,000 procedures for all approaches (open, vaginal, laparoscopic, laparoscopically assisted vaginal and robot assisted) and all pathological conditions (benign, malignant, any), except for open peripartum hysterectomy (6,279 events) and laparoscopic hysterectomy for malignancy (1,553 events). Similarly, weighted pooled mean rates for ureteric injury were 9-577 events per 100,000 procedures for all hysterectomy approaches and pathologies, except for open peripartum hysterectomy (666 events) and laparoscopic hysterectomy for malignancy (814 events). Surgeon inexperience was the prime risk factor for injury, and improved anatomical knowledge the leading preventative strategy.

CONCLUSIONS

Caesarean section and most types of hysterectomy carry low rates of urological injury. Obstetricians and gynaecologists should counsel the patient for her individual risk of injury, prospectively establish risk factors and implement preventative strategies.

Urologic Complication after Laparoscopic Hysterectomy in Gynecology Oncology: A Single-Center Analysis and Narrative Review of the Literature

Background and Objectives: Minimally invasive surgery (MIS) has recently increased its application in the treatment of gynecological malignancies. Despite technological and surgical advances, urologic complications (UC) are still the main concern in gynecology surgery. Current literature reports a wide range of urinary tract injuries, and consistent scientific evidence is still lacking or dated. This study aims to report a large single-center experience of urinary complications during laparoscopic hysterectomy for gynecologic oncologic disease. Materials and Methods: All patients who underwent laparoscopic hysterectomy for gynecologic malignancy at the Department of Medicine and Surgery of the University Hospital of Parma from 2017 to 2021 were retrospectively included. Women with endometrial cancer, cervical cancer, ovarian cancer, uterine sarcoma, or borderline ovarian tumors were included. Patients undergoing robotic surgery with incomplete anatomopathological data or patients lost during follow-up were excluded from the analysis. Intraoperative and postoperative UC were analyzed and ranked according to the Clavien-Dindo classification. Results: Two hundred-sixty patients were included in the study: 180 endometrial cancer, 18 cervical cancer, nine ovarian cancer, two uterine sarcomas, and 60 borderline ovarian tumors. Nine (3.5%) UCs were reported (five intraoperative and four postoperative complications). No anamnestic variables showed a statistical correlation with the surgical complication in the univariable analyses. C1 radical hysterectomy, a higher FIGO stage, and postoperative adjuvant treatment (p-value = 0.001, p-value = 0.046, and p-value = 0.046, respectively) were independent risk factors associated with the occurrence of UC. Conclusions: The urological complication rates in patients with oncological disease are relatively rare events in the expert hands of dedicated surgeons. Radical hysterectomy, FIGO stage, and adjuvant treatment are independent factors associated with urinary complications.

Three-Dimensional in Vivo Anatomical Study of Female Iliac Vein Variations

OBJECTIVE

To investigate female iliac vein variations by using the computed tomography angiography (CTA) three-dimensional (3 D) reconstruction technique.

METHODS

We retrospectively studied 1623 patients undergoing abdominal and pelvic CTA scanning for gynecological diseases from December 2009 to December 2018. Accurate digital 3 D models of the iliac vein were constructed using Mimics 19.0 software and used to study the morphology and variations. Variations in the common iliac vein (CIV), external iliac vein (EIV) and internal iliac vein (IIV) were classified as type I, abnormal number of veins; type II, abnormal communicating branches; or type III, other variations.

RESULTS

The overall variation rates of the iliac vein and CIV were 51.57% (837/1623) and 20.33% (330/1623), respectively. The main type of CIV variation was type II. The main type I CIV variation was the absence of the CIV (98.15%), which mostly occurred on the right side (64.81%, 35/54). Type II CIV variation was the most common, with abnormal communicating branches between the left CIV and right IIV (81.78%, 211/258). The overall variation rates of the EIV and IIV were 36.66% (595/1623) and 49.60% (805/1623), respectively, mainly on the right side. The main type of variation was type I. Among them, the division of the IIV into two branches plus convergence with the ipsilateral EIV was the most common (22.98%, 373/1623).

CONCLUSION

In this study, approximately half of the patients had iliac vein variations. The preoperative identification of iliac vein variation may reduce vascular injury in pelvic surgery.

The incidence of urologic complications requiring urologic procedure in radical hysterectomy and difference between abdominal radical hysterectomy and laparoscopic radical hysterectomy

Objective

To evaluate the incidence of urologic complications requiring a urologic procedure during the perioperative period and compare the differences between abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH).

Methods

We identified all Korean women who underwent radical hysterectomy (RH) between January 2006 and December 2019 using the National Health Insurance Service database. Complications requiring surgical intervention-based urologic procedures between ARH and LRH were investigated.

Results

A total of 12,068 patients were classified into the ARH group and 8,837 patients were classified into the LRH group. Urologic complications requiring urologic procedures occurred in 1,546 of 20,905 patients (7.40%) who underwent RH. The most common urologic procedure was double-J insertion (R326, 5.18%), followed by bladder repair (R3550, 0.90%). There was no significant difference in urologic complications requiring urologic procedures between the ARH and LRH groups (odds ratio [OR]=1.027; 95% confidence interval [CI]=0.925–1.141; p=0.612). The incidence of bladder repair (R3550) was significantly higher in patients who underwent LRH (OR=1.620; 95% CI=1.220–2.171; p<0.001). Urologic complications requiring urologic procedures were statistically higher in the LRH group during the first half (OR=1.446; 95% CI=1.240–1.685; p<0.001), but more in the ARH group during the second half (OR=0.696; 95% CI=0.602–0.804; p<0.001) of the study period.

