Effectiveness and Long-term Outcomes of Nerve-Sparing Radical Hysterectomy for Cervical Cancer

Perineural Invasion in Cervical Cancer: A Hidden Trail for Metastasis

Perineural invasion (PNI), the neoplastic invasion of nerves, is an often overlooked pathological phenomenon in cervical cancer that is associated with poor clinical outcomes. The occurrence of PNI in cervical cancer patients has limited the promotion of Type C1 surgery. Preoperative prediction of the PNI can help identify suitable patients for Type C1 surgery. However, there is a lack of appropriate preoperative diagnostic methods for PNI, and its pathogenesis remains largely unknown. Here, we dissect the neural innervation of the cervix, analyze the molecular mechanisms underlying the occurrence of PNI, and explore suitable preoperative diagnostic methods for PNI to advance the identification and treatment of this ominous cancer phenotype.

Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review

OBJECTIVE

To synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary.

DESIGN

We performed a literature search on PubMed using the search terms "pelvis" and "nerve-sparing." Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures.

RESULTS

224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms.

CONCLUSION

Surgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.

Laparoscopic Modified Radical Hysterectomy for Severe Endometriosis: A Single-Center Case Series

STUDY OBJECTIVE

The main objective is to describe the feasibility and report a single-center experience of a standardized laparoscopic modified radical hysterectomy technique among patients with severe endometriosis and pouch of Douglas obliteration.

DESIGN

A single-center case series of laparoscopic modified radical hysterectomy performed at the Poissy Hospital between December 2012 and May 2021.

SETTINGS

Single-center, gynecology unit (level III) with a focus on endometriosis.

PATIENTS

Patients with severe endometriosis (stage 4 American Fertility Society) and pouch of Douglas obliteration.

MEASUREMENTS AND MAIN RESULTS

Fifty-two patients with severe endometriosis underwent the surgical procedure. Of these patients, 23.1% underwent a rectal shaving (n = 12), 1.9% a discoid resection (n = 1), and 17.3% a rectal resection (n = 9), including a protective ileostomy in 1 case. Ureterolysis was performed on 82.7% of patients (n = 43). The average hospital stay was 3.3 days. Seven patients required intermittent self-catheterization (13.5%). Minor complications (Clavien-Dindo grade 1 and 2) occurred in 25.9% of the patients and severe complications in 3.8% of them (Clavien-Dindo grade 3, no grade 4). Two patients (3.8%) were reoperated: one for a postoperative occipital alopecia (balding) and the other for vaginal dehiscence with evisceration. Approximately 50 patients (96.2%) had a complete resection of endometriosis. The median follow-up was 14 months (interquartile range, 6-23 mo) with 94.3% of them improved (much and very much) and 3.8% minimally improved.

CONCLUSION

In our experience, laparoscopic modified radical hysterectomy is a reliable procedure with a low rate of severe complications. This technique needs to be assessed by other surgeons and others centers across the country and abroad, to determine the likelihood of it succeeding.

Challenges in the Diagnosis and Individualized Treatment of Cervical Cancer

Cervical cancer is still the fourth most common cancer in women throughout the world; an estimated 604,000 new cases were observed in 2020. Better knowledge of its pathogenesis, gained in recent years, has introduced new preventive and diagnostic approaches. Knowledge of its pathogenesis has made it possible to provide individualized surgical and drug treatment. In industrialized countries, cervical cancer has become a less frequent tumor entity due to the accessibility of the human papilloma virus vaccination, systematic preventive programs/early detection programs, health care infrastructure and the availability of effective therapy options. Nevertheless, globally, neither mortality nor morbidity has been significantly reduced over the past 10 years, and therapy approaches differ widely. The aim of this review is to address recent advances in the prevention, diagnostic investigation and treatment of cervical cancer globally, focusing on advances in Germany, with a view toward providing an updated overview for clinicians. The following aspects are addressed in detail: (a) the prevalence and causes of cervical cancer, (b) diagnostic tools using imaging techniques, cytology and pathology, (c) pathomechanisms and clinical symptoms of cervical cancer and (d) different treatment approaches (pharmacological, surgical and others) and their impact on outcomes.

Laparoscopic modified radical hysterectomy for women with stage IV AFS endometriosis and obliterated Douglas space: a technical note (with video)

Excision of deep infiltrating endometriosis has to be complete to prevent symptomatic recurrences but with more complications. The patients with obliterated Douglas space who wish a definitive treatment for their pain require a more complex hysterectomy to remove all the lesions. Laparoscopic modified radical hysterectomy may allow to perform safely this surgery following 9 steps. The dissection is standardized according to anatomical landmarks. The key steps are: extrafascial dissection of uterine pedicle by opening the pararectal spaces and paravesical space, nerve sparing, ureterolysis if needed, the retrograde dissection of rectovaginal space and the rectal step if needed. The rectal step depends on depth of rectal infiltration and on the number of nodules (rectal shaving, disc excision or rectal resection). This standardized procedure could help surgeons to achieve a complex radical surgery for patients with endometriosis and obliterated Douglas space.

Impact of timing of urinary catheter removal on voiding dysfunction after radical hysterectomy for early cervical cancer

OBJECTIVES

To evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.

METHODS

We performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100 mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.

RESULTS

Among 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used enhanced recovery after surgery (ERAS) pathways. 29 (12.4%) patients had urinary catheter removal between 1-5 days postoperatively (group 1), 141 (60.3%) between 6-10 days (group 2), and 64 (27.3%) between 11-15 days (group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between group 1 (17.2%), group 2 (11.3%), and group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3-5 days) compared with group 2 (8 days, IQR 7-10 days) and group 3 (13 days, IQR 11-15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or re-admission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.

CONCLUSION

There was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.