Three classes of radical vaginal hysterectomy for treatment of endometrial and cervical cancer

Revisiting Querleu-Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery?

In 2008, Querleu and Morrow proposed a novel classification of radical hysterectomy, which was quickly accepted by the professional oncogynecological community. The Querleu and Morrow (Q-M) classification of radical hysterectomy has provided a unique opportunity for uniform surgical and anatomical terminology. The classification offers detailed explanations of anatomical landmarks and resection margins for the three parametria of the uterus. However, there are still some disagreements and misconceptions regarding the terminology and anatomical landmarks of the Q-M classification. This article aims to highlight the surgical anatomy of all radical hysterectomy types within the Q-M classification. It discusses and illustrates the importance of anatomical landmarks for defining resection margins of the Q-M classification and reviews the differences between Q-M and other radical hysterectomy classifications. Additionally, we propose an update of the Q-M classification, which includes the implementation of parauterine lymphovascular tissue, paracervical lymph node dissection, and Selective-Systematic Nerve-Sparing type C2 radical hysterectomy. Type D was modified according to current guidelines for the management of patients with cervical cancer. The detailed explanation of the surgical anatomy of radical hysterectomy and the proposed update may help achieve surgical harmonization and precise standardization among oncogynecologists, which can further facilitate accurate and comparable results of multi-institutional surgical clinical trials.

Oncologic outcomes after Total Mesometrial Resection (TMMR) or treatment according to current international guidelines in FIGO (2009) stages IB1-IIB cervical cancer: an observational cohort study

Background

According to international guidelines, standard treatment (ST) with curative intent in cervical cancer (CC) comprises radical hysterectomy and pelvic lymphadenectomy in early stages (International Federation of Gynecology and Obstetrics (FIGO) 2009 IB1, IIA1), adjuvant chemoradiation is recommended based on risk factors upon final pathology. Definitive chemoradiation is recommended in locally advanced stages (FIGO 2009 IB2, IIA2, IIB). Total mesometrial resection (TMMR) with therapeutic lymph node dissection (tLND) without adjuvant radiation has emerged as a promising treatment. Here we compare oncologic outcome by TMMR + tLND or ST.

Methods

In this observational cohort study, women treated according to international guidelines were identified in the population-based registries from Sweden and women treated with TMMR were identified in the Leipzig Mesometrial Resection (MMR) Study Database (DRKS 0001517) 2011-2020. Relevant clinical and tumour related variables were extracted. Recurrence-free survival (RFS) and overall survival (OS) by ST or TMMR was analysed with log-rank test, cumulative incidence function and proportional hazard regression yielding hazard ratios (HR) with 95% confidence intervals (CI), adjusted for relevant confounders.

Findings

Between 2011 and 2020, 1007 women were included in the final analysis. 733 women were treated according to ST and 274 with TMMR. RFS at five years was 77.9% (95% CI 74.3-81.1) and 82.6% (95% CI 77.2-86.9) for the ST and TMMR cohorts respectively (p = 0.053). In early-stage CC, RFS was higher after TMMR as compared to ST, 91.2% vs 81.8% (p = 0.002). In the adjusted analysis, TMMR was associated with a lower hazard of recurrence (HR 0.39; 95% CI 0.22-0.69) and death (HR 0.42; 95% CI 0.21-0.86) compared to ST. The absolute difference in risk of recurrence at 5 years was 9.4% (95% CI 3.2-15.7) in favor of TMMR. In locally advanced CC, no significant differences in RFS or OS was observed.

Interpretation

Compared to ST, TMMR without radiation therapy was associated with superior oncologic outcomes in women with early-stage cervical cancer whereas no difference was observed in locally advanced disease. Our findings together with previous evidence suggest that TMMR may be considered the primary option for both early-stage and locally advanced cervical cancer confined to the Müllerian compartment.

Funding

This study was supported by grants from Centre for Clinical Research Sörmland (Sweden) and Region Stockholm (Sweden).