Conclusion

There was no difference of urologic complications between ARH and LRH with regard to urologic procedures. The incidence of urologic procedures decreases with time in patients who underwent LRH.

Previous studies have been insufficient to detect clinically significant difference in urologic complications between abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH). It is clinically more important to evaluate urologic complications that require urologic procedures rather than urologic complications alone. The incidence of urologic complications requiring urologic procedures related to radical hysterectomy was evaluated using data from the National Health Insurance Service. There was no difference in urologic complications between ARH and LRH.

A retrospective assessment of the safety and efficacy of laparoscopic radical hysterectomy in Japan during the early years following its introduction: a Japanese Gynecologic Oncology Group study (JGOG1081S)

OBJECTIVE

To evaluate the safety and efficacy of laparoscopic radical hysterectomy (LRH) for cervical cancer, in terms of morbidity and short-term oncologic outcome following LRH's introduction into Japan.

METHODS

We conducted a retrospective analysis of patients with early-stage cervical cancer (FIGO staging IA2, IB1, and IIA1) who underwent LRH from Dec 2014 to Dec 2016. We assessed the morbidity, overall survival (OS) and recurrence-free survival (RFS), and prognostic factors for RFS.

RESULTS

A total of 251 patients were included from 22 facilities across Japan. There were 8 cases of stage IA2 cervical cancer, 226 of IB1, and 17 of IIA1. The median operating time was 343 min and the median blood loss was 190 ml. Two patients (0.8%) had a postoperative complication with a Clavien-Dindo classification of grade 3 or higher. After a median follow-up time of 15.6 months, the 2-year RFS was 87.4%, and the 2-year OS was 97.8%. When the 2-year RFS rate was compared with whether the patient pathologically had tumors of less than 2 cm, versus 2 cm or more, the RFS was 95.8% and 80.4%, respectively. Multivariate analysis found that tumor size and the route of lymph node removal were independent prognostic factors for recurrence.

CONCLUSION

When LRH was first introduced into Japan, we found that the route of lymph node removal was an independent prognostic factor for recurrence in addition to large tumors (≥ 2 cm). Our results suggest that prognosis may be secured by paying attention to the lymph node removal route.

Concurrent Learning Curves of 3-Dimensional and Robotic-Assisted Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer Using 2-Dimensional Laparoscopic Radical Hysterectomy as a Benchmark: A Single Surgeon's Experience

Background

For early-stage cervical cancers, radical hysterectomy (RH) with pelvic lymphadenectomy has been the standard care. This study compared the learning curves and intra-, peri-, and post-operative outcomes for 3-dimensional laparoscopic RH (3D-LRH) and robotic-assisted (RA)-LRH by a surgeon highly skilled in 2-dimensional (2D)-LRH for treatment of early-stage cervical cancer.

Material/Methods

Two hundred and thirty-nine patients with early-stage cervical cancer (FIGO stage: Ia2–IIa2) admitted to Shanghai Obstetrics and Gynecology Hospital, Fudan University were recruited into this prospective study: 54, 85, and 100 patients underwent 2D-, 3D-, and RA-LRH, respectively and were followed up. Patients’ demographic, clinical, and operative information was retrieved and compared. CUSUM (cumulative summation) analysis using a benchmark derived from previously performed 2D-LRHs.

Results

Both 3D- and RA-LRH had a steep learning curve. 3D-LRH was superior to 2D- and RA-LRH in terms of significantly shorter operating time. For all approaches, the operating time was associated with the uterus size of the patient and was not affected by other parameters. All approaches of LRH yielded comparable radicality and operative results other than operative time.

Conclusions

Both 3D- and RA-LRH approaches had similar radicality, and intra-operative and post-operative complication rates, however, 3D-LRH had the shortest operating time and lowest amount of blood loss. After reaching proficiency, RA-LRH had comparable operating time with that of 2D-LRH, and might be even shorter in cases where surgeon has acquired more experience. In countries where labor costs are low; 3D-LRH might be preferable to 2D- and RA-LRH for early-stage cervical cancer.

Morbidity after surgical management of cervical cancer in low and middle income countries: A systematic review and meta-analysis

OBJECTIVE

To investigate morbidity for patients after the primary surgical management of cervical cancer in low and middle-income countries (LMIC).

METHODS

The Pubmed, Cochrane, the Cochrane Central Register of Controlled Trials, Embase, LILACS and CINAHL were searched for published studies from 1st Jan 2000 to 30th June 2017 reporting outcomes of surgical management of cervical cancer in LMIC. Random-effects meta-analytical models were used to calculate pooled estimates of surgical complications including blood transfusions, ureteric, bladder, bowel, vascular and nerve injury, fistulae and thromboembolic events. Secondary outcomes included five-year progression free (PFS) and overall survival (OS).

