Adjuvant Radiotherapy for Groin Node Metastases Following Surgery for Vulvar Cancer: A Systematic Review

Background: Lymph node metastasis in vulvar cancer is a critical prognostic factor associated with higher recurrence and decreased survival. A survival benefit is reported with adjuvant radiotherapy but with potential significant morbidity. We aim to clarify whether there is high-quality evidence to support the use of adjuvant radiotherapy in this setting. Objectives: The aim of the study was to assess the effectiveness and safety of adjuvant radiotherapy to locoregional metastatic nodal areas. Search Methods: We conducted a comprehensive and systematic literature search of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Google Scholar, ClinicalTrials.gov, and the National Cancer Institute. We considered only randomized controlled trials (RCTs). Main Results: We identified 1,760 records and finally retrieved only one eligible RCT (114 participants with positive inguinofemoral lymph nodes). All women had undergone radical vulvectomy and bilateral inguinal lymphadenectomy and had been randomized to adjuvant radiotherapy or to intraoperative ipsilateral pelvic lymphadenectomy without adjuvant radiotherapy. At 6 years, the overall survival (OS) was 51% versus 41% in favor of radiotherapy (HR 0.61; 95% CI 0.30-1.3) without significance and with very low certainty of evidence. At 6 year, the cumulative incidence of cancer-related deaths was 29% versus 51% in favor of adjuvant radiotherapy (HR 0.49; 95% CI 0.28-0.87). Recurrence-free survival at 6 years was 59% after adjuvant radiotherapy versus 48% after pelvic lymphadenectomy (HR 0.39; 95% CI 0.17-0.88). Three (5.3%) versus 13 (24.1%) groin recurrences were noted, respectively, in the adjuvant radiotherapy and pelvic lymphadenectomy groups. There was no significant difference in acute toxicities for pelvic lymphadenectomy compared to radiotherapy. In women with positive pelvic lymph nodes (20%), the OS at 6 year was 36% compared with 13% in favor of adjuvant radiotherapy. Late cutaneous toxicity rate appeared to be greater after radiotherapy (19% vs. 15%) but with less chronic lymphedema (16% vs. 22%). Conclusion: There is only very low-quality evidence on administering adjuvant radiotherapy for inguinal lymph node metastases. Although the identified study was a multicenter RCT, there was a reasonable imprecision and inconsistency because of small study numbers, wide confidence intervals in the data, and early trial closure, resulting in downgrading of the evidence.

The efficacy of peritoneal flap fixation on symptomatic lymphocele formation following robotic-assisted laparoscopic radical prostatectomy with pelvic lymph node dissection: a systematic review and meta-analysis

BACKGROUND

Pelvic lymphocele is the most common complication after robot-assisted radical prostatectomy (RARP) with pelvic lymph node dissection (PLND), of which symptomatic lymphocele (sLC) ranges up to 10% and is associated with poorer perioperative outcomes. Peritoneal flap fixation (PFF) is a promising intraoperative modification to reduce sLC formation but the clinical evidence failed to reach consistency.

MATERIALS AND METHODS

Randomized and nonrandomized comparative studies comparing postoperative sLC occurrence with or without PFF after RARP with PLND were identified through a systematic literature search via MEDLINE/PubMed, Embase, Web of Science, and CENTRAL up to July 2023. Outcome data of sLC occurrence (primary) and major perioperative events (secondary) were extracted. Mean difference and risk ratio with 95% CI were synthesized as appropriate for each outcome to determine the cumulative effect size.

RESULTS

Five RCTs and five observatory studies involving 3177 patients were finally included in the qualitative and quantitative analysis. PFF implementation significantly reduced the occurrence of sLC (RR 0.35, 95% CI: 0.24-0.50), and the specific lymphocele-related symptoms, without compromised perioperative outcomes including blood loss, operative time, and major nonlymphocele complications. The strength of the evidence was enhanced by the low risk of bias and low inter-study heterogeneity of the eligible RCTs.

CONCLUSION

PFF warrants routine implementation after RARP with PLND to prevent or reduce postoperative sLC formation.

Comparison of the efficacy and safety of total laparoscopic hysterectomy without and with uterine manipulator combined with pelvic lymphadenectomy for early cervical cancer

OBJECTIVE

Some studies have reported that the prognosis of total laparoscopic hysterectomy (TLH) for early-stage cervical cancer (CC) is worse than that of open surgery. And this was associated with the use of uterine manipulator or not. Therefore, this study retrospectively analyzes the efficacy and safety of TLH without uterine manipulator combined with pelvic lymphadenectomy for early-stage CC.

METHODS

Fifty-eight patients with CC (stage IB1-IIA1) who received radical hysterectomy from September 2019 to January 2020 were divided into no uterine manipulator (n = 26) and uterine manipulator group (n = 32). Then, clinical characteristics were collected and intraoperative/postoperative related indicators were compared.

RESULTS

Patients in the no uterine manipulator group had significantly higher operation time and blood loss than in the uterine manipulator group. Notably, there was no significant difference in hemoglobin change, blood transfusion rate, number of pelvic nodules, anal exhaust time, complications and recurrence rate between the two groups. Additionally, patients in the uterine manipulator group were prone to urinary retention (15.6%) and lymphocyst (12.5%), while the no uterine manipulator group exhibited high probability of bladder dysfunction (23.1%) and urinary retention (15.4%). Furthermore, the 1-year disease-free survival rate and the 1-year overall survival rate were not significantly different between the two groups.