Vaginal hysterectomy for the treatment of low-risk endometrial cancer: Surgical technique, costs, and perioperative and oncologic results

OBJECTIVES

This study aimed to describe an operative technique for vaginal hysterectomy (VH) and assess the costs, perioperative, and oncological outcomes for this procedure when used in the treatment of patients with low-risk endometrial cancer (LREC).

METHODS

A retrospective analysis of medical records was conducted on patients who underwent VH to treat precursor and invasive endometrial lesions between April 2019 and November 2021 at a single center in São Paulo, Brazil.

RESULTS

Thirty-four patients met the inclusion criteria. The mean patient age was 61.9 years, and the mean body mass index (BMI) was 34. Obese patients (BMI ≥ 30) accounted for 77% of the sample. Preoperative functional capacity measures were Eastern Cooperative Oncology Group (ECOG) 0-1 and ECOG-2 for 91% and 9% of the patients, respectively. The mean operative time and length of hospital stay were 109 min and 1.2 days, respectively. Four patients had a conversion of the surgical route to laparotomy. No major intraoperative complications were observed. Patients who underwent surgical conversion had a greater uterine volume (227 versus 107 mL, p = 0.006) and longer operative time (177 versus 96 min, p = 0.001). The total cost associated with VH was, on average, US$ 2058.77 (R$ 10,925.91), representing 47% of the cost associated with non-vaginal routes. Twenty-eight patients received a definitive diagnosis of endometrial carcinoma; of these, three received adjuvant radiotherapy. The mean follow-up period was 34.6 months for the patients diagnosed with cancer. One case of disease recurrence occurred 16.6 months after surgery, with one death at 28.6 months of follow-up.

CONCLUSIONS

These findings suggest that VH could be a feasible and cost-effective alternative for selected patients with LREC in low-resource settings.

International expert consensus on the surgical anatomic classification of radical hysterectomies

BACKGROUND

The anatomic descriptions and extents of radical hysterectomy often vary across the literature and operative reports worldwide. The same nomenclature is often used to describe varying procedures, and different nomenclature is often used to describe the same procedure despite the availability of guideline and classification systems. This makes it difficult to interpret retrospective surgical reports, analyze surgical databases, understand technique descriptions, and interpret the findings of surgical studies.

OBJECTIVE

In collaboration with international experts in gynecologic oncology, the purpose of this study was to establish a consensus in defining and interpreting the 2017 updated Querleu-Morrow classification of radical hysterectomies.

STUDY DESIGN

The anatomic templates of type A, B, and C radical hysterectomy were documented through a set of 13 images taken at the time of cadaver dissection. An online survey related to radical hysterectomy nomenclature and definitions or descriptions of the associated procedures was circulated among international experts in radical hysterectomy. A 3-step modified Delphi method was used to establish consensus. Image legends were amended according to the experts' responses and then redistributed as part of a second round of the survey. Consensus was defined by a yes response to a question concerning a specific image. Anyone who responded no to a question was welcome to comment and provide justification. A final set of images and legends were compiled to anatomically illustrate and define or describe a lateral, ventral, and dorsal excision of the tissues surrounding the cervix.

RESULTS

In total, there were 13 questions to review, and 29 experts completed the whole process. Final consensus exceeded 90% for all questions except 1 (86%). Questions with relatively lower consensus rates concerned the definitions of types A and B2 radical hysterectomy, which were the main innovations of the 2017 updated version of the 2008 Querleu-Morrow classification. Questions with the highest consensus rates concerned the definitions of types B1 and C, which are the most frequently performed radical hysterectomies.

CONCLUSION

The 2017 version of the Querleu-Morrow classification proved to be a robust tool for defining and describing the extent of radical hysterectomies with a high level of consensus among international experts in gynecologic oncology. Knowledge and implementation of the exact definitions of hysterectomy radicality are imperative in clinical practice and clinical research.