FINDINGS

Data were available for 46 studies, including 10,847 patients from 11 middle income countries. Pooled estimates were: blood transfusion 29% (95%CI 0.19-0.41, P = 0.00, I2 = 97.81), nerve injury 1% (95%CI 0.00-0.03, I2 77.80, P = 0.00), bowel injury, 0.5% (95%CI 0.01-0.01, I2 = 0.00, P = 0.77), bladder injury 1% (95%CI 0.01-0.02, P = 0.10, I2 = 32.2), ureteric injury 1% (95%CI 0.01-0.01, I2 0.00, P = 0.64), vascular injury 2% (95% CI 0.01-0.03, I2 60.22, P = 0.00), fistula 2% (95%CI 0.01-0.03, I2 = 77.32, P = 0.00,), pulmonary embolism 0.4% (95%CI 0.00-0.01, I2 26.69, P = 0.25), and infection 8% (95%CI 0.04-0.12, I2 95.72, P = 0.00). 5-year PFS was 83% for laparotomy, 84% for laparoscopy and OS was 85% for laparotomy cases and 80% for laparoscopy.

CONCLUSION

This is the first systematic review and meta-analysis of surgical morbidity in cervical cancer in LMIC, which highlights the limitations of the current data and provides a benchmark for future health services research and policy implementation.

Anatomical Variations of Iliac Vein Tributaries and Their Clinical Implications During Complex Pelvic Surgeries

BACKGROUND

During high sacrectomies and lateral pelvic compartment exenterations, isolating the external and internal iliac veins within the presacral area is crucial to avoid inadvertent injury and severe hemorrhage. Anatomical variations of external iliac vein tributaries have not been previously described, whereas multiple classifications of internal iliac vein tributaries exist.

OBJECTIVE

We sought to clarify the iliac venous system anatomy using soft-embalmed cadavers.

DESIGN

This is a descriptive study.

SETTINGS

This study was conducted in Chulalongkorn University, Thailand.

PATIENTS

We examined 40 iliac venous systems from 20 human cadavers (10 males, 10 females).

INTERVENTIONS

Blue resin dye infused into the inferior vena cava highlighted the iliac venous system, which was meticulously dissected and traced to their draining organs.

MAIN OUTCOME MEASURES

Iliac vein tributaries and their valvular system were documented and analyzed.

RESULTS

The external iliac vein classically receives 2 tributaries (inferior epigastric and deep circumflex iliac) near the inguinal ligament. However, external iliac vein tributaries in the presacral area were found in 20 venous systems among 15 cadavers (75%). The mean diameter of each tributary was 4.0 ± 0.35 mm, with 72% arising laterally. We propose a simplified classification for internal iliac vein variations: pattern 1 in 12 cadavers (60%) where a single internal iliac vein joins a single external iliac vein to drain into the common iliac vein; pattern 2 in 7 cadavers (35%) where the internal iliac vein is duplicated; and pattern 3 in 1 cadaver (5%) where bilateral internal iliac veins drain into a common trunk before joining the common iliac vein bifurcation.

LIMITATIONS

This study is limited by the number of cadavers included.

CONCLUSIONS

A comprehensive understanding of previously unreported highly prevalent external iliac vein tributaries in the presacral region is vital during complex pelvic surgery. A simplified classification of internal iliac vein variations is proposed. See Video Abstract at http://links.lww.com/DCR/A900.

Reconstruction of three-dimensional vascular models for lymphadenectomy before surgery

Introduction: A three-dimensional (3D) model of the pelvic vessels was reconstructed before surgery to aid in the understanding of the individual anatomy and help guide lymphadenectomy performance.Material and methods: Thirty patients with early-stage cervical cancer who were scheduled for lymphadenectomy at Nanfang Hospital, Southern Medical University from January 2017 to June 2017 were included. Three-dimensional models of the pelvic vessels were obtained.Results: All 3D models of the 30 patients were reconstructed successfully and were consistent with the operative findings.The most common structural types posterior to the common iliac artery (CIA) and CIA bifurcation (CIAB) were non-vessel structures (23/30 patients) and the common iliac vein (CIV) (27/30); these were observed separately on the left pelvic vein. The confluence of common iliac vein (CCIV) (29/30) and CIV (20/30) were most commonly observed posterior to the CIA and CIAB; these were observed separately on the right pelvic vein. Venous abnormalities were identified in 15 patients. There were variants in venous confluence shown to be homolateral to the CIV (2/15) and contralateral to the CIV (2/15) and CCIV (4/15).Conclusions: Three-dimensional models of the pelvic vessels can provide information on individual anatomy features that can help guide lymphadenectomy performance.

Systematic Review of Topical Hemostatic Agent Use in Minimally Invasive Gynecologic Surgery

Background and Objectives:

To perform a systematic review of articles evaluating hemostatic effectiveness and peri-operative outcomes when topical hemostatic agents (HA) are used in minimally invasive gynecologic surgeries (MIGS) for benign conditions.

Methods:

Studies published through March 31, 2017 were retrieved through PubMed, EMBASE, Cochrane, and ClinicalTrials.gov to identify all eligible studies. No studies were excluded based on publish date. All comparative studies or case series with >10 participants reporting use of at least one topical HA in MIGS for benign conditions were included as long as full-text articles were available and written in English. Studies were excluded if surgery was done for malignancy or completed via an open approach. Articles that included multiple surgical subspecialties were excluded if data related to MIGS was unable to be isolated. Evaluation for eligibility and data extraction was performed by three independent reviewers. Quality of evidence was also assessed by each reviewer.

