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Kanno K, Yanai S, Masuda S, Ochi Y, Sawada M, Sakate S, Andou M. Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis. Arch Gynecol Obstet 2024; 310:1677-1685. [PMID: 39150505 DOI: 10.1007/s00404-024-07674-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 07/25/2024] [Indexed: 08/17/2024]
Abstract
PURPOSE Drug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE. METHODS We retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE. RESULTS Between the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22 min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49 ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2 days, p = 0.45) and perioperative complications with Clavien-Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery. CONCLUSION Compared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.
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Affiliation(s)
- Kiyoshi Kanno
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan.
| | - Shiori Yanai
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
| | - Sayaka Masuda
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
| | - Yoshifumi Ochi
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
| | - Mari Sawada
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
| | - Shintaro Sakate
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
| | - Masaaki Andou
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, 250 Bakuro-cho, Kurashiki, Okayama, 710-8522, Japan
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Kanno K, Yanai S, Sawada M, Sakate S, Andou M. Nerve-sparing surgery for deep lateral parametrial endometriosis. Fertil Steril 2022; 118:992-994. [PMID: 36171149 DOI: 10.1016/j.fertnstert.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 06/15/2022] [Accepted: 08/01/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVE Although dLPE is not overly rare, isolation of the autonomic nerves from dLPE cannot always be guaranteed. In patients with endometriosis lesions that are embedded in the deep parametrium, nerve-sparing techniques are no longer considered feasible, except for those with unilateral involvement. However, even one-sided radical parametrectomy may actually lead to bladder dysfunction, which seriously affects the quality of life. Therefore, the objective is to demonstrate the anatomical and technical highlights of nerve-sparing laparoscopic surgery for deep lateral parametrial endometriosis (dLPE). DESIGN Stepwise demonstration of this method with a narrated video footage. SETTING An urban general hospital. PATIENT(S) A 38-year-old woman, para 1, presented with a 5-year history of severe chronic pelvic and gluteal pain, all of which were resistant to pharmacotherapy. The patient showed no neurological disorders, such as bladder dysfunction. Magnetic resonance imaging revealed right ovarian endometrioma and hydrosalpinx with dLPE reaching the lateral pelvic wall. Based on the dermatome involved, we suspected that the main lesion causing gluteal pain was located around the second and third sacral roots. INTERVENTION(S) Laparoscopic excision of dLPE with a pelvic autonomic nerve-sparing technique, decompression of somatic nerves and preservation of all branches of the internal iliac vessels. Assessment of preserved tissue perfusion using indocyanine green. The procedure was performed using 8 steps, as follows: step 1, adhesiolysis and adnexal surgery; step 2, complete ureterolysis; step 3, identification and dissection of the hypogastric nerve and inferior hypogastric plexus with development of the pararectal space; step 4, dissection of the internal iliac vessels; step 5, identification and dissection of the sacral roots S2-S4 and the pelvic splanchnic nerves; step 6, complete removal of dLPE; step 7, hemostasis and assessment of tissue perfusion using indocyanine green; and step 8, application of barrier agents to prevent adhesion. Dissection of the pelvic nerves before dLPE excision revealed the relationship between the lesions and pelvic innervation, thereby reducing the risk of nerve injury, whether by minimizing the risk of neuropraxia or by allowing as many nerve fibers as possible to be spared in patients with some invasion of the pelvic nerve system. We considered even partial preservation of these nerves as beneficial to the resumption of pelvic organ functions. The step-by-step technique should help perform each stage of the surgery in a logical sequence, ensuring easy and safe completion of the procedure. MAIN OUTCOME MEASURE(S) Relief from severe pain, avoidance of postoperative morbidity (including intermittent self-catheterization). RESULT(S) The patient developed no perioperative complications, including postoperative bladder, rectal, or sexual dysfunctions. Pain was completely resolved. CONCLUSION(S) Nerve-sparing surgery is technically safe and feasible for selected patients with dLPE. Suitably tailored treatment should be provided for each individual based on both latest scientific evidence and life planning for the patient.
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Affiliation(s)
- Kiyoshi Kanno
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan.
| | - Shiori Yanai
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Mari Sawada
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Shintaro Sakate
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
| | - Masaaki Andou
- Department of Obstetrics and Gynecology, Kurashiki Medical Center, Okayama, Japan
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Komatsu H, Okawa M, Hikino K, Iida Y, Osaku D, Kudoh A, Chikumi J, Sato S, Oishi T, Harada T. A simplified procedure of nerve‐sparing radical hysterectomy. J Obstet Gynaecol Res 2022; 48:766-773. [DOI: 10.1111/jog.15154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 12/22/2021] [Accepted: 01/07/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Hiroaki Komatsu
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Masayo Okawa
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Kohei Hikino
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Yuki Iida
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Daiken Osaku
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Akiko Kudoh
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Jun Chikumi
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Shinya Sato
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Tetsuro Oishi
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
| | - Tasuku Harada
- Department of Obstetrics and Gynecology Tottori University School of Medicine Yonago Tottori Prefecture Japan
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Wang J, Sun L, Ni T, Huang Y, Wang L, Yuan J, Fan Q, Li Y, Wang Y. A practical method of using the anatomical space of the vesicouterine ligament for laparoscopic radical hysterectomy: a retrospective cohort study. J Int Med Res 2021; 48:300060520926857. [PMID: 32600083 PMCID: PMC7328497 DOI: 10.1177/0300060520926857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective To investigate the practicality of a new method using anatomical spaces for performing standard laparoscopic radical hysterectomy (LRH) without ureteral injury in patients with cervical cancer. Methods Clinicopathological characteristics and perioperative complications were retrospectively analysed in 440 patients with stages IB1 to IIB cervical cancer. The patients were assigned to two of the following groups: LRH by our method of using anatomical landmarks (anatomical space group, n = 217) and the traditional method (traditional group, n = 223). Results The mean operative duration and time of vesicouterine ligament (VUL) dissection were significantly shorter (173.87 ± 30.39 vs. 210.83 ± 44.55 minutes; 32.75 ± 7.23 vs. 43.48 ± 11.22 minutes), and blood loss was less in the anatomical space group compared with the traditional group. The rate of the intraoperative complication of ureteral injury was also significantly lower in the anatomical space group compared with the traditional group (0 vs. 5). Conclusions LRH by the anatomical method, using the axillary space and other potential spaces as anatomical landmarks, results in less blood loss and reduced ureteral injury compared with the traditional method. This method is safe and practical for separating the ureter from the VUL in patients with cervical cancer.
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Affiliation(s)
- Jing Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China.,Shanghai Key Laboratory of Embryo Original Disease, Shanghai, China
| | - Lulu Sun
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Department of Obstetrics and Gynecology, Shijiazhuang Obstetrics and Gynecology Hospital, Shijiazhuang, Hebei Province, China
| | - Ting Ni
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yong Huang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Lihua Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Jiangjing Yuan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Qiong Fan
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yuhong Li
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
| | - Yudong Wang
- Department of Gynecologic Oncology, The International Peace Maternity and Child Health Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Shanghai Municipal Key Clinical Specialty, Shanghai, China
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Zapardiel I, Kocian R, Köhler C, Klat J, Germanova A, Jacob A, Bajsova S, Böhmer G, Lay L, Gil-Ibañez B, Havelka P, Kipp B, Szewczyk G, Toth R, Staringer JC, De Santiago J, Coronado PJ, Poka R, Laky R, Luyckx M, Fastrez M, Dusek L, Hernandez A, Cibula D. Voiding recovery after radical parametrectomy in cervical cancer patients: An international prospective multicentre trial - SENTIX. Gynecol Oncol 2021; 160:729-734. [PMID: 33419610 DOI: 10.1016/j.ygyno.2020.12.018] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Accepted: 12/15/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Voiding dysfunctions represent a leading morbidity after radical hysterectomy performed in patients with early-stage cervical cancer. The aim of this study was to perform ad hoc analysis of factors influencing voiding recovery in SENTIX (SENTinel lymph node biopsy in cervIX cancer) trial. METHODS The SENTIX trial (47 sites, 18 countries) is a prospective study on sentinel lymph node biopsy without pelvic lymphadenectomy in patients with early-stage cervical cancer. Overall, the data of 300 patients were analysed. Voiding recovery was defined as the number of days from surgery to bladder catheter/epicystostomy removal or to post-voiding urine residuum ≤50 mL. RESULTS The median voiding recovery time was three days (5th-95th percentile: 0-21): 235 (78.3%) patients recovered in <7 days and 293 (97.7%) in <30 days. Only seven (2.3%) patients recovered after >30 days. In the multivariate analysis, only previous pregnancy (p = 0.033) and type of parametrectomy (p < 0.001) significantly influenced voiding recovery >7 days post-surgery. Type-B parametrectomy was associated with a higher risk of delayed voiding recovery than type-C1 (OR = 4.69; p = 0.023 vs. OR = 3.62; p = 0.052, respectively), followed by type-C2 (OR = 5.84; p = 0.011). Both previous pregnancy and type C2 parametrectomy independently prolonged time to voiding recovery by two days. CONCLUSIONS Time to voiding recovery is significantly related to previous pregnancy and type of parametrectomy but it is not influenced by surgical approach (open vs minimally invasive), age, or BMI. Type B parametrectomy, without direct visualisation of nerves, was associated with longer recovery than nerve-sparing type C1. Importantly, voiding dysfunctions after radical surgery are temporary, and the majority of the patients recover in less than 30 days, including patients after C2 parametrectomy.
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Affiliation(s)
- Ignacio Zapardiel
- Gynaecologic Oncology Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain.
| | - Roman Kocian
- Gynaecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, CEEGOG, Prague, Czech Republic
| | - Cristhardt Köhler
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - Jaroslav Klat
- Department of Obstetrics and Gynaecology, University Hospital Ostrava, Ostrava, Poruba, Czech Republic
| | - Anna Germanova
- Gynaecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, CEEGOG, Prague, Czech Republic
| | - Anna Jacob
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - Sylva Bajsova
- Department of Obstetrics and Gynaecology, University Hospital Ostrava, Ostrava, Poruba, Czech Republic
| | - Gerd Böhmer
- Department of Special Operative and Oncologic Gynaecology, Asklepios-Clinic Hamburg, Hamburg, Germany
| | - Laura Lay
- Department of Gynaecology, Institute of Oncology Angel H Roffo University of Bueno s Aires, Buenos Aires, Argentina
| | - Blanca Gil-Ibañez
- Unit of Gynaecological Oncology, Institute Clinic of Gynaecology, Obstetrics and Neonatology (ICGON), Hospital Clinic of Barcelona, Barcelona, Spain
| | - Pavel Havelka
- Department of Obstetrics and Gynaecology, Bata Hospital Zlin, Czech Republic, CEEGOG, Zlin, Czech Republic
| | - Barbara Kipp
- Department of Obstetrics and Gynaecology, Cantonal Hospital of Lucerne, Lucerne, Switzerland
| | - Grzegorz Szewczyk
- Department of Obstetrics and Gynaecology, Institute of Mother and Child, Warsaw, Poland
| | - Robert Toth
- Oncology Institute of East Slovakia, Košice, Slovakia
| | - Juan Carlos Staringer
- Department of Gynaecology and Obstetrics, Hospital Español de Buenos Aires, Buenos Aires, Argentina
| | | | - Pluvio J Coronado
- Departamento de Obstetricia y Ginecología, Hospital Clínico San Carlos, Madrid, Spain
| | - Robert Poka
- Institute of Obstetrics and Gynaecology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Rene Laky
- Gynaecology, Medical University of Graz, Graz, Austria
| | - Mathieu Luyckx
- Department of Gynaecology, Universite catholique de Louvain, Cliniques Universitaires St Luc, 1200, Brussels, Belgium
| | - Maxime Fastrez
- Department of Obstetrics and Gynaecology, St Pierre University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Ladislav Dusek
- Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Alicia Hernandez
- Gynaecologic Oncology Unit, La Paz University Hospital-IdiPAZ, Madrid, Spain
| | - David Cibula
- Gynaecologic Oncology Centre, Department of Obstetrics and Gynaecology, First Faculty of Medicine, Charles University and General University Hospital, CEEGOG, Prague, Czech Republic
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Gil-Moreno A, Carbonell-Socias M, Salicrú S, Bradbury M, García Á, Vergés R, Puig OP, Sánchez-Iglesias JL, Cabrera-Díaz S, de la Torre J, Gómez-Hidalgo NR, Pérez-Benavente A, Díaz-Feijoo B. Nerve-sparing versus non-nerve-sparing radical hysterectomy: surgical and long-term oncological outcomes. Oncotarget 2019; 10:4598-4608. [PMID: 31360307 PMCID: PMC6642047 DOI: 10.18632/oncotarget.27078] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 06/29/2019] [Indexed: 02/01/2023] Open
Abstract
Objectives There are controversies regarding the long-term oncological safety of preservation of pelvic innervation during radical hysterectomy (RH). This study aimed to analyze the feasibility and safety of nerve-sparing radical hysterectomy (NSRH) for cervical cancer compared with non-NSRH following 17 years of experience in a tertiary cancer referral center. Materials and Methods Between May 1999 and June 2016, all patients who underwent RH for cervical cancer were followed-up prospectively. Comparison analyses regarding surgical outcomes, complications, overall survival (OS), disease-free survival (DFS), and cancer-specific survival (CSS) were performed between patients treated with NSRH and non-NSRH. Results A total of 188 patients were included (113 non-NSRH and 75 NSRH). The median follow-up was 112 months. Estimated blood loss and hospital stay were all significantly lower in the NSRH group. Overall intraoperative complication rate (p = 0.02) and need for transfusion (p = 0.016) were lower in the NSRH group. There were no differences in the median operation time, OS, DFS, CSS, or recurrence rates between the NSRH and non-NSRH group. Conclusions Our study provides a wide perspective on the developments of nerve-sparing procedures for the management of women with early-stage cervical cancer. Our results suggest that NSRH is a feasible and safe procedure, with reduced morbidity outcomes.
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Affiliation(s)
- Antonio Gil-Moreno
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Melchor Carbonell-Socias
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Sabina Salicrú
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Melissa Bradbury
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ángel García
- Department of Pathology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramona Vergés
- Radiotherapy Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Oriol Puig Puig
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - José Luís Sánchez-Iglesias
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Silvia Cabrera-Díaz
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Javier de la Torre
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Natalia R Gómez-Hidalgo
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Assumpció Pérez-Benavente
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Berta Díaz-Feijoo
- Unit of Gynecologic Oncology, Department of Obstetrics and Gynecology, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
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