Application of Laparoscopic Surgery in Gynecological Oncology

Robotic single-site surgery versus laparoendoscopic single-site surgery in early-stage endometrial cancer: a case-control study

Introduction

Laparoendoscopic single-site surgery (LESS) can reduce the limited invasiveness of conventional laparoscopy while providing superior cosmetic results. Robotic single-site surgery (RSSS) can overcome this shortcoming to a certain extent.

Aim

To evaluate the advantages of RSSS in treating early-stage endometrial cancer by comparing RSSS with LESS.

Material and methods

From January 2018 to August 2018, patients diagnosed with endometrial cancer from endometrial curettage and imaging studies were selected for this prospective cohort study, with 22 undergoing RSSS and 18 undergoing LESS. All surgical procedures were performed using the conventional da Vinci Si surgical system with the Lagiport single port or a conventional laparoendoscopic instrument with the Lagiport single port. Operative time was recorded electronically. Intraoperative parameters and postoperative parameters were recorded and further analyzed.

Results

The operation was successfully completed, and a pure single-point approach was adopted. There were no laparotomy or intraoperative complications. Compared with the LESS group, the RSSS group had significantly longer pre-surgical time, significantly lower median operation time, significantly lower median blood loss, and significantly lower vaginal cuff closure time. The median length of hospital stay in the RSSS group was significantly lower than that in the LESS group. There was no significant difference in the incidence of early and late complications between the two groups. No recurrence events were observed in either the RSSS or the LESS group.

Conclusions

RSSS is feasible and safe in patients with early-stage endometrial cancer. RSSS can reduce operating time, blood loss and length of hospital stay compared with LESS.

Impacts of laparoscopic hysterectomy on functions of coagulation and fibrinolysis system

The main objective of the study is to compare the impacts of laparoscopic hysterectomy and total abdominal hysterectomy on the functions of coagulation and fibrinolysis system. Seventy-five patients who had undergone hysterectomy were randomly divided into laparoscopic hysterectomy group (n = 38) and total abdominal hysterectomy group (n = 37). The prothrombin time (PT), activated partial thromboplastin time (APTT), thrombin time (TT), fibrinogen, D-dimer, von Willebrand factor, α-granule membrane protein-140, thrombin-activated fibrinolysis inhibitor (TAFI) and platelet count were detected at preoperative 24 h (N0), postoperative 24 h (N1) and postoperative 48 h (N2). Compared with N0, values of PT, APTT and TT were significantly decreased at N1 in both groups, whereas von Willebrand factor, platelet count and α-granule membrane protein-140 levels at N1 were significantly increased (P < 0.05). There was no significant difference between N0 and N2 (P > 0.05). Compared with N0, fibrinogen, D-dimer and TAFI levels in both groups were significantly higher at N1 (P < 0.05), and there was no significant difference between N0 and N2 (P > 0.05). The intergroup comparison showed no significant difference of above indexes between two groups (P > 0.05). The univariate analysis showed that TAFI was negatively correlated with TT (r = -0.365, P < 0.01), APTT (r = -0.183, P < 0.05) and PT (r = -0.121, P < 0.05), whereas not correlated with other indicators. Laparoscopic hysterectomy may increase the risk of postoperative venous thrombosis.

[Feasibility and fiability of laparoscopic surgery in the uterine cancers in normal-weight patients]

OBJECTIVES

Evaluate the fiability and feasibility of laparoscopic surgery for the management of uterine cancers [endometrial cancer (EC) and early-stage cervical cancer (ESCC)] with patients who have a BMI ≤ 30 kg/m(2), within the setting of a gynaecological oncology department.

PATIENTS AND METHODS

This retrospective, monocentric and descriptive study was carried out between January 2003 and May 2011 at the Institute Claudius-Regaud, a centre for cancer diagnosis, treatment and research. A policy promoting laparoscopy as a first choice treatment has been established at the institute since 2003.

RESULTS

Two hundred and three patients were included. Eighty-five patients were early-stage cervical cancer patients and 118 patients were endometrial cancer patients. The study shows a high fiability rate for laparoscopy in non-obese patients, with a 98.8% rate for EC patients and a 98.8% rate for ESCC patients. The feasibility rates were 80.1% and 96.6%, respectively. The incidence of laparoconversion was reported at 1.2% and 3.1% for ESCC and EC patients, respectively, while the incidence of peroperative complications was 5.9% and 7.4%. The incidence of postoperative complications rank ≥ 3 according to "Memorial secondary events grading system" was 3 (3.5%) for CCUP and 3 (2.5%) for CE.

DISCUSSION AND CONCLUSION

The results of this study show high fiability and feasibility levels for the laparoscopic treatment of uterine cancers in non-obese patients. There is no need to implement the more expensive robotic-assisted surgery in this group of patients. Mastering advanced laparoscopic surgery remains a mainstay in gynaecologic oncology.

Comparison of perioperative outcomes and cost between robotic-assisted and conventional laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL)

STUDY OBJECTIVE

To compare perioperative outcomes and cost of robotic-assisted and laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) for treatment of gynecologic malignant conditions.

DESIGN

Prospective non-randomized study (Canadian Task Force classification II-2).

SETTING

Tertiary center for women's health.

PATIENTS

Sixty-two patients with gynecologic cancer operated on by the same surgical team.

INTERVENTIONS

Thirty-two patients underwent TIPAL via robotic-assisted laparoscopy, and 30 via conventional laparoscopy. Comparison analyses of perioperative outcomes and estimated costs were performed.

MEASUREMENTS AND MAIN RESULTS

There were no differences between robotic-assisted and laparoscopy insofar as age, body mass index, presurgical morbidity, operating time (92.5 minutes for robotics vs 96.6 minutes for laparoscopy), number of aortic nodes (12 vs. 12), hospitalization stay (2 vs. 2 days), or rate of complications (12.5% vs. 13.3%). Blood loss tended to be lower in the robotic group (75.0 vs. 92.5 mL; p = .08). Surgical cost was higher in the robotic group ($3.42 vs. $2.55; p < .001), although hospitalization cost was similar.

CONCLUSION

Robotic-assisted and laparoscopy provide similar perioperative outcomes. However, the robotic-assisted approach is associated with higher surgical cost.

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.

First 100 early endometrial cancer cases treated with laparoendoscopic single-site surgery: a multicentric retrospective study

OBJECTIVE

We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer.

STUDY DESIGN

This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011.

RESULTS

All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control.

CONCLUSION

LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer.

Is surgical restaging indicated in apparent stage IA pure ovarian dysgerminoma? The MITO group retrospective experience

OBJECTIVE

Conservative surgery followed by platinum-based chemotherapy is considered the standard approach for pure ovarian dysgerminoma (POD), except for correctly staged IA patients. The aim of study was to evaluate the outcome of IA POD patients with incomplete surgical staging in order to define the proper management.

METHODS

Data concerning primary treatment and recurrence were reviewed for 26 patients with stage IA POD treated in MITO (Multicenter Italian Trials in Ovarian Cancer) centers.

RESULTS

Median age was 22.5years. Primary surgery was fertility sparing for 17 patients (65.4%) and radical surgery was performed in 9 patients due to older age or gonadal dysgenesis. Only five patients (19.2%) had complete surgical staging; 38.5% had lymph node dissection, 46.2% had peritoneal biopsies and/or omentectomy and 65.4% had peritoneal washing. Seven patients received adjuvant chemotherapy. Overall recurrence rate was 11.5%: all recurrences occurred in the group submitted to incomplete staging procedure. No patients treated with adjuvant chemotherapy relapsed. One patient had pelvic recurrence, one patient relapsed in the abdomino-pelvic peritoneum and lymph nodes and the third patient showed a peritoneum, lymph nodal and residual ovary relapse. All patients with recurrence were cured by salvage therapy: 2 patients were treated with surgery plus chemotherapy and one only with chemotherapy. After a median follow-up of 100months all patients are alive without evidence of disease. Six patients opted for conception and delivered healthy infants, two with IVF with donor oocyte.

CONCLUSIONS

IA POD prognosis is excellent. Conservative surgery with a complete surgical staging is the gold standard. Patients with incomplete staging could undergo surgical restaging or surveillance. Chemotherapy should be reserved to relapse with excellent chances of therapeutic success.