Results:

From 132 articles, a total of 8 studies were included in this systematic review. We found that use of fibrin sealant decreased time to hemostasis, postoperative hemoglobin drop, and estimated blood loss (EBL) compared with bipolar energy and reduced the overall operative time in laparoscopic myomectomy. When fibrin sealant use at time of myomectomy was compared to bipolar energy there was no significant difference in the rate of postoperative complications. Furthermore, there was less of a decrease in anti-Mullerian hormone (AMH) level when a thrombin-gelatin matrix was used compared to bipolar energy on ovarian tissue.

Conclusion:

Application of topical HA in MIGS can reduce operative time, blood loss, and ameliorate damage to ovarian function. However, more data needs to be gathered for use of HA during different types of gynecologic procedures (adnexal surgery, myomectomy, and hysterectomy) to provide better quality evidence to guide their use.

Impact of hospital care volume on clinical outcomes of laparoscopic radical hysterectomy for cervical cancer: A systematic review and meta-analysis

BACKGROUND

In cervical cancer, the impact of hospital volume of laparoscopic radical hysterectomy (LRH) has not been investigated systematically as in ovarian cancer.The aim of this study was to investigate the impact of hospital care volume of LRH on treatment outcomes of patients with cervical cancer.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched with the terms "cervical cancer," "radical hysterectomy," and "laparoscopy." The selection criteria included studies presenting operative outcomes and/or perioperative complications of LRH from high-volume hospitals (HVHs) (≥15 cases/year) and low-volume hospitals (LVHs) (<15 cases/year). Fifty-nine studies including 4367 cases were selected. Linear regression analysis weighted by the average annual case number in each study was performed to evaluate differences between the groups.

RESULTS

In HVH, a higher number of lymph nodes (24.5 vs 21.1; P = .037) were retrieved by LRH in older women (48.4 vs 44.5 years; P = .010) with tendencies of shorter operation time (224.4 vs 256.4 minutes; P = .096) and less blood loss (253.1 vs 322.2 mL; P = .080). Compared with LVH, HVH had fewer patients with stage IA disease (13.8 vs 24.4%; P = .003) and more patients with stage IIA disease (15.3 vs 7.1%; P = .052) with comparable 5-year overall survival (93.1 vs 88.6%; P = .112).

CONCLUSION

HVH is a prognostic factor for operative outcome and perioperative complications in patients with cervical cancer undergoing LRH. The exact effect of hospital volume on survival outcome needs to be evaluated.

A collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: A randomized clinical trial

OBJECTIVE

To evaluate the efficacy of a collagen-fibrin patch for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies.

METHODS

In a multicenter, randomized, clinical trial, 164 women with pelvic lymphadenectomy were allocated either to bilateral pelvic application of two collagen-fibrin patches or no intervention. Main outcome was efficacy, defined as reduction of symptomatic lymphocele rate diagnosed within four weeks after surgery. Secondary outcomes were asymptomatic lymphoceles and subsequent interventions. Sample size was based on the assumption that application of a collagen-fibrin patch reduces the prevalence of symptomatic lymphoceles by at least 66%. The study was single-blinded, i.e., patients and primary outcome assessors, but not surgeons, were blinded to the treatment allocation.

RESULTS

A total of 75 women were randomized to the intervention and 89 to the control group. All women received the allocated intervention. In total, 42 (27.4%) lymphoceles and 8 (5.2%) symptomatic lymphoceles were observed. Symptomatic lymphoceles were observed in 5/68 (7.4%) women in the intervention group and 3/85 (3.5%) women in the control group (p = 0.47). Asymptomatic lymphoceles were observed in 16 (23.5%) women in the intervention group compared to 18 (21.2%) in the control group (p = 0.85). In a multivariate logistic regression model, no independent risk factor for the development of a symptomatic lymphocele was ascertained.

DISCUSSION

Intraoperative application of collagen-fibrin patches to the pelvic side walls does not reduce the incidence of symptomatic lymphoceles in women with gynecologic malignancies undergoing pelvic lymphadenectomy.

Long-Term Oncological Outcomes After Laparoscopic Versus Abdominal Radical Hysterectomy in Stage IA2 to IIA2 Cervical Cancer: A Matched Cohort Study

OBJECTIVE

The aim of the study was to investigate the long-term oncological outcomes of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for treatment of stage IA2 to IIA2 cervical cancer.

METHODS

We matched stage IA2 to IIA2 cervical cancer patients with known risk factors for recurrence who underwent ARH or LRH.

RESULTS

After matching, a total of 203 patient pairs (LRH-ARH) were included. The LRH and ARH group had similar 5-year recurrence-free survival (RFS) rates (91.3% vs 90.4%, P = 0.83) and overall survival (OS) rates (93.2% vs 92.1%, P = 0.94). Patients with different tumor size (≤2, 2-4, >4 cm) had similar 5-year OS and RFS. Even in patients with pelvic lymph node metastasis, the 5-year RFS (69.20% vs 69.20%, P = 0.87) and OS (77.4% vs 76.3%, P = 0.83) did not differ statistically between the 2 groups. The LRH and ARH group had similar mean time to recurrence (16.29 vs 22.15 months, P = 0.68) and pattern of recurrence (P = 0.63). Compared with ARH, LRH resulted in significantly shorter operating time, less blood loss, and shorter hospital stay. The intraoperative complications rate was similar between the 2 groups (P = 0.72). The rate of postoperative complications was significantly lower in the LRH group than in the ARH group (P = 0.004).