CONCLUSION

There was no significant difference in the efficacy and safety of TLH with or without uterine manipulator combined with pelvic lymphadenectomy in the treatment of patients with early-stage CC. However, the latter requires consideration of the negative effects of high operation time and blood loss.

Predictors of Non-Sentinel Lymph Node Metastasis in Patients with Positive Sentinel Lymph Node in Early-Stage Cervical Cancer: A SENTICOL GROUP Study

BACKGROUND

The goal of this study was to identify the risk factors for metastasis in the remaining non-sentinel lymph nodes (SLN) in the case of positive SLN in early-stage cervical cancer.

METHODS

An ancillary analysis of two prospective multicentric databases on SLN biopsy for cervical cancer (SENTICOL I and II) was performed. Patients with early-stage cervical cancer (FIGO 2018 IA to IIA1), with bilateral SLN detection and at least one positive SLN after ultrastaging, were included.

RESULTS

405 patients were included in SENTICOL I and Il. Fifty-two patients had bilateral SLN detection and were found to have SLN metastasis. After pelvic lymphadenectomy, metastatic involvement of non-SLN was diagnosed in 7 patients (13.5%). Patients with metastatic non-SLN were older (51.9 vs. 40.8 years, p = 0.01), had more often lympho-vascular space invasion (LVSI) (85.7% vs. 35.6%, p = 0.03), and had more often parametrial involvement (42.9% vs. 6.7%, p = 0.003). Multivariate analysis retained age (OR = 1.16, 95% IC = [1.01-1.32], p = 0.03) and LVSI (OR = 25.97, 95% IC = [1.16-582.1], p = 0.04) as independently associated with non-SLN involvement.

CONCLUSIONS

Age and LVSI seemed to be predictive of non-SLN metastasis in patients with SLN metastasis in early-stage cervical cancer. Larger cohorts are needed to confirm the results and clinical usefulness of such findings.

Effect of Peritoneal Interposition Flap to Prevent Symptomatic Lymphoceles in Robot-Assisted Radical Prostatectomy with Pelvic Lymphadenectomy: A Meta-Analysis and Systematic Review

Background: This systematic review and meta-analysis investigated whether peritoneal interposition flap (PIF) prevent lymphocele formation after robot-assisted radical prostatectomy with extended pelvic lymph node dissection. Materials and Methods: We performed a systematic review and cumulative meta-analysis of the primary outcomes according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, Assessing the Methodological Quality of Systematic Reviews guidelines and risk-of-bias tool. Five databases, including Medline, PubMed, Cochrane Library, Scopus, and Web of Science, were systematically searched. The time frame of the search was set from the creation of the database to February 2023. Results: Meta-analysis of symptomatic lymphoceles (sLCs) rates revealed significant difference between PIF and no PIF group (eight studies pooled; p = 0.005), The sLCs rates account for 2.6% (28/1074) and 7.1% (85/1186) in the PIF and no PIF group, respectively. The resulting odds ratio was 0.34 (95% confidence interval: 0.16-0.73), taking into account the heterogeneity of these studies (Q = 14.32, p = 0.05; I2 = 51%). Conclusion: PIF is an effective intraoperative modification on the prevention or reduction of sLC, which is worthy of further clinical promotion. Systematic Review Registration: National Institute for Health and Care Research, identifier CRD42022364461.

[Research Progress in Preoperative Evaluation of Lymph Node Metastasis of Bladder Cancer]

Bladder cancer is a common malignant tumor of the urinary system.The prognosis of patients with positive lymph nodes is worse than that of patients with negative lymph nodes.An accurate assessment of preoperative lymph node statushelps to make treatmentdecisions,such as the extent of pelvic lymphadenectomy and the use of neoadjuvant chemotherapy.Imaging examination and pathological examination are the primary methods used to assess the lymph node status of bladder cancer patients before surgery.However,these methods have low sensitivity and may lead to inaccuate staging of patients.We reviewed the research progress and made an outlook on the application of clinical diagnosis,imaging techniques,radiomics,and genomics in the preoperative evaluation of lymph node metastasis in bladder cancer patients at different stages.

Beyond Sentinel Lymph Node: Outcomes of Indocyanine Green-Guided Pelvic Lymphadenectomy in Endometrial and Cervical Cancer

BACKGROUND

The aim of our study was to compare the number of lymph nodes removed during indocyanine green (ICG)-guided laparoscopic/robotic pelvic lymphadenectomy with standard systematic lymphadenectomy in endometrial cancer (EC) and cervical cancer (CC).

METHODS

This is a multicenter retrospective comparative study (Clinical Trial ID: NCT04246580; updated on 31 January 2023). Women affected by EC and CC who underwent laparoscopic/robotic systematic pelvic lymphadenectomy, with (cases) or without (controls) the use of ICG tracer injection within the uterine cervix, were included in the study.