Radical Hysterectomy After the LACC Trial: Back to Radical Vaginal Surgery

OPINION STATEMENT

Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually abandoned due to painful perineal incision, a high rate of urinary dysfunction, and the inability to perform lymph node assessment. However, the heritage of this approach has been still used and taught in a few centers outside their Austrian birthplace. A combined vaginal and laparoscopic approach was developed in the 1990s by French and German surgeons who designed diverse surgical techniques for which a novel classification is proposed. All these techniques are different from the so-called laparoscopically assisted radical vaginal hysterectomy (LARVH), a term widely used for laparoscopic radical hysterectomies with vaginal extraction of the specimen. Interestingly, after the publication of the LACC trial (Laparoscopic Approach to Cervical Cancer), the radical vaginal approach has found a very timely application. The creation of a vaginal cuff before performing radical laparoscopic hysterectomy described in 2007 by Leblanc as "Schautheim" operation can be used as a protective maneuver to avoid tumor spillage and potentially overturn the negative outcome of minimally invasive surgery in early-stage cervical cancer. As a result, the combination of radical vaginal and laparoscopic steps of surgery is one possible evolution after the LACC trial that needs further investigation. The forgotten vaginal surgical technique needs a specific learning curve. The creation of a vaginal cuff should be mastered by every gynecological oncologist.

New developments in the surgical therapy of cervical carcinoma

For almost a century abdominal radical hysterectomy has been the standard surgical treatment of early-stage macroscopic carcinoma of the uterine cervix. The excessive parametrial resection of the original procedures of Wertheim, Okabayashi, and Meigs has later been "tailored" to tumor extent. Systematic pelvic and eventually periaortic lymph node dissection is performed to identify and treat regional disease. Adjuvant (chemo)radiation therapy is liberally added to improve locoregional tumor control when histopathological risk factors are present. The therapeutic index of the current surgical treatment, particularly if combined with radiation, appears to be inferior to that of primary chemoradiation as an oncologically equivalent therapeutic alternative. Several avenues of new conceptual and technical developments have been used since the 1990s with the goal of improving the therapeutic index. These are: surgical staging, including sentinel node biopsy and nodal debulking; minimal access and recently robotic radical hysterectomy; fertility-preserving surgery; nerve-sparing radical hysterectomy; total mesometrial resection based on developmentally defined surgical anatomy; and supraradical hysterectomy. The superiority of these new developments over the standard treatment remains to be demonstrated by controlled prospective trials. Multimodality therapy including surgery for locally advanced disease represents another area of clinical research. Both neoadjuvant chemotherapy followed by radical surgery, with or without adjuvant radiation, and completion surgery after (chemo)radiation are feasible and have to be compared to primary chemoradiation as the new nonsurgical treatment standard. Surgical treatment of postirradiation persisting or recurrent cervical carcinoma has been traditionally limited to pelvic exenteration for central disease. Applying the principle of developmentally derived anatomical compartments increases R0 resectability. The laterally extended endopelvic resection allows even the extirpation of a subset of visceral pelvic side wall tumors with clear margins. Many questions regarding the indication for these "ultraradical" operations, the surgery of irradiated tissues, and the optimal reconstructive procedures are still open and demand multi-institutional controlled trials to be answered.

Classification of radical hysterectomy

Since the first publications about surgery for cervical cancer, many radical procedures that accord with different degrees of radicality have been described and done. Here, we propose a basis for a new and simple classification for cervical-cancer surgery, taking into account the curative effect of surgery and adverse effects, such as bladder dysfunction. The international anatomical nomenclature is used where it applies. For simplification, the classification is based only on lateral extent of resection. We describe four types of radical hysterectomy (A-D), adding when necessary a few subtypes that consider nerve preservation and paracervical lymphadenectomy. Lymph-node dissection is considered separately: four levels (1-4) are defined according to corresponding arterial anatomy and radicality of the procedure. The classification applies to fertility-sparing surgery, and can be adapted to open, vaginal, laparoscopic, or robotic surgery. In the future, internationally standardised description of techniques for communication, comparison, clinical research, and quality control will be a basic part of every surgical procedure.