CONCLUSIONS

Laparoscopic radical hysterectomy was associated with fewer operating time, blood loss, postoperative complication, and earlier recovery. Laparoscopic radical hysterectomy is an oncologically safe alternative to ARH.

Distribution of iliac veins posterior to the common iliac artery bifurcation related to pelvic lymphadenectomy: A digital in vivo anatomical study of 442 Chinese females

OBJECTIVES

To investigate the distribution of iliac veins posterior to common iliac artery bifurcation (CIAB) for pelvic lymphadenectomy.

METHODS

After IRB approval was obtained, computer tomography angiography data of 442 female pelvises were acquired. After vascular three-dimensional (3D) reconstructions, the structural types, frequencies and diameters of iliac veins immediately posterior to CIAB were investigated and measured. To quantify iliac vein courses, linear distances and their distances on sagittal, coronal and vertical axes from CIAB to external/internal iliac veins confluence (EIIVC) were geometrically measured.

RESULTS

There were five structural types of iliac veins distribution immediately posterior to CIAB: common iliac vein (CIV, 13.8%), no occurrence of great vein (N, 71.27%, 0), EIIVC (1.58%) and external iliac vein (EIV, 13.35%) on the left side, while confluence of common iliac veins (CCIV, 8.82%), CIV (77.38%), N (1.58%, 0), EIIVC (6.11%), and EIV (6.11%) on right. The venous diameters immediately posterior to CIAB in "CCIV", "CIV" and "EIIVC" were significantly larger than that in "EIV" (P<0.05). Their linear distances and their distances on each axis from CIAB to external/internal iliac veins confluence (EIIVC) from CIAB to EIIVC were obtained.

CONCLUSIONS

In this study, we presented new distribution of iliac veins posterior to CIAB, including structural types, frequencies, venous diameters immediately posterior to CIAB, and their quantified courses from CIAB to EIIVC. It could help surgeons reduce the risk of vascular injury, hemorrhage or transfusion in pelvic lymphadenectomy.

Utility of an Internal Retractor (EndoGrab) for the Management of the Vesicouterine Ligament during Laparoscopic Radical Hysterectomy

BACKGROUND/AIMS

The study aims to prevent serious urologic injury during a radical hysterectomy; we propose that one of the most important procedural steps is the careful management of the vesicouterine ligament (VUL).

PATIENTS AND METHODS

Between January 2013 and October 2014, we used a novel internal retractor in 17 patients undergoing a laparoscopic radical hysterectomy (LRH) for early-stage cervical cancer to obtain and secure a better surgical view. For management of the VUL during the laparoscopic procedure, we routinely used an internal retractor (EndoGrab; Virtual Ports, Misgav, Israel) and vessel tape to reposition the ureter in a safe lateral-caudal direction.

RESULTS

Using an EndoGrab, we were easily able to reproduce a suitable surgical view that simulated the one obtained by an abdominal route for radical hysterectomy. Using this improved laparoscopic procedure, we completed radical hysterectomies in all 17 cases without a ureteral injury complication.

CONCLUSION

Our modified method using an EndoGrab is effective for the prevention of ureteral injury during a LRH, and its ease of use makes it suitable even for those surgeons early in their laparoscopic learning curve.

Early postoperative bladder training in patients submitted to radical hysterectomy: is it still necessary? A randomized trial

OBJECTIVES

To evaluate the role of bladder training during postoperative hospital stay in patients submitted to nerve-sparing radical hysterectomy, and to identify any clinical or surgical factor associated with postoperative bladder dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

Parallel group randomized single institution trial, on gynaecologic malignancies patients conducted in Catholic University of Sacred Heart Rome, between April 2009 and November 2011. Randomization was on 1:1, using a block randomized computer-generated list.

INTERVENTIONS

Patients underwent Querleu-Morrow type B2 or C1 radical hysterectomy. After 2 days from surgery, patients were randomized to perform or not bladder training (scheduled clamping and unclamping of the trans-urethral catheter every three hours). Main outcome measures Necessity and duration of clean intermittent self catheterization.

RESULTS

Randomized participants were 111 women (bladder training arm n = 55; control arm n = 56). A total of 22 women (19.8%) required clean intermittent self catheterization, equally distributed in the two arms. At univariate analysis, only the type of radical hysterectomy was significantly associated with need of clean intermittent self catheterization (type C1 vs. type B2; p = 0.013). At univariate analysis, duration of clean intermittent self-catheterization was not associated with age, BMI, type of hysterectomy and of neo-adjuvant treatment.

CONCLUSIONS

Functional bladder disfunctions are the most common long-term complications following radical hysterectomy. Systematic postoperative bladder training following nerve-sparing radical hysterectomy does not influence the rate of urinary retention or re-admission for bladder catheterization.

A collagen-fibrin patch (Tachosil®) for the prevention of symptomatic lymphoceles after pelvic lymphadenectomy in women with gynecologic malignancies: a randomized clinical trial

Background

Lymphoceles are a common complication after pelvic lymphadenectomy in women with gynecologic malignancies. Although typically asymptomatic, lymphoceles can superinfect requiring medical or surgical intervention. A single center randomized controlled trial provided first evidence, that a collagen-fibrin patch (Tachosil®) is effective in the prevention of symptomatic lymphoceles after pelvic lymphadenectomy.