RESULTS

The two groups were homogeneous for age (p = 0.08), Body Mass Index, International Federation of Gynaecology and Obstetrics (FIGO) stages (p = 0.41 for EC; p = 0.17 for CC), median estimated blood loss (p = 0.76), median operative time (p = 0.59), and perioperative complications (p = 0.66). Nevertheless, the number of lymph nodes retrieved during surgery was significantly higher (p = 0.005) in the ICG group (n = 18) compared with controls (n = 16).

CONCLUSIONS

The accurate and precise dissection achieved with the use of the ICG-guided procedure was associated with a higher number of lymph nodes removed in the case of systematic pelvic lymphadenectomy for EC and CC.

Treatment of Early-Stage Gynecological Cancer-Related Lower Limb Lymphedema by Lymphaticovenular Anastomosis-The Triple Incision Approach

Background and Objectives: Lower extremity lymphedema (LEL) is one of the most relevant chronic and disabling sequelae after gynecological cancer therapy involving pelvic lymphadenectomy (PL). Supermicrosurgical lymphaticovenular anastomosis (LVA) is a safe and effective procedure to treat LEL, particularly indicated in early-stage cases when conservative therapies are insufficient to control the swelling. Usually, preoperative assessment of these patients shows patent and peristaltic lymphatic vessels that can be mapped throughout the limb to plan the sites of skin incision to perform LVA. The aim of this study is to report the efficacy of our approach based on planning LVA in three areas of the lower limb in improving early-stage gynecological cancer-related lymphedema (GCRL) secondary to PL. Materials and Methods: We retrospectively reviewed the data of patients who underwent LVA for the treatment of early-stage GCRL following PL. Patients who had undergone groin dissection were excluded. Our preoperative study based on indocyanine green lymphography (ICG-L) and color doppler ultrasound (CDU) planned three incision sites located in the groin, in the medial surface of the distal third of the thigh, and in the upper half of the leg, to perform LVA. The primary outcome measure was the variation of the mean circumference of the limb after surgery. The changes between preoperative and postoperative limbs’ measures were analyzed by Student’s t-test. p values < 0.05 were considered significant. Results: Thirty-three patients were included. In every patient, three incision sites were employed to perform LVA. A total of 119 LVA were established, with an average of 3.6 for each patient. The mean circumference of the operated limb showed a significant reduction after surgery, decreasing from 37 cm ± 4.1 cm to 36.1 cm ± 4.4 (p < 0.01). Conclusions: Our results suggest that in patients affected by early-stage GCRL secondary to PL, the placement of incision sites in all the anatomical subunits of the lower limb is one of the key factors in achieving good results after LVA.

Comparison of perioperative complications for extended vs standard pelvic lymph node dissection in patients undergoing radical prostatectomy for prostate cancer: a meta-analysis

INTRODUCTION

Pelvic lymph node dissection (PLND) is widely performed for staging in men undergoing radical prostatectomy (RP) for prostate cancer. Our goal was to synthesize all available evidence and data to evaluate perioperative complications for two templates of PLND, standard (sPLND) vs extended (ePLND), at the time of RP in patients with prostate cancer.

METHODS

A meta-analysis was performed on relevant literature about complications during PLND. Pubmed, Scopus, WebofScience, and Cochrane Library were systematically searched through July 2021. Meta-analysis was conducted with both fixed-effects and random-effects models to estimate risk ratios (RRs) between treatments. A subgroup analysis was also conducted based on surgery type - open vs robotic.

RESULTS

13 (1 randomized clinical trial and 12 observational studies) studies published between 1997 and 2019 with a total of 7,036 patients were analyzed. Pooled data showed complications in a random-effects model was lower in the sPLND group than the ePLND group (RR, 0.62; 95% CI 0.40-0.97). In a subgroup analysis, neither the open surgery subgroup nor the robotic surgery subgroup showed significant differences in complication rate between sPLND and ePLND.

CONCLUSION

ePLND is associated with a significantly greater risk of perioperative complication compared to sPLND, but not when comparing these templates performed via a robotic approach. Additional studies comparing the complication rates of sPLND and ePLND when utilizing a robotic approach should be conducted.

Fertility-sparing surgery for early-stage cervical cancer: A case series study on the efficacy and feasibility of cervical conization followed by pelvic lymphadenectomy

OBJECTIVES

To evaluate the oncologic and obstetric outcomes of cervical conization followed by pelvic lymphadenectomy, which is used as a fertility-sparing procedure, in reproductive-aged patients with early-stage cervical cancer.

METHODS

We performed a retrospective study of patients with stage IA1-IB1 cervical cancer who underwent cervical conization followed by pelvic lymphadenectomy from 2011 to 2020 at Kumamoto University Hospital.

RESULTS

In total, eight patients underwent conization followed by pelvic lymphadenectomy. The median age of the patients was 33 (range: 28-36) years. Four (50.0%) patients were nulliparous. Seven (87.5%) patients were diagnosed with squamous cell carcinoma (87.5%) and one (12.5%) with adenocarcinoma. Five (62.5%), two (25.0%), and one (12.5%) presented with stage IA1, IA2, and IB1 disease, respectively. Five (62.5%) patients had lymphovascular space invasion (LVSI) based on the assessment of specimens obtained via conization. However, none had lymph node metastasis based on pelvic lymphadenectomy. Regarding long-term oncologic outcomes, recurrence was not observed at a median follow-up of 60 (range: 8-107) months. In addition, obstetric outcomes were consistently favorable in terms of achieving pregnancy, preterm delivery, and live birth. During the study period, two patients who actively attempted to conceive had four pregnancies, resulting in full-term deliveries, and one was on her first trimester of pregnancy.