Do we need a new classification for radical hysterectomy? Insights in surgical anatomy and local tumor spread from human embryology

OBJECTIVE

Current surgical treatment of cervical carcinoma is based on the assumption of undirected intra- and transcervical local tumor propagation and is executed by tailored excision of the paracervical tissues. We have recently demonstrated that cervical carcinoma spreads for extended phases during its malignant progression within the permissive compartment of the Müllerian morphogenetic unit (Lancet Oncol 2005;6:751-56) and proposed Müllerian compartment resection as the new principle for surgical treatment of cervical cancer. Do we need a new classification of radical hysterectomy?

METHODS

The therapeutic index of the surgical treatment of cervical carcinoma FIGO stages IB1-IIB by extirpation of the Müllerian compartment through total mesometrial resection (TMMR) without adjuvant radiation is evaluated by an ongoing controlled prospective trial at the University of Leipzig.

RESULTS

From 7/1998 to 12/2006, 163 patients with cervical carcinoma, FIGO stages IB1 (n=94), IB2 (n=21), IIA (n=14) and IIB (n=34) have been treated with TMMR and nerve-sparing therapeutic lymph node dissection. Twenty-five patients received (neo)adjuvant chemotherapy. No patient underwent adjuvant radiotherapy although 95 patients (58%) would have needed this additional modality in case of conventional radical hysterectomy because of their high-risk histopathological tumor features. At a median follow-up time of 45 months (3-104 months), recurrence-free and disease-specific overall survival is 93% and 96%. Maximum treatment-related morbidity according to the Franco-Italian score has been grade 2 in 12 patients (8%).

CONCLUSIONS

The developmental view of local tumor spread and surgical anatomy holds a great promise for improving the therapeutic index of surgical cervical cancer therapy and challenges both the classification of radical hysterectomy based on tailored paracervical resection and the indication for adjuvant radiation.

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

BACKGROUND

This report presents the incidence of complications and conversions during laparoscopic radical hysterectomy and lymphadenectomy performed for invasive cervical carcinoma. The data are analyzed, and strategies to help prevent future complications are discussed.

METHODS

From July 2000 to December 2005 at the authors' institution, 317 laparoscopic radical hysterectomy and lymphadenectomy procedures for invasive cervical carcinoma were performed. The authors reviewed the database of patients who underwent laparoscopic radical hysterectomy and lymphadenectomy to examine complications and analyze factors associated with conversion to an open surgical procedure.

RESULTS

All but four surgical procedures were laparoscopically completed. Pelvic lymphadenectomy was performed for all the remaining 313 patients, 143 of whom underwent paraaortic lymphadenectomy. Major and minor intraoperative complications occurred for 4.4% (n = 14) of the patients. The overall conversion rate was 1.3% (n = 4), including 3 emergencies and 1 elective conversion. Seven patients had vessel injuries, five of which were repaired or treated laparoscopically. One left external iliac vein required laparotomy, and one patient underwent laparotomy to control bleeding sites. Operative cystotomies occurred in five patients, which were repaired laparoscopically. Two patients underwent laparotomy because of hypercapnia and ascending colon injury. Postoperative surgery complications occurred in 5.1% (n = 16) of the patients, including 5 patients with ureterovaginal fistula, 4 with vesicovaginal fistula requiring reoperation, 1 with ureterostenosis treated by placement of a double-J ureteral stent, and 6 with bladder dysfunctions (retention) that exhibited complete resolution within 3 to 6 months by intermittent training and catheterization.

CONCLUSIONS

Laparoscopic radical hysterectomy and lymphadenectomy is becoming a routine procedure in the armamentarium of many gynecologists. Complications unique to laparoscopy do exist, but they decrease with repeated training of the procedure and gradually enriched experiences.