Methods/Design

We will perform a multicentre, blinded, randomized, controlled trial comprising 140 women with gynecologic malignancies undergoing pelvic lymphadenectomy. Women will be randomly allocated to Tachosil® application or no application. Primary outcome is efficacy, defined as lymphocele CTCAE 4.03 grade ≥2 within four weeks after surgery. Secondary outcomes are asymptomatic lymphocele verified by ultrasound, medical or surgical intervention. Assuming a two-sided 5% significance level, a power of 80%, and a drop out rate of 10%, a sample size of 68 patients per group was calculated to detect a 66% absolute decrease in symptomatic lymphoceles.

Discussion

We aim to provide further evidence for the efficacy of a collagen-fibrin patch in the prevention of symptomatic lymphoceles in women with gynecological malignancies undergoing pelvic lymphadenectomy.

Trial registration

This study is registered at ClinicalTrials.gov (NCT01470677, protocol ID: TACHO-1). This study is registered at the EudraCT database (EudraCT number: 2011-003115-34).

Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome

PURPOSE

The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls.

METHODS

One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs.

RESULTS

In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P < 0.001). Bladder function resumed sooner (P < 0.001), and patients were discharged earlier after VALRH (P < 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740).

CONCLUSION

VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach.

A cohort study evaluating paraaortic lymphadenectomy in endometrial cancer

The current study sought to assess the role of paraaortic lymphadenectomy (LNE) in females with endometrial cancer. A retrospective analysis of patients diagnosed with endometrial cancer of stage IA to II preoperatively, between 2009 and 2011 was conducted. Patients were included who had suffered from endometrial cancer without preoperative adjuvant therapy and who underwent hysterectomy plus systematic pelvic LNE and paraaortic LNE by laparoscopy or laparotomy. A total of 54 patients who underwent surgery for preoperative endometrial cancer were selected. All patients underwent LNE. The incidences of pelvic and paraaortic lymph node metastases were 11.1% (6/54) and 7.4% (4/54), with a total positive lymph node rate of 14.8% (8/54). In addition, among the 8 positive cases, 5 patients underwent laparotomy and 3 underwent laparoscopy; 3 cases were classified as stage I and 5 as stage II preoperatively. Of these, 7 patients were identified with pathology-related risk factors, including low differentiation or clear cell adenocarcinoma postoperatively. Discordance of pathological differentiation between the pre- and postoperative stages reached 57.1% (4/7). The results revealed the high occurrence of positive lymph nodes in endometrial cancer which demonstrate the importance of systematic LNE. Additonally, no severe complications were caused by LNE besides lymph cysts. In summary, it is neccesary to perform LNE, particularly the removal of the paraaortic lymph node, in patients with endometrial cancers in order to improve postoperative therapy. Laparoscopy has similar surgical effects as laparotomy, but has a number of advantages.

Vaginal-assisted laparoscopic radical hysterectomy: rationale, technique, results

The authors conclude that vaginal-assisted laparoscopic radical hysterectomy is an oncologic viable alternative to abdominal radical hysterectomy, laparoscopic-assisted radical vaginal hysterectomy, totally laparoscopic radical hysterectomy, and robotic radical hysterectomy.

Objective:

Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications.

Methods:

The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumor-adapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin.

Results:

All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively.

Conclusion:

VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with early-stage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.

Urologic complications of laparoscopic radical hysterectomy and lymphadenectomy

INTRODUCTION AND HYPOTHESIS

The purpose of this study was to evaluate the intra- and postoperative urologic complications and management in patients with cervical or endometrial cancer treated with laparoscopic radical hysterectomy and lymphadenectomy.

METHODS

We retrospectively reviewed the medical records of 146 patients with cervical or endometrial cancer who underwent total laparoscopic radical hysterectomy with lymphadenectomy between August 2002 and April 2011. The intra- and postoperative urologic complications were analyzed.

RESULTS

Double ureteral stents were inserted prophylactically in 13 patients (8.9 %), 2 of whom had postoperative urologic complications. Nine patients (6.2 %) had postoperative urologic complications. Of four patients with ureterovaginal fistulas, two were treated conservatively with cystoscopic placement of ureteral stents and two underwent ureteroneocystostomies. Vesicovaginal fistulas occurred in two patients, both of whom underwent vesicovaginal fistula repairs. One patient noted to have a bladder injury intraoperatively had a laparoscopic repair, and one patient noted to have a ureteral injury postoperatively was treated conservatively with cystoscopic placement of ureteral stents.

CONCLUSIONS

Iatrogenic lower urinary tract injuries during laparoscopic radical hysterectomy are relatively common complications. Intraoperative prophylactic ureteral stent insertion and the early detection of urologic complications postoperatively is advised for patients who undergo laparoscopic radical hysterectomies.

Surgical and Oncological Outcome of Total Laparoscopic Radical Hysterectomy in Obese Women With Early-Stage Cervical Cancer

Objective

To evaluate the clinical experience of the total laparoscopic radical hysterectomy (TLRH) for the surgical management of cervical cancer in obese (body mass index [BMI] >30 kg/m2) and nonobese (BMI <30 kg/m2) women.

Methods

Data were collected prospectively on intraoperative and postoperative parameters and complications for all women undergoing a TLRH for cervical cancer. Patients were classified as obese, BMI >30 kg/m2, or nonobese, BMI <30 kg/m2. Assessment of surgical radicality was made by comparing the excision specimens in the 2 groups with a cohort of open radical hysterectomy cases performed before the introduction of the TLRH.

Results

A total of 58 women underwent a TLRH; 15 (25.9%) were obese and 43 (74.1%) were in the nonobese group. There was no significant difference in intraoperative blood loss or median duration of surgery between the obese and nonobese groups. The median hospital stay in both groups was 3 days (range, 2–13 days). Four cases were converted to laparotomy (7%); all were in the nonobese group. Postoperatively, 3 patients developed ischemic ureterovaginal fistulae (5%) between days 5 and 7 after surgery; all were in the nonobese group. There was no significant difference in the parametrial length, maximum vaginal cuff length, and number of lymph nodes excised between the 2 groups. To date, there has been one recurrence during the median follow-up period of 19 months (range, 3–42 months). She belonged to the nonobese group.

Conclusions

The TLRH is a surgically safe procedure for early-stage cervical cancer. Obesity did not adversely affect the performance of TLRH or the radicality of the excision. In obese women, TLRH should be the favored route of surgery for all women who require a radical hysterectomy owing to its favorable perioperative outcome and short hospital stay.

Laparoscopic hysterectomy in the treatment of endometrial cancer: NCI experience

BACKGROUND

The standard treatment for women with endometrial cancer is total abdominal hysterectomy and pelvic lymphadenectomy for surgical staging. Total laparoscopic radical hysterectomy (TLH) is an alternative approach providing surgical and patient related advantages to laparoscopy.

METHODS

Twenty female patients with early stage endometrial cancer were operated upon by TLH and pelvic lymphadenectomy, aiming to assess the safety and efficacy of TLH.

RESULTS

The mean operative time was 296.8 min conversion to laparotomy was done in one patient due to bleeding from the uterine vessels. The mean blood loss was 517.5 cc. The uterus was removed transvaginally in 18 patients (90%) and via a small Pfannenstiel incision in two patients (10%). The mean number of pelvic lymph nodes retrieval was 21.2. Postoperative bleeding occurred in one patient (5%) which necessitated exploration. One patient (5%) suffered a pulmonary embolism. Four patients (20%) developed pyrexia, and one patient (5%) suffered from a chest infection. One patient (5%) had wound infection. The mean hospital stay was 4.5 days (range 3-10).

CONCLUSION

TLH with pelvic lymphadenectomy is a safe and effective approach in the treatment of early endometrial carcinoma.

Twelve-year experience with laparoscopic radical hysterectomy and pelvic lymphadenectomy in cervical cancer

OBJECTIVES

This study aims to evaluate the morbidity, oncological outcome, and prognostic factors of cervical cancer patients treated with laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH).

METHODS

Patients with cervical cancer undergoing LRH at the First People's Hospital of Foshan between August 1998 and March 2010 were enrolled in this study. The medical records were reviewed.

RESULTS

A total of 240 patients were identified. According to FIGO stage, the number of patients with stage Ia2, Ib1, Ib2, IIa, and IIb was 2, 163, 34, 35, and 6, respectively. The conversion rate was 1.25%. Intraoperative and postoperative complications occurred in 7.08% and 9.16% patients, respectively. Other medical problems included 74 cases (30%) of bladder dysfunction. Excluding the lost cases, the median follow-up of 221 cases was 35 months, and 5-year survival rate for Ia2, Ib1, Ib2, IIa was 100%, 82%, 66%, 60%, respectively. Univariate analysis showed factors impacting the survival rate were FIGO stage>Ib1, non-squamous histologic type, deep cervical stromal invasion, and lymph node metastasis (P=0.027, 0.023, 0.007, 0.000). The Cox-proportional hazards regression analysis indicated that only lymph node metastasis (OR=3.827, P=0.000) was independent of poor prognostic factor. The 5-year survival rates in Ib1 were 88% with negative lymph nodes and 59% with positive lymph nodes (P=0.000).

CONCLUSIONS

Our data demonstrate that LRH can be performed in stage Ia2-Ib1 or less advanced node negative cervical cancer patients without compromising survival. The feasibility of LRH for more advanced patients needs further investigations.

Complications of laparoscopic radical hysterectomy and pelvic lymphadenectomy--experience of 117 patients

OBJECTIVE

To describe the combined surgical technique of laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH + LPL) for cervical cancers and summarize our experiences in prevention and treatment of complications, so as to provide strategies to prevent and appropriately manage the complications that may occur during these procedures.

METHODS

A retrospective study was conducted on LRH + LPL in 117 cases of cervical cancer with International Federation of Gynecology and Obstetrics stages Ib (n = 96) and II a (n = 21) from August 1998 to December 2006. The intraoperative and postoperative complications were analyzed.

RESULTS

The overall conversion rate was 1.7% (2/117). Four patients had vessel injuries, 3 of which were treated laparoscopically. One patient had a common iliac vein laceration that could not be controlled laparoscopically after failing to deal with the injured branch of common iliac vein. Cystotomy occurred in 5 patients. One case of stage IIa with a bladder laceration longer than 3 cm was converted to laparotomy during the early stages of the learning curve. The remaining 4 were managed laparoscopically. Postoperative complications occurred in 38.5% (n = 45) of the patients, including 38 patients with urinary retention who exhibited complete resolution within 6 months by intermittent training and catheterization, 4 with lymphocyst who underwent conservation treatment, 1 with ureteral fistula that was treated by cystoscopic placement of double-J ureteral stents, 1 with mild adynamic bowel obstruction who received conservative management, and 1 with vesicovaginal fistula that was closed by conservative treatment.

CONCLUSIONS

With the continuous skilled laparoscopic technology, mastering the tips of prevention, and treatment of complications, LRH + LPL will be widely performed in the future.

Robot-assisted surgery in gynaecology

Robotic surgery is the latest development in minimal invasive surgery. It provides superior visualisation and dexterity and therefore allows the surgeon to perform complex tasks that would exceed his/her abilities with conventional laparoscopy and would be associated with an increased morbidity if performed by laparotomy. Current evidence demonstrates the feasibility and safety of this technology in gynaecology. The costs of robotic surgery remain one of the main sources of controversy but are expected to come down with further developments of the technology. If evidence-based long-term outcome evaluations show the superiority of robotic surgery in comparison to conventional laparoscopic and open surgery, this technology will have a major impact on gynaecological surgery.

The outcome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: a prospective analysis of 295 patients

OBJECTIVES

Cervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy and transperitoneal approach for lymphadenectomy have become the standard techniques for invasive cervical cancer. We report the indications, techniques, results, and oncological outcome in a single center experience.

METHODS

Between February 2001 and June 2007 we performed laparoscopic radical hysterectomies for cervical cancer in 295 patients. Their initial techniques, operation data, complications, postoperative course, oncological outcome, and survival were evaluated.

RESULTS

Out of 295 procedures, 290 were successful. Para-aortic lymphadenectomy was performed in 156 patients (52.9%), and pelvic lymphadenectomy was performed in all 295 patients. The median blood loss was 230 mL (range, 50-1200 mL). The mean operation time was 162 min (range, 110-350), which included the learning curves of 3 surgeons. In 5 cases (1.7%), conversion to open surgery was necessary due to bleeding (3 cases), bowel injury (1 case), and hypercapnia (1 case). Other major intraoperative injuries occurred in 12 patients (4.1%). Positive lymph nodes were detected in 80 cases (27.1%), lymphovascular space invasion in 54 cases (18.3%), and surgical margins were negative for tumor in all patients. The mean hospital stay was 10.3 days. Postoperative complications occurred in 10.8% patients, ureterovaginal fistula in 5 cases, vesicovaginal fistula in 4, ureterostenosis in 3 cases, deep venous thrombosis in 9 cases, lymphocyst in 4 cases, lymphedema in 5 cases, and 1 case with trocar insertion site metastasis. Other medical problems included 47 cases (15.9%) of bladder dysfunction and 62 cases (21.0%) of rectum dysfunction or constipation. The median follow-up was 36.45 months (range, 8-76 months). Recurrences or metastasis occurred in 48 patients (16.3%). Of these patients, 43 (14.6%) have died of their disease, and 5 (1.7%) are alive with disease. The overall disease-free survival was 95.2% for Ia, 96.2% for Ib, 84.5% for IIa, 79.4% for IIb, 66.7% for IIIa, and 60.0% for IIIb.

CONCLUSION

Laparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2-IIb cervical carcinoma. With more experience it is envisaged that IIb stage patients can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available, our follow-up data for up to 76 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcome.

A comparison of urinary complications following total laparoscopic radical hysterectomy and laparoscopic pelvic lymphadenectomy to open abdominal surgery

OBJECTIVE

The objective of this study was to compare total laparoscopic radical hysterectomy (TLRH) and laparoscopic pelvic lymphadenectomy (LPS) to total abdominal radical hysterectomy (TARH) and pelvic lymphadenectomy (LPT) in terms of urinary tract lesions and postoperative urinary retention.

METHODS

Starting in 2004, we treated all early stage cervical cancer patients with TLRH and LPS. The control group for this analysis was a historical cohort of patients treated with TARH+LPT. Within the TLRH+LPS group, we assessed whether the width of parametrial tissue removed was a risk factor for urinary tract injuries or postoperative urinary retention.

RESULTS

Fifty women were included in the TLRH+LPS group and forty-eight were included in the TARH+LPT group. There were no conversions from laparoscopy to laparotomy. There was no statistically significant difference in intraoperative urinary complications between the groups. Four (8%) intraoperative urinary tract injuries in the LPS (3 cystotomies and 1 ureteral lesions all repaired laparoscopically) and 2 (4.2%) in the LPT group (2 cystotomies) occurred (p=0.68). Similarly, there was no statistically significant difference in postoperative urinary complications between groups. Urinary postoperative complications were: 1 (2%) ureterovaginal and 1 vesicovaginal fistulas, 1 delayed ureteric fistula in LPS group vs. 0 in LPT group (p=0.24). Urinary retention was complained by 7 (14%) and 7 (14.6%) patients in LPS and LPT groups respectively (p=1.00). The average width of parametrial tissue removed in the LPS group was 32.2+14.0 mm in patients with vs. 39.5+13.6 mm in patients without urinary complications (p=0.11).

CONCLUSIONS

A laparoscopic approach is comparable to the laparotomy in terms of urinary lesions and postoperative retention. The width of parametrium removed does not affect the risk of urinary lesions or postoperative retention.