Laparoscopic radical hysterectomy with pelvic lymphadenectomy for early, invasive cervical carcinoma

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.

Laparoscopic procedure compared with open radical hysterectomy with pelvic lymphadenectomy in early cervical cancer: a retrospective study

Objective

To compare clinical outcomes in laparoscopic and open radical hysterectomy with pelvic lymphadenectomy (LRH) in early cervical cancer without the selection bias.

Methods

One special retrospective study was conducted with more than 400 patients involved in laparoscopic procedure.

Results

Our results suggest that estimated blood loss and transfusion requirements were significantly lower in the LRH group. Postoperative hospital stay was also significantly shorter in the LRH group. Significant difference was found in the number of pelvic lymph nodes retrieved between the LRH and open radical hysterectomy with pelvic lymphadenectomy (ORH) groups. There were no differences in operating time, perioperative complications, progression-free survival, and overall survival between the LRH and ORH groups.

Conclusion

LRH can be considered a safe and effective alternative to conventional open surgery (ORH) for early-stage cervical cancer.

Radical Hysterectomy: Efficacy and Safety in the Dawn of Minimally Invasive Techniques

STUDY OBJECTIVE

To analyze the effect that the introduction of minimally invasive procedures has had on surgical and oncologic outcomes when compared with conventional open radical hysterectomy (ORH) in a national reference cancer after 17 years of experience in radical hysterectomy.

DESIGN

A prospective controlled study (Canadian Task Force classification II-2).

SETTING

A university teaching hospital.

PATIENTS

All patients who underwent radical hysterectomy as primary treatment for cervical cancer in our institution between May 1999 and June 2016, with a total of 188 patients.

INTERVENTIONS

Patients underwent ORH or minimally invasive surgery (MIS) (i.e., laparoscopic or robotically assisted radical hysterectomy).

MEASUREMENTS AND MAIN RESULTS

Seventy-six patients underwent ORH, 90 laparoscopic radical hysterectomy, and 22 robotically assisted radical hysterectomy. Blood loss and hospital stay were inferior in the MIS group (p <.0001). The laparotomic group presented shorter operation times (p = .0001). With a median follow-up of 112.4 months, a total of 156 patients (83%) were alive and free of disease at the time of the data analysis. Overall survival was higher in the MIS group when compared with the ORH group (91 vs 78.9, p = .026). There were no differences regarding recurrence rates between the surgical approaches.

CONCLUSION

With 1 of the largest follow-up periods in the literature, this study provides added evidence that MIS could become the preferable surgical approach for early-stage cervical cancer since it appears to reduce morbidity without affecting oncologic results.

Quality of laparoscopic radical hysterectomy in developing countries: a comparison of surgical and oncologic outcomes between a comprehensive cancer center in the United States and a cancer center in Colombia

OBJECTIVE

To help determine whether global collaborations for prospective gynecologic surgery trials should include hospitals in developing countries, we compared surgical and oncologic outcomes of patients undergoing laparoscopic radical hysterectomy at a large comprehensive cancer center in the United States and a cancer center in Colombia.

METHODS

Records of the first 50 consecutive patients who underwent laparoscopic radical hysterectomy at The University of Texas MD Anderson Cancer Center in Houston (between April 2004 and July 2007) and the first 50 consecutive patients who underwent the same procedure at the Instituto de Cancerología-Clínica las Américas in Medellín (between December 2008 and October 2010) were retrospectively reviewed. Surgical and oncologic outcomes were compared between the 2 groups.

RESULTS

There was no significant difference in median patient age (US 41.9 years [range 23-73] vs. Colombia 44.5 years [range 24-75], P=0.09). Patients in Colombia had a lower median body mass index than patients in the US (24.4 kg/m(2) vs. 28.7 kg/m(2), P=0.002). Compared to patients treated in Colombia, patients who underwent surgery in the US had a greater median estimated blood loss (200 mL vs. 79 mL, P<0.001), longer median operative time (328.5 min vs. 235 min, P<0.001), and longer postoperative hospital stay (2 days vs. 1 day, P<0.001).

CONCLUSIONS

Surgical and oncologic outcomes of laparoscopic radical hysterectomy were not worse at a cancer center in a developing country than at a large comprehensive cancer center in the United States. These results support consideration of developing countries for inclusion in collaborations for prospective surgical studies.

A comparative study of laparoscopic radical hysterectomy with radical abdominal hysterectomy for early-stage cervical cancer: a long-term follow-up study

OBJECTIVE

To determine whether laparoscopic radical hysterectomy (LRH) is a feasible alternative to radical abdominal hysterectomy (RAH) for early-stage cervical cancer.

STUDY DESIGN

A retrospective, matched case-control study of 24 consecutive cases with International Federation of Gynecology and Obstetrics stage I-II cervical cancer who underwent LRH by a single surgeon between January 1994 and December 2001. Cases were matched with controls (ratio 1:2) who underwent RAH by surgeon, age, stage and histology. Patient characteristics, clinical course, intra-operative complications and disease-free survival were compared between the two groups. Median counts were analyzed using the Mann-Whitney U-test. Differences between means were compared using Student's t-test. Dichotomous groupings were analyzed using Chi-squared test and Fisher's exact test as appropriate. Survival data were estimated using Kaplan-Meier estimates and compared with the log-rank test.

RESULTS

The mean estimated blood loss in the RAH group was significantly greater than that in the LRH group (836.0 ml and 414.3 ml, respectively; p<0.001). Five patients (20.8%) from the LRH group and 23 patients (47.9%) from the RAH group received blood transfusion (p<0.03). The mean length of hospital stay was significantly shorter in the LRH group compared with the RAH group (10.7 days and 18.8 days, respectively; p<0.01). No statistically significant difference existed between the two groups with respect to operative time, pelvic lymph node count, frequency of lymph node involvement, extent of parametrial or vaginal resection margins, adjuvant treatment and intra-operative complications. Median follow-up was 78 months for the LRH group and 75 months for the RAH group. There was no significant difference in the 5-year disease-free survival rate between the groups (90.5% and 93.3% for LRH and RAH, respectively; p=0.918).

CONCLUSIONS

LRH is a useful alternative to RAH for the management of early-stage cervical cancer. The benefits of LRH include reduced blood loss, fewer transfusions and shorter hospital stay, with comparable oncologic outcome.

Long-term survival outcomes of laparoscopically assisted radical hysterectomy in treating early-stage cervical cancer

OBJECTIVE

The objective of the study was to determine the long-term disease-free and overall survival outcomes of laparoscopic treatment of early-stage cervical cancer.

STUDY DESIGN

This was a longitudinal study of prospectively registered patients of cervical cancer undergoing laparoscopic surgery from June 1994 to December 2005.

RESULTS

A total of 139 patients were included, in which 60 patients were in International Federation of Gynecology and Obstetrics stage IA, 76 in IB, and 3 in IIA. Mean operation time was 231.1 +/- 6.1 minutes. Median number of pelvic lymph node retrieval was 16. Major intraoperative complications included 1 great vessel injury, 1 ureteral injury, 1 colon injury, and 6 cystotomies. In a median follow-up of 92.1 months, the mean +/- SEM cumulative disease-free and overall survival rates were 91.01% +/- 2.77% and 92.78% +/- 3.06%, respectively.

CONCLUSION

The laparoscopic approach has favorable long-term survival outcomes and perioperative morbidity. With the advantage of minimal invasiveness, laparoscopic treatment by experienced surgeons is an ideal alternative for early-stage cervical cancer.

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.

Trends in laparoscopic and robotic surgery among gynecologic oncologists: A survey update

OBJECTIVES

To assess the use of traditional and robotic assisted laparoscopy by Society of Gynecologic Oncology (SGO) members and to compare the results with those of our published survey in 2004.

METHODS

Surveys were mailed to SGO members, and anonymous responses were collected by mail or through a web site. Data were analyzed and compared with those of our previous survey. In addition, we gathered information on the effect of robotic assisted surgery on the management of gynecologic malignancies.

RESULTS

Three hundred eighty-eight (46%) of 850 SGO members responded to the survey. Three hundred fifty-two (91%) indicated that they performed laparoscopic surgery in their practice (compared with 84% in the 2004 survey). The three most common laparoscopic procedures were laparoscopic hysterectomy and staging for uterine cancer (43%), diagnostic laparoscopy for adnexal masses (39%), and prophylactic bilateral oophorectomy for high-risk women (11%). Although 76% of respondents had received either limited or no laparoscopic training during their fellowship, 78% now believe that maximum or much emphasis should be placed on laparoscopic training (55% in the 2004 survey). Twenty-four percent of respondents indicated that they performed robotic assisted surgery, with 66% indicating that they planned to increase their use of the procedure in the next year.

CONCLUSIONS

We found an overall increase in the use of and perceived indications for minimally invasive surgery in gynecologic oncology among SGO members. Endometrial cancer staging has become an accepted indication for laparoscopy. In addition, most respondents were planning on increasing their use of robotic assisted surgery in the next year.

Surgicopathologic outcome of laparoscopic versus open radical hysterectomy

OBJECTIVE

To compare the surgicopathologic outcome of total laparoscopic radical hysterectomy (LRH) with that of abdominal radical hysterectomy (ARH) for the treatment of early-stage cervical cancer.

METHODS

Radical hysterectomy specimens of sequential patients undergoing LRH (N=50) were compared with those of historical controls selected from consecutive women who have had conventional ARH (N=48), and who met the same criteria for eligibility as the cases. To evaluate the extent of parametrial resection, parametrial tissues were systematically measured at their widest dimensions before tissue processing.

RESULTS

No difference was found in demographics, histologic type, tumor stage and grade between the two groups. The parametrial width was similar between LRH and ARH in both type II (right parametrium: 2.4 cm (1-3) vs. 2.3 (1.8-4.0), p=0.28; left parametrium: 2.3 cm (1.8-4) vs. 2.2 (1.2-3.0), p=0.54) and type III radical hysterectomy (right parametrium: 3.8 cm (2.3-6.5) vs. 3.4 (1.7-7.0), p=0.59; left parametrium: 3.6 cm (2-6) vs. 3.5 (1.5-6.5), p=0.82). There were no significant differences between the two groups with regard to lymph nodes yield and likelihood of identifying positive margins or metastatic disease.

CONCLUSION

Our results suggest that laparoscopically managed patients with cervical cancer undergo a similar extent of surgery as those treated with the traditional ARH, as judged by objective pathologic criteria.

Feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy: Our experience

STUDY OBJECTIVE

The purpose of this study was to retrospectively evaluate, in a series of 65 patients, the feasibility, morbidity, and safety of total laparoscopic radical hysterectomy with lymphadenectomy for early cervical carcinoma.

DESIGN

Retrospective, nonrandomized study (Canadian Task Force classification II-2).

SETTING

Advanced Gynecological Endoscopy Center, Malzoni Medical Center, Avellino, Italy.

PATIENTS

Sixty-five nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage Ia1 with lymphvascular space involvement, Ia2, and Ib1 early cervical cancer.

INTERVENTION

Fourteen patients underwent a laparoscopic class II procedure, and 51 patients underwent a class III procedure according to the Piver classification. All the patients underwent total laparoscopic radical hysterectomy with pelvic lymphadenectomy during the study period, and none of the surgeries required conversion to laparotomy. Paraaortic lymphadenectomy is not routinely performed unless suspicious pelvic lymph nodes are confirmed to have metastatic disease on frozen section evaluation.

MEASUREMENTS AND MAIN RESULTS

Fifty-six patients had squamous cell carcinoma; 7 patients had adenocarcinomas, and 2 had adenosquamous carcinoma. The mean age was 40.5 years (95% CI 27.7-69.1) and the SD was +/- 7.5. The median weight was 56.2 kg (range 44-75 kg). The median operative time was 196 minutes (range 182-240 minutes), and the surgical margins were free of disease in all cases. The median blood loss was 55 mL (range 30-80 mL). No patient required an intraoperative blood transfusion. The median length of hospital stay was 4 days (range 3-7 days).

CONCLUSION

Laparoscopic treatment of cervical cancer offers patients the potential benefits of decreased discomfort with decreased convalescence time, but it should be reserved for oncologic surgeons trained in extensive laparoscopic procedures.

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.

Total laparoscopic radical hysterectomy and pelvic lymphadenectomy using harmonic shears

STUDY OBJECTIVE

To describe the feasibility and outcome of total laparoscopic radical hysterectomy with or without pelvic lymphadenectomy for patients with stage I cervical cancer or severe pelvic endometriosis using harmonic shears as the sole instrument for dissection, division, and maintenance of hemostasis of all major surgical pedicles.

DESIGN

Retrospective review (Canadian Task Force classification II-2).

SETTING

University hospital and affiliate institutions.

PATIENTS

Seven patients who underwent total laparoscopic radical hysterectomy using harmonic shears for International Federation of Gynecology and Obstetrics stage IA2 to IB1 cervical cancer and pelvic endometriosis at our institution or affiliate hospital from January 2004 through February 2005.

INTERVENTION

A retrospective review of patients that underwent total laparoscopic radical hysterectomy with or without pelvic lymphadenectomy at our institution using harmonic shears was performed. Information regarding preoperative, intraoperative, and postoperative events was recorded and analyzed.

MEASUREMENTS AND MAIN RESULTS

Pelvic lymphadenectomy was performed in all cancer cases. Mean patient age was 40 years (range 30-53 years). Mean estimated blood loss was 143 mL (range 100-200 mL). Mean operating time was 293 minutes (range 255-385 minutes). Mean pelvic node count was 27.8 (range 24-34) for cancer cases. Mean hospital stay was 3.2 days (range 2-7 days). One patient developed a vaginal cuff abscess postoperatively that was managed conservatively with drainage in the office setting followed by intravenous antibiotics. Another patient developed urinary retention for 2 weeks after surgery. There were no other intraoperative or postoperative complications.

CONCLUSION

Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using harmonic shears is a technically feasible and safe procedure. Larger studies and long-term follow-up are required to determine the oncologic outcomes of these patients.

Total laparoscopic radical hysterectomy and lymphadenectomy: The M. D. Anderson Cancer Center Experience

OBJECTIVE

To retrospectively evaluate the feasibility and morbidity of total laparoscopic radical hysterectomy and lymphadenectomy.

METHODS

We performed a retrospective review of all patients who underwent a total laparoscopic radical hysterectomy at our institution between May 2004 and August 2005. Data collected included age, body mass index, stage, histopathologic subtype, tumor grade, estimated blood loss, perioperative blood transfusions, number and status of lymph nodes obtained, status of surgical margins, length of hospital stay, time to resumption of normal bladder function, intraoperative and postoperative complications, and disease-free interval.

RESULTS

Twenty patients underwent total laparoscopic radical hysterectomy during the study period. None of the surgeries required conversion to laparotomy. The median patient age was 41.5 years (range, 25-76). Eighteen patients had cervix cancer (5 stage IA2 and 13 stage IB1), and 2 had endometrial cancer (1 stage IB and 1 stage IIIA). Among those with cervix cancer, 12 had adenocarcinoma, 4 squamous cell carcinoma, and 2 adenosquamous carcinoma. The median weight was 70 kg (range, 49-112). The median number of resected pelvic lymph nodes was 13 (range, 9-26). One patient had nodal disease. The surgical margins were free of disease in all cases. The median blood loss was 200 ml (range, 25-700 ml). Only 1 patient required an intraoperative blood transfusion (1 U packed red blood cells). The median length of hospital stay was 1 day (range, 1-5). There were 3 short-term complications--unintentional cystotomy, pulmonary embolus, and pneumomediastinum with subcutaneous emphysema. There were 2 long-term complications--vaginal eviscerations and a lymphocyst. The median time to resumption of normal bladder function was 16 days (range, 13-29). The median follow-up time was 8 months range (1-16). All patients remain free of disease at the time of this report.

CONCLUSIONS

Total laparoscopic radical hysterectomy can be performed safely with minimal blood loss and postoperative morbidity, and patients undergoing this procedure may be discharged after an overnight stay in the hospital.

Total laparoscopic radical hysterectomy (type II-III) with pelvic lymphadenectomy in early invasive cervical cancer

STUDY OBJECTIVE

To describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy in early cervical cancer.

DESIGN

Retrospective, nonrandomized study (Canadian Task Force classification II-2).

SETTING

Acute-care, teaching hospital.

PATIENTS

Twenty-seven nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 (n = 4) or IB1 (n = 23) cancer of the cervix.

INTERVENTION

Laparoscopic type II (n = 9) or type III (n = 18) hysterectomy with systematic bilateral pelvic lymphadenectomy. Monopolar coagulation, vascular clips, and harmonic scalpel were used. Resection of the cardinal and uterosacral ligaments was performed with Endo GIA stapling and the harmonic scalpel.

MEASUREMENTS AND MAIN RESULTS

Histopathologically, there were 20 cases of squamous carcinoma, 6 adenocarcinomas, and 1 adenosquamous carcinoma. The operation was performed entirely by laparoscopy in 26 patients. One patient underwent laparotomy because of equipment failure. The patients' mean age was 45.1 years (95% CI 41.7-48.4), with a median body mass index of 26.0 kg/m2. The mean number of resected pelvic nodes was 19.1 (95% CI 17.02-21.2). Three patients had microscopic metastatic nodal disease. The surgical margins were free of disease in all cases. The median blood loss was 400 mL (range 250-700 mL). The median length of stay was 5 days. Major intraoperative complications did not occur. All patients are free of disease after a median follow-up of 32 months (range 4-52 months).

CONCLUSION

Radical hysterectomy can be successfully completed by laparoscopy in patients with early cervical cancer. This procedure may reduce the morbidity associated with abdominal or transvaginal radical hysterectomy.

Laparoscopic modified radical hysterectomy: a strategy for a clinical dilemma

OBJECTIVE

To investigate the role of laparoscopic modified radical (type 2) hysterectomy when cervical cancer cannot be excluded or documented preoperatively.

METHODS

Between 1996 and 2004, 50 patients with cervical intraepithelial neoplasia (CIN III) or adenocarcinoma in situ (AIS) involvement of cone endocervical margins and/or endocervical curettings, who were not candidates for observation or repeat conization, underwent laparoscopy to perform a modified radical hysterectomy.

RESULTS

Forty-nine (98.0%) modified radical hysterectomies were completed laparoscopically and one (2.0%) patient required a laparotomy. Of the overall group, 35 (70.0%) had residual pathology; 26 (52.0%) were precancerous lesions, and 9 (18.0%) had invasive disease (5 adenocarcinomas, 3 squamous lesions, and 1 adenosquamous carcinoma). Of the nine with cancer, one had stage IA1 disease, three had stage IA2 disease, and five had stage IB1 disease. Five (55.6%) invasive lesions were diagnosed intraoperatively (frozen section), and a laparoscopic pelvic and lower aortic lymph node dissection was performed. The median operative time was 96 min (range 58-185), blood loss 100 ml (50-450), and postoperative hospital stay 2.5 days (range 1-14). There were no incidences of prolonged urinary retention fistulas, or other serious complications. All patients with cancer remain disease-free (median follow-up 44.2 months, range 1-88.7 months).

CONCLUSIONS

Laparoscopic modified radical hysterectomy is a treatment option for patients for whom cervical cancer cannot be definitively excluded, and can be completed with acceptable operative time, blood loss, and hospitalization.

Laparoscopic radical hysterectomy for invasive cervical cancer: 8-year experience of a pilot study

OBJECTIVE

The aim of this study was to retrospectively evaluate, in a series of 50 consecutive patients, the feasibility, morbidity, and survival outcome of the laparoscopic radical hysterectomy for carcinoma of the uterine cervix.

METHODS

Fifty patients with invasive cervical cancer were operated on by laparoscopic radical hysterectomy between 1993 and 2001 at two cancer centers. Patients in a good general condition with a cervical carcinoma less than 4 cm and a body mass index up to 29 were eligible. Thirty-one patients had prior brachytherapy.

RESULTS

The median overall operative time was 258 min. The mean number of harvested pelvic external iliac nodes was 13.22 per patient. The median postoperative hospital stay was 7.5 days. Two patients had major urinary complications; one had a bladder fistula and one a ureteral stenosis. The median follow-up was 44 months. The overall 5-year survival rate of FIGO stage Ia2 and Ib1 patients was 96%.

CONCLUSION

Our results demonstrate that radical hysterectomy can be performed by laparoscopy in stage IB1 or less advanced node negative cervical cancer patients without compromising survival. Prior brachytherapy did not affect the feasibility of this radical procedure.

Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using the argon-beam coagulator: pilot data and comparison to laparotomy

OBJECTIVES

The aim of this study was to describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy for stage I cervical cancer using the argon-beam coagulator.

METHODS

A retrospective review was performed of patients with FIGO stage IA1-IB1 cervical cancer who underwent a total laparoscopic approach for definitive surgical treatment. Comparison was made to a cohort of 195 patients who were treated with laparotomy.

RESULTS

Between 12/2000 and 12/2002, 19 patients were offered the laparoscopic approach. The procedure was completed laparoscopically in 17 patients (89.5%). Two patients, in the beginning of the study, underwent conversion to laparotomy, 1 due to parametrial bleeding and 1 due to pelvic adhesions and cystotomy. Mean age was 42.6 years (range, 30-69 years); mean body mass index was 23.1 (range, 18-30); FIGO stage included IA1 with LVI (2), IA2 (6), IB1 (11). Mean pelvic lymph node count was 25.5 (range, 15-39), and 1 patient (5.3%) had positive nodes. Mean estimated blood loss was 301 cc (range, 75-1500 cc) compared to 693 cc in the laparotomy group (P < 0.01), mean operating time was 371 min (range, 230-600 min) compared to 295 min in the laparotomy group (P < 0.01), and mean hospital stay was 4.5 days (range, 3-11 days) compared to 9.7 days in the laparotomy group (P < 0.01). There were no ureteral injuries or fistula formation. All patients remain clinically disease free at the time of this report.

CONCLUSIONS

Total laparoscopic radical hysterectomy with pelvic lymphadenectomy for selected patients with stage I cervical cancer is feasible, safe, and associated with a low morbidity in the pilot phase. Estimated blood loss and postoperative hospitalization appear shorter than historical controls, at the cost of longer operating time. Oncologic outcome requires longer follow-up.

Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer

OBJECTIVE

The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors.

METHODS

Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98).

RESULTS

Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%.

CONCLUSION

Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.

Urologic complications of major pelvic surgery

The close proximity of pelvic organs makes the genitourinary system susceptible to injury during major pelvic surgery. Iatrogenic injury remains the most common cause of lower urinary tract trauma. Recent modifications in surgical technique, such as sharp mesorectal incision and nerve-sparing radical prostatectomy, have decreased the incidence of many of these complications. Genitourinary complications due to pelvic surgery remain common, however, and as new surgical advancements are made, new complications may present. An understanding of the prevention, recognition, and treatment of urologic complications is important for every surgeon performing major pelvic surgery.