Ten-year results of a prospective study on the prognostic role of ploidy in endometrial carcinoma

BACKGROUND

To improve the outcome of endometrial cancer patients, a more accurate prognostic assessment is mandatory. The aims of the study were to evaluate the role of flow cytometric DNA ploidy as an independent prognostic factor in patients with endometrial cancer and to verify if ploidy was able to distinguish patients with different prognosis into homogeneous subgroups for grade of differentiation and stage.

METHODS

In a prospective study, DNA ploidy was evaluated from fresh tumor samples in 174 endometrial cancer patients who underwent surgery as the first treatment. Ploidy, as well as classical parameters, were analyzed in relation to the length of disease-free survival and disease-specific survival.

RESULTS

DNA aneuploidy was found in 49 patients (28.2%). Patients with DNA-aneuploid tumors had a significantly reduced disease-free interval and disease-specific survival (P < .0001). The 10-year survival probability was 53.2% for DNA-aneuploid patients and 91.0% for patients with DNA-diploid tumors. By multivariate analysis DNA-aneuploid type was the strongest independent predictor of poor outcome, followed by age and stage. Patients with DNA-aneuploid tumor had a significantly higher risk ratio for recurrence (5.03) and death due to disease (6.50) than patients with DNA-diploid tumors. Stratification by DNA-ploidy within each group by grade of differentiation allowed identification of patients with significantly different outcome. In grade 2 tumors, 10-year survival was 45.0% in aneuploid cases and 91.9% in diploid cases (P < .0001). Patients with advanced-stage (>I) diploid tumor did significantly better than patients with stage I aneuploid tumor (P = .04).

CONCLUSIONS

The presence of DNA-aneuploid type in endometrial cancer identifies high-risk cases among the patients considered 'low risk' according to stage and grade of differentiation.

Pelvic floor dysfunction and radical hysterectomy

Although the survival outcome for treated, early-stage, node-negative cervical cancer is excellent, the operation of radical hysterectomy conveys major morbidity, particularly with respect to bladder and bowel function. There may be some degree of spontaneous recovery, but a significant proportion of postoperative women will have to live with the disabling effects of surgery for decades, and few seek help for their distress. As such, quality of life issues have become highly relevant in the management of this disease, and attention has turned to reducing morbidity, especially to the pelvic viscera. This review presents an overview of the surgical mechanisms presumed to be responsible for pelvic floor denervation and describes subsequent bladder and bowel dysfunction, together with future possibilities for minimizing morbidity, including less radical, more individual surgery, and nerve-sparing techniques.

Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly

OBJECTIVE

The purpose of this study was to analyze the outcome of vaginal and abdominal hysterectomy for treatment of endometrial cancer in elderly patients.

METHODS

In a retrospective series of 171 patients with age > or =70 years and at stages I-III, we evaluated operative and hospitalization data, as well as morbidity, mortality, and long-term survival associated with vaginal and abdominal hysterectomy. A total of 128 patients were operated on with vaginal hysterectomy and 43 cases underwent abdominal hysterectomy.

RESULTS

Medically compromised patients were significantly more frequent in the vaginal surgery group (P = 0.01). Overall, the 10-year disease-specific survival rates after vaginal and abdominal hysterectomy were 80% and 78%, respectively (P = n.s.). Limiting the analysis to stage I (130 patients), 10-year disease-specific survival was 83% in 95 women operated on by the vaginal route and 84% in 35 patients operated by the abdominal approach (P = n.s.). Patients in the vaginal surgery group had a significantly shorter operative time (P = 0.01), less blood loss (P < 0.05), and were discharged earlier (P < 0.05). Severe complications occurred in 5.4% of the vaginal and in 7.0% of the abdominal procedures. Perioperative mortality was zero after vaginal hysterectomy and 2.3% after abdominal hysterectomy, respectively.