CONCLUSION

Cervical conization combined with pelvic lymphadenectomy represents a feasible conservative management for histologically well-selected patients with early-stage cervical cancer. Furthermore, an optimal histopathological evaluation of conization specimens will contribute to decision-making regarding the use of this fertility-sparing procedure.

Successful pregnancy with stage IB2 uterine cervical cancer: A case report

Background

Although cervical cancer is one of the most common malignancies in pregnancy, its management mainly follows the guidelines for nonpregnant disease state. Within the limited time, patients, and healthcare workers must make difficult decisions to either delay treatment until documented fetal maturity or start immediate treatment based on the disease stage.

Case

The patient was a 37‐year‐old woman: gravida 1, para 0. Her cervical cytology revealed a high‐grade squamous intraepithelial lesion at 8 weeks' gestation. Moreover, invasive squamous cell carcinoma was suspected based on the findings of uterine cervix biopsy. Cervical conization was performed at 11 weeks' gestation, confirming a histopathological diagnosis of squamous cell carcinoma, pT1b2. Cervical cytology findings continued to be negative for intraepithelial lesion or malignancy from 2 weeks after conization until 2 weeks before a cesarean section. In addition, we performed abdominal pelvic lymphadenectomy at 16 weeks' gestation to determine whether the patient could continue her pregnancy. No lymph node metastasis or local recurrence was observed. Finally, a cesarean section and modified radical hysterectomy were performed at 35 weeks' gestation. There was no carcinoma invasion or metastasis. A baby girl weighing 2056 g was delivered with 1‐ and 5‐min Apgar scores of 8 and 9, respectively. Five years postoperatively, there was no evidence of cancer recurrence.

Conclusion

Management of cervical cancer during pregnancy by using a combination strategy of deep conization and pelvic lymphadenectomy could be an effective strategy for carefully and safely assessing risks of recurrence and metastasis.

Laparoscopic repair of segmental obturator nerve injury defect using an artificial nerve conduit: A case report

Obturator nerve injury is an uncommon complication frequently associated with pelvic gynecologic or urologic cancer surgery. It can lead to disability or adversely affect quality of life. Large segmental defects are particularly difficult to manage as the limited mobility of the nerve prevents tension-free direct end-to-end anastomosis. A 36-year-old woman with cervical cancer underwent sentinel lymph node biopsy, laparoscopic radical hysterectomy, and bilateral adnexectomy. During the procedure, the sentinel lymph node (right obturator node) adherent to the obturator nerve was resected together with the nerve segment leaving a 3 cm defect. Immediate laparoscopic obturator nerve repair was performed using an artificial nerve conduit leading to successful recovery. We report this unique case due to rarity of large segmental obturator nerve defects and present laparoscopic nerve repair with artificial nerve conduits as a useful treatment alternative of these important injuries, without nerve donor site morbidity.

The Adequacy of Pelvic Lymphadenectomy During Radical Cystectomy for Carcinoma Urinary Bladder: A Narrative Review of Literature

An adequate pelvic lymph node dissection (PLND) is an essential part of radical cystectomy for muscle invasive bladder cancer. However, the definition of what constitutes an adequate PLND is often shrouded in controversy. Various authors have defined different anatomic templates of PLND based on levels of pelvic lymph nodes. Some have suggested other surrogate markers of the adequacy of PLND, namely lymph node count and lymph node density. While individual studies have shown the efficacy and reliability of some of the above markers, none of them have been recommended forthright due to the absence of robust prospective data. The use of non-standardized nomenclature while referring to the above variables has made this matter more complex. Most of older data seems to favor use of extended template of PLND over the standard template. On the other hand, one recent randomized controlled trial (RCT) did not show any benefit of one template over the other in terms of survival benefit, but the study design allowed for a large margin of bias. Therefore, we conducted a systematic search of literature using EMBASE, Medline, and PubMed using PRISMA-P checklist for articles in English Language published over last 20 years. Out of 132 relevant articles, 47 articles were included in the final review. We have reviewed existing literature and guidelines and have attempted to provide a few suggestions toward a uniform nomenclature for the various anatomical descriptions and the extent of PLND done while doing a radical cystectomy. The results of another large RCT (SWOG S1011) are awaited and until we have a definitive evidence, we should adhere to these suggestions as much as possible and deal with each patient on a case to case basis.

Lower-Limb Lymphedema after Sentinel Lymph Node Biopsy in Cervical Cancer Patients

Simple Summary

Lower-limb lymphedema (LLL) is a well-recognized adverse outcome of the surgical management of cervical cancer. Recently, sentinel lymph node (SLN) biopsy has emerged as an alternative procedure to systematic pelvic lymphadenectomy (PLND) aiming to decrease the risk of complications, especially LLL development. Our study represents the first prospective analysis of LLL incidence in cervical cancer patients after a uterine procedure with SLN biopsy, without systematic PLND. In an international multicenter trial SENTIX, the group of 150 patients was prospectively evaluated using both objective and subjective LLL assessments in 6 months intervals for 2 years. Contrary to the expectations, our results showed that SLN biopsy does not eliminate the risk of LLL development which occurred in a mild or moderate stage in about 26% of patients with a median interval to the onset of 9 months.

Abstract

Background: To prospectively assess LLL incidence among cervical cancer patients treated by uterine surgery complemented by SLN biopsy, without PLND. Methods: A prospective study in 150 patients with stage IA1–IB2 cervical cancer treated by uterine surgery with bilateral SLN biopsy. Objective LLL assessments, based on limb volume increase (LVI) between pre- and postoperative measurements, and subjective patient-perceived swelling were conducted in six-month periods over 24-months post-surgery. Results: The cumulative incidence of LLL at 24 months was 17.3% for mild LLL (LVI 10–19%), 9.2% for moderate LLL (LVI 20–39%), while only one patient (0.7%) developed severe LLL (LVI > 40%). The median interval to LLL onset was nine months. Transient edema resolving without intervention within six months was reported in an additional 22% of patients. Subjective LLL was reported by 10.7% of patients, though only a weak and partial correlation between subjective-report and objective-LVI was found. No risk factor directly related to LLL development was identified. Conclusions: The replacement of standard PLND by bilateral SLN biopsy in the surgical treatment of cervical cancer does not eliminate the risk of mild to moderate LLL, which develops irrespective of the number of SLN removed.

Sentinel node mapping using indocyanine green and near-infrared fluorescence imaging technology for endometrial cancer: A prospective study using a surgical algorithm in Indian patients

Background:

Indocyanine green (ICG) fluorescence with high-definition, three-dimensional imaging systems is emerging as the latest strategy to reduce trauma and improve surgical outcomes during oncosurgery.

Materials and Methods:

This is a prospective study involving 100 patients with carcinoma endometrium who underwent robotic-assisted Type 1 pan-hysterectomy, with ICG-directed sentinel lymph node (SLN) biopsy from November 2017 to December 2019. The aim was to assess the feasibility and diagnostic accuracy of SLN algorithm and to evaluate the location and distribution of SLN in pelvic, para-aortic and unusual areas and the role of frozen section.

Results:

The overall SLN detection rate was 98%. Bilateral detection was possible in 92% of the cases. Right side was detected in 98% of the cases and left side was visualised in 92% of the cases. Complete node dissection was done where SLN mapping failed. The most common location for SLN in our series was obturator on the right hemipelvis and internal iliac on the left hemipelvis. SLN in the para-aortic area was detected in 14% of cases. In six cases, SLN was found in atypical locations, that is pre-sacral area. Eight patients had SLN positivity for metastasis and underwent complete retroperitoneal lymphadenectomy. Comparison of final histopathological report with frozen section reports showed no false negatives.

Conclusions:

SLN mapping holds a great promise as a modern staging strategy for endometrial cancer. In our experience, cervical injection was an optimal method of mapping the pelvis. ICG showed a high overall detection rate, and bilateral mapping appears to be a feasible alternative to the more traditional methods of SLN mapping in patients with endometrial cancer. The ICG fluorescence imaging system is simple and safe and may become a standard in oncosurgery in view of its staging and anatomical imaging capabilities. This approach can reduce the morbidity, operative times and costs associated with complete lymphadenectomy while maintaining prognostic and predictive information.

Obturator nerve injury diagnosed by nerve conduction: a case report

The obturator nerve lies deep within the pelvis, and it can be damaged by direct injury during surgery. In this study, nerve conduction was used to confirm an obturator nerve injury in a patient who presented with hip adductor weakness following gynecological surgery for endometrial cancer. A 56-year-old woman complained of weakness in the right adductor muscles after a laparoscopic hysterectomy due to endometrial cancer. Seven days after surgery, the degree of weakness of the right hip adductor was Medical Research Council (MRC) Scale 1; thus, a nerve conduction velocity test was conducted. To obtain the compound muscle action potentials of the obturator nerve, stimulation was performed (1.5 cm inferior and 1.5 cm lateral to the pubic tubercle) with a surface electrical simulator and recording (midpoint of the right medial thigh) of the adductor muscles. The compound muscle action potentials of the right obturator nerve showed lower amplitude (left side: 2.7 mV vs. right side: 0.3 mV) and delayed onset latency (left side: 3.2 ms vs. right side: 2.2 ms). These results indicate a partial right obturator neuropathy. Therefore, nerve conduction could be useful to diagnose an early-stage obturator nerve injury and provide information on the degree of damage.

Pelvic Lymphadenectomy in Gynecologic Oncology-Significance of Anatomical Variations

Pelvic lymphadenectomy is a common surgical procedure in gynecologic oncology. Pelvic lymph node dissection is performed for all types of gynecological malignancies to evaluate the extent of a disease and facilitate further treatment planning. Most studies examine the lymphatic spread, the prognostic, and therapeutic significance of the lymph nodes. However, there are very few studies describing the possible surgical approaches and the anatomical variations. Moreover, a correlation between anatomical variations and lymphadenectomy in the pelvic region has never been discussed in medical literature. The present article aims to expand the limited knowledge of the anatomical variations in the pelvis. Anatomical variations of the ureters, pelvic vessels, and nerves and their significance to pelvic lymphadenectomy are summarized, explained, and illustrated. Surgeons should be familiar with pelvic anatomy and its variations to safely perform a pelvic lymphadenectomy. Learning the proper lymphadenectomy technique relating to anatomical landmarks and variations may decrease morbidity and mortality. Furthermore, accurate description and analysis of the majority of pelvic anatomical variations may impact not only gynecological surgery, but also spinal surgery, urology, and orthopedics.

Robotic surgical staging of lymphadenectomy during pregnancy - case report

OBJECTIVE

We aim to present a case of a 43-year-old patient dia-gnosed with cervical adenocarcinoma in the 15th week of pregnancy, who underwent robotically-assisted staging in a laparoscopic pelvic lymphadenectomy. Further therapeutic approach was based on the results of subsequent lymph node histopathologic assessment.

CONCLUSION

In pregnant women with cervical cancer, robot-assisted laparoscopic lymphadenectomy is a method of choice for surgical staging.

Evaluating the importance of routine drainage following laparoscopic pelvic lymph node dissection for gynecological malignancies

OBJECTIVE

To determine the efficacy of drainage following pelvic lymph node (PLN) dissection, especially for cases involving laparoscopic surgery.

METHODS

In this retrospective study, 368 patients with malignant gynecological tumors who underwent systemic PLN dissection at Keio University Hospital between January 2012 and October 2018 were enrolled. Drainage tubes were placed in the retroperitoneal fossa in all patients. Medical records were used for data collection.

RESULTS

Laparoscopy was performed on 81 patients, and laparotomy was performed on 287 patients. In the laparoscopy group, tubes were removed 1 day post surgery. In the laparotomy group, tubes were removed 1 day post surgery in 167 patients and 4 days post surgery in 120 patients. Compared with the laparotomy group, we determined the laparoscopy group to have a significantly lower prevalence of lymphocyst (6.2% vs 20.2%, p = 0.002) but a similar prevalence of lymphedema (4.9% vs 5.2%), and symptomatic lymphocyst (2.5% vs 4.5%). The two laparotomy groups did not differ significantly with respect to the prevalence of lymphedema (4.8% vs 5.8%), lymphocyst (20.4% vs 20.0%), or symptomatic lymphocyst (4.2% vs 5.0%).

CONCLUSION

Our results suggest that routine drainage should be omitted, especially in cases involving laparoscopic surgery.

A narrative review of pelvic lymph node dissection in prostate cancer

Pelvic lymph node dissection (PLND) is an important component in the staging and prognostication of prostate cancer. We performed a narrative review to assess the literature surrounding PLND: (I) the current guideline recommendations and contemporary utilization, (II) the calculation of patient-specific risk to perform PLND using available nomograms, (III) to review the extent of dissection, and its associated outcomes and complications. Due to the improved lymph node yield, better staging, and theoretical improvement in the control of micro-metastatic disease, guidelines have supported the use of (extended-) PLND in patients deemed to be at intermediate or high risk of lymph node involvement (often at a threshold of 5% on modern risk nomograms). However, in practice, real-world utilization of PLND varies considerably due to multiple reasons. Conflicting evidence persists with no clear oncological benefit to PLND, and a small, but important, risk of morbidity. Complications are rare, but include lymphoceles; thromboembolic events; and more rarely, obturator nerve, vascular, and ureteric injury. Furthermore, changing disease incidence and stage migration in the context of earlier detection overall have led to a decreased risk of nodal disease. The trade-offs between the benefits, harms, and risk tolerance/threshold must be carefully considered between each patient and their clinician.

Robot-Assisted Nerve-Sparing Excision of a Symptomatic Obturator Nerve Schwannoma: A Case Report

Reports in the literature have presented the feasibility of a minimally invasive resection of retroperitoneal or pelvic schwannomas. However, there are only a few reports in the literature about a robot-assisted nerve-sparing approach towards obturator schwannomas.

We present a case of a concomitant excision of a symptomatic obturator nerve schwannoma in a patient undergoing robot-assisted radical prostatectomy with pelvic lymphadenectomy. The patient complained about an ongoing, low-grade sensory dysfunction in the left proximal thigh area, without loss of muscular function. A preoperative pelvic MRI incidentally showed a thickening of the left obturator nerve of about 1 cm. During pelvic lymphadenectomy, the thickening was identified, an axial incision was made to the nerve sheath, and a small tumor mass (9 mm x 5 mm x 3 mm) was excised, thereby decompressing the nerve fibers and simultaneously preserving the continuity of the obturator nerve. The nerve sheath was closed using a 7-0 monofilament suture. Frozen section biopsy that was undertaken during the surgical procedure excluded the presence of a malignancy.

There were no intra- or postoperative complications. Postoperatively, the patient described a temporary sensory dysfunction of the left inner-thigh area, which regressed completely. The histopathological result confirmed a benign schwannoma of the obturator nerve. In experienced hands, the robot-assisted approach appears safe and feasible as a technique to excise a schwannoma of the obturator nerve, without the need to proceed to a full nerve resection.

A Study of Prognostic Factors of Chinese Patients with Gynecologic Tract Carcinosarcomas Prognosis of Gynecologic Carcinosarcomas

Background

Thinking of the rarity and malignancy of gynecologic tract carcinosarcomas (GTCS), the aim of the study was to investigate the possible predictors of relapse-free survival (RFS) and overall survival (OS) for GTCS patients.

Methods

We performed a retrospective cohort study of women with GTCS at our hospital between January 2009 and December 2013. We used the Kaplan–Meier method to calculate RFS and OS, and Cox regression analysis to define the survival effects of risk factors.

Results

A total of 45 GTCS patients were included in the study. The median follow-up time was 46 months. Cox regression analysis showed that lymph node metastasis was significantly associated with worse RFS (HR: 3.145; 95%CI: 1.181–8.378; P=0.022) and OS (HR: 4.065; 95%CI: 1.57–10.524; P=0.004). Pelvic lymphadenectomy had a favorable RFS (HR: 0.213; 95%CI: 0.057–0.796; P= 0.021).

Conclusion

Lymph node metastasis significantly affected the prognosis of uterine carcinosarcoma. Pelvic lymphadenectomy could reduce the relapse rate of GTCS patients.

Does the Sentinel Lymph Node Sampling Alone Improve Quality of Life in Early Cervical Cancer Management?

Objective: In this subanalysis of the prospective randomized multicenter SENTICOL 2 study, we compared the quality of life (QoL), in two arms, in association with lower-limb consequences in women with early stage cervical cancer undergoing randomized sentinel lymph node (SLN) sampling alone or SLN sampling and full pelvic lymphadenectomy. Methods: 206 patients with an early stage cervical cancer and a negative SLN, were randomized. Every patient had a SLN detection based on a combination of radio-isotope (Nanocis®) and blue dye (Bleu Patenté®) injections. One hundred and One patients, the "standard" group, had complete pelvic lymphadenectomy, 105 patients, the "SLN alone" group, had SLN biopsy without lymphadenectomy. At each visit (V0: preoperative, V1: 1 month, V2: 3 months and V3: 6 months following surgery) the patients completed a Short Form Health Survey (SF36) questionnaire and another questionnaire related to leg lymphedema. SF36 scores variations (compared to the baseline values) were assessed with a standard analysis and by an evaluation of the area under the curve (AUC). Several lower-limb circumferences and signs were also determined. Results: General characteristics of the patients were well-balanced between groups. Physical function and general health dimensions of the SF36 scale were significantly improved at V1 and V2 in the "SLN alone" group. Mental health was also statistically better in the "SLN alone" group at V2. Other dimensions were similar. The two groups had similar evaluation at V3. AUC of SF36 sub-scores was also in favor of the "SLN alone" arm, but the difference was not statistically significant. The analysis about the lymphedema of the legs showed a reduced (but not significant) risk in the "SLN alone" group for the top-of-thigh and the mid-thigh perimeters. Lymphedema symptoms reported by the patients were significantly less severe in the "SLN alone" group. Conclusion: Our study demonstrates a trend for a better quality of life and less severe leg heaviness and leg fatigue when a full pelvic lymphadenectomy is avoided.

Impact of Extent of Lymphadenectomy on Survival in Patients With Endometrial Cancer: A Matched Cohort Study

BACKGROUND/AIM

This study aimed to determine whether a pelvic and para-aortic lymphadenectomy (PPAL) improves survival compared with a pelvic lymphadenectomy (PL) in patients with endometrial cancer.

PATIENTS AND METHODS

Data from all women operated for endometrial cancer between 1998 and 2013 were extracted from the Surveillance, Epidemiology and End Results database. Women treated with PL were matched with those treated with PPAL according to age and risk of recurrence. The primary endpoint was disease-specific survival (DSS).

RESULTS

A total of 1015 patients who underwent PL were matched with 1015 patients who underwent PPAL. The 3-year DSS probabilities for patients at intermediate- and high-risk (IHR) of recurrence were similar in the PPAL group and the PL group. Multivariate analysis of prognostic factors indicated that in patients with an IHR of recurrence, PPAL did not reduce the risk of death compared with PL.

CONCLUSION

For patients with an IHR of recurrence, the extent of lymphadenectomy does not impact DSS.

Laparoscopic repair of bowel herniation into the space between the obturator nerve and the umbilical artery after pelvic lymphadenectomy for cervical cancer

Bowel herniation through the space between the exposed structures after pelvic lymphadenectomy is a very rare cause of postoperative bowel obstruction. Here, a case of laparoscopic release of bowel migration into the space after pelvic lymphadenectomy is described. This is the seventh such reported case in the world. A 38-year-old woman who had a history of undergoing laparoscopic radical hysterectomy and bilateral pelvic lymphadenectomy for cervical cancer was diagnosed with strangulated bowel obstruction. Emergency laparoscopic surgery was performed, and bowel migration into the space between the right umbilical artery and the obturator nerve was detected. The loop of strangulated bowel was released laparoscopically, and bowel blood flow was improved. To prevent recurrence of bowel migration, the umbilical artery was resected. It is very important to consider the possibility of bowel herniation into the space between exposed structures in patients with bowel obstruction after minimally invasive pelvic lymphadenectomy.

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.

The role of para-aortic lymphadenectomy in stage IIIC endometrial cancer: A single-institute study

The therapeutic value of para-aortic lymphadenectomy (PAL) in women with endometrial cancer (EC) remains uncertain. We retrospectively analysed 25 patients with stage IIIc EC (17 stage IIIC1; 8 IIIC2) who were treated in our institution. All subjects had undergone pelvic lymphadenectomies in which para-aortic nodes were sampled, or removed only when these nodes were enlarged. Sampling of para-aortic nodes or PAL was performed in all patients with stage IIIC2 disease and one of 17 with stage IIIC1 disease. Para-aortic lymph nodes were the most frequent site of recurrence in stage IIIC1 patients, but no such recurrences occurred in stage IIIC2 patients. Overall survival tended to be shorter in stage IIIC1 patients than stage IIIC2 patients. Our findings indicate that PAL improves the outcomes of patients with EC and high risk of para-aortic lymph node metastasis, such as those with positive pelvic lymph nodes or enlargement of para-aortic lymph nodes. Impact statement Para-aortic lymph node (PALN) metastases are important prognostic factors in endometrial cancer. Overall survival of patients with stage IIIC1 disease is generally longer than for those with stage IIIC2 disease. Retrospective studies - but no prospective studies - have suggested that para-aortic lymphadenectomy (PAL) provides a survival benefit. In our institution, we had performed PAL or para-aortic sampling for patients with enlarged PALNs; therefore, as most IIIC1 patients had no enlarged PALNs, they underwent pelvic lymphadenectomy only, whereas all IIIC2 patients had enlarged PALNs and underwent pelvic lymphadenectomy and PAL or PALN sampling in addition to pelvic lymphadenectomy. However, under this policy, survival of stage IIIC1 patients was not better than for stage IIIC2 patients. Our retrospective study indicates a survival benefit for PAL in patients with pelvic node-positive or enlarged PALN. PAL warrants a prospective randomised trial to see whether it should be a standard treatment in these patients.

Value of 111 In-prostate-specific membrane antigen (PSMA)-radioguided surgery for salvage lymphadenectomy in recurrent prostate cancer: correlation with histopathology and clinical follow-up

OBJECTIVES

To evaluate the use of ¹¹¹ In-labelled prostate-specific membrane antigen (PSMA)-I&T-based radioguided surgery (¹¹¹ In-PSMA-RGS) for salvage surgery in recurrent prostate cancer (PCa) using comparison of intra-operative gamma probe measurements with histopathological results of dissected specimens. In addition, to determine the success of ¹¹¹ In-PSMA-RGS with regard to postoperative prostate-specific antigen (PSA) responses, PCa-specific treatment-free survival rates and postoperative complication rates.

PATIENTS AND METHODS

A total of 31 consecutive patients with localized recurrent PCa undergoing salvage surgery with PSMA-targeted radioguided surgery using a ¹¹¹ In-labelled PSMA ligand between April 2014 and July 2015 were retrospectively included in this study. The preoperative (interquartile range; range) median PSA level was 1.3 (0.57-2.53 ng/mL; 0.2-13.9 ng/mL). Results of ex vivo radioactivity rating (positive vs negative) of resected tissue specimens were compared with findings of postoperative histological analysis. Best PSA response without additional treatment was determined after ¹¹¹ In-PSMA-RGS, and salvage-surgery-related postoperative complications and PCa-specific additional treatments were recorded.

RESULTS

In 30/31 patients, ¹¹¹ In-PSMA-RGS allowed intra-operative identification of metastatic lesions. In total, 145 surgical specimens were removed and 51 showed metastatic involvement at histological analysis. According to ¹¹¹ In-PSMA-RGS ex vivo measurements, 48 specimens were correctly classified as metastatic and 87 as cancer-free, four were false-negative and six were false-positive compared with histological evaluation. Follow-up information was available for 30/31 patients. PSA declines of >50% and >90% were observed in 23/30 patients and in 16/30 patients, respectively. In 18/30 patients, a PSA decline to <0.2 ng/mL was observed. In 10/30 patients further PCa-specific treatment was given after a median (range) of 125 (48-454) days post-¹¹¹ In-PSMA-RGS. The remaining 20 patients remained treatment-free at a median (range) follow-up of 337 (81-591) days. Of 30 patients, 10 presented with surgery-related complications (Clavien-Dindo grade 1, n = 6, Clavien-Dindo grade 3b, n = 4).

CONCLUSION

¹¹¹ In-PSMA-RGS proved to be of high value for intra-operative detection of even small metastatic lesions in patients with PCa scheduled for salvage lymphadenectomy. It allows the exact localization and resection of metastatic tissue during ¹¹¹ In-PSMA-RGS and is therefore anticipated to have a beneficial influence on further disease progression; however, identification of suitable patients on the basis of PSMA-positron-emission tomography imaging as well as clinical variables is essential for satisfactory results to be obtained.

A digital anatomical study of the corona mortis in females

It was a different study from traditional anatomy to construct three-dimensional (3D) model of the corona mortis (CMOR) through contrasted enhanced computed tomography (CT) scanning. This will provide an aid for the understanding of the fine anatomy of CMOR, as well as surgical produces. A medical image processing system was used to process computed tomography scanning data collected from 330 cases of woman patients. Accurate digital 3D models of the CMOR were used to study the incidence, location, and the morphological patterns. These models have a rotation of 360° and allow displaying from different views. The incidence was 51.1% for the venous CMOR, 14.1% for the arterial CMOR in the 660 sides pelvic wall and vessel models. The mean distance from the symphysis pubis for the venous CMOR was 66