CONCLUSIONS

Vaginal hysterectomy showed a high cure rate, shorter operative time, less blood loss, reduced morbidity, and no mortality and therefore may be considered the elective approach for treatment of elderly patients with endometrial cancer.

Vesical dysfunctions after radical hysterectomy for cervical cancer: a critical review

Functional disorders of the lower urinary tract are the most common long-term complications following radical surgery for cancer of the uterine cervix (8-80%). These disturbances were associated to the partial interruption of the autonomic fibers innervating the bladder during the resection of anterior, lateral and posterior parametrium and vaginal cuff. The pathophysiology of these changes is actually debated. The nature of the surgical damage appears to be a decentralization rather than a complete denervation and bladder dysfunctions may be either the unmasking of intrinsic detrusor activity, characterized by a loss of beta-adrenergic innervation and a consequent alfa-adrenergic hyperinnervation or the influence of remaining sympathetic innervation. No data on long-term bladder function in patients who underwent class 4 radical hysterectomy have been reported. In our experience on long-term vesical function in 38 patients with locally advanced cervical cancer treated with neoadjuvant chemotherapy and 4 Piver type radical hysterectomy, urinary symptoms were reported in 11 patients (29%), while a normal urodynamic finding was recorded in only nine patients (24%). The most common bladder dysfunction was the storage dysfunction (47%). The voiding dysfunction was present in one patient (3%) and stress urinary incontinence in 20 patients (53%). The parametrial and vaginal resections were compared among the urodynamic diagnosis The size of lateral parametria measured on the giant sections did not differ among the groups of urodynamic diagnosis, while the length of vagina removed was significantly longer in patients with detrusor dysfunctions (storage and voiding dysfunctions) than in patients with normal diagnosis or genuine stress incontinence.

Traitement chirurgical des adénocarcinomes de l’endomètre : voies d’abord. Revue de la littérature

Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO's criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.

Radical vaginal hysterectomy: classic and modified

RVH offers significant advantages to the corresponding abdominal procedure, including: the possibility for regional anesthesia, particularly in patients with poor medical conditions; reduced surgical trauma because of the absence of an abdominal incision; applicability in obese patients; shorter surgical time when performed by an experienced surgeon; decreased need for blood transfusions; lower risk for complications; faster postoperative recovery period; shorter hospitalization. The primary drawback to the use of RVH for early stage cervical cancer has always been the lack of lymph node dissection. This has now been modified by the widespread use of laparoscopic lymphadenectomy. The increasing reliability of noninvasive radiologic techniques has provided and will continue to provide greater possibilities for preoperative staging to best determine the needs of the patient. The authors believe that an oncologic surgeon familiar with advanced laparoscopic techniques and RVH is able to take advantage of the benefits of both routes. Furthermore, a surgeon skilled in these techniques and RAH has the tools to ideally care for the specific needs, of each patient. The authors encourage individualization of surgical management, with special emphasis on the revision of the role of RVH in gynecologic oncology.

Vaginal hysterectomy

Vaginal hysterectomy represents the ultimate minimal access hysterectomy. The indications for the procedure extend well beyond those of prolapse. Good training and advances in surgical technique allow the removal of enlarged fibroid uteri as well as vaginal oophorectomy. This article also considers the complications which may follow.

Extraperitoneal pelvic lymphadenectomy to complement vaginal operations for cervical and endometrial cancer

OBJECTIVE

The aim of the current study was to test the applicability of a personal modification of Mitra extraperitoneal pelvic lymphadenectomy in combination with radical vaginal operations for treatment of endometrial and cervical cancer.

METHOD

In a prospective series, 82 patients were submitted to extraperitoneal pelvic lymphadenectomy. In 34 cases of stage I endometrial cancer the procedure was combined with a class I vaginal hysterectomy and in 48 cases of cervical cancer stage Ib-IIIb lymphadenectomy was associated with a class II or III radical vaginal hysterectomy. Type of anesthesia, number of lymph nodes removed, operating time, blood loss and postoperative complications were recorded.

RESULT

The operation was performed with spinal anesthesia in 43% of the cases. Thirty-seven patients (45%) were high surgical risk because of associated diseases. The median operative time for lymphadenectomy was 20 min for each side; the vaginal procedures took a median of 25 min (class I) and 40 min (class II-III). Blood transfusions were necessary in seven cases (8. 5%). A median of 26 lymph nodes were removed from each patient. Lymphocyst occurred in seven patients (8.5%), retroperitoneal hematoma in two and retroperitoneal abscess in one.

CONCLUSION

Extraperitoneal pelvic lymphadenectomy has proven to be a safe and quick technique to complement vaginal operations for endometrial and cervical cancer. Specific features of this approach are: (1) fast, timesaving procedure; (2) possible use of spinal anesthesia; and (3) applicability in high surgical risk patients.

Preoperative evaluation of tumor ploidy in endometrial carcinoma: An accurate tool to identify patients at risk for extrauterine disease and recurrence

BACKGROUND

Tumor ploidy is a strong prognostic factor in patients with endometrial carcinoma, but generally is evaluated only after surgery. The availability of a simple and reliable method to determine tumor ploidy before any treatment is initiated could be helpful in the selection of patients at high risk for advanced primary disease and subsequent recurrence, with several possible benefits. The objectives of the current study were: 1) to test the accuracy of flow cytometric determination of tumor ploidy from preoperative outpatient endometrial biopsies compared with standard postoperative evaluation from the surgical specimen and 2) to correlate this preoperative parameter with the local recurrence and extrauterine tumor spread.

METHODS

Tumor ploidy from both preoperative biopsy material and the macroscopic surgical specimens was evaluated prospectively in 50 consecutive patients with endometrial carcinoma. DNA analyses were performed in a blind fashion. Patients were followed for a median of 26 months (range, 16-46 months).

RESULTS

In 9 of 50 cases (18%) an aneuploid tumor was found by the standard postoperative analysis. All 9 aneuploid tumors (100%) also were identified correctly by the preoperative test on biopsy material. Occult extrauterine tumor spread was found in 10 patients (20%). The incidence rate of aneuploidy among these tumors was 50% compared with 10% in surgical International Federation of Gynecology and Obstetrics Stage I tumors (P = 0.01). The recurrence rate was 55.5% (5 of 9 tumors) in the aneuploid group and 2.4% (1 of 41 tumors) in the diploid group (P < 0.001). The disease free survival rates of patients with diploid and aneuploid tumors were 97.5% and 44.4%, respectively (P < 0.0001).

CONCLUSIONS

Preoperative tumor ploidy determination based on outpatient endometrial biopsy is as accurate as the standard postoperative evaluation in patients with endometrial carcinoma. Tumor aneuploidy confirms the usefulness of this method in selecting patients at risk for occult extrauterine tumor diffusion and recurrence.

Laparoscopic assistance for extended radicality of radical vaginal hysterectomy: description of a technique

OBJECTIVE

We developed and standardized a surgical technique, which allows radical hysterectomy by a combined laparoscopic and vaginal approach with radicalness equivalent to a type III procedure according to Rutledge.

METHOD

Thirty-six consecutive patients with cervical cancer stage IB1-IIIA with high risk for parametrial involvement were treated between May 1996 and March 1998.

RESULTS

Bilateral para-aortic and pelvic lymphadenectomy and resection of the cardinal ligaments was performed laparoscopically using bipolar coagulation. Dissection of the ureters and resection of bladder pillars and uterosacral ligaments was performed transvaginally. On average 6.5 cm of cardinal ligament could be removed per side.

CONCLUSIONS

With the laparoscopic-vaginal technique described a radical hysterectomy type III can be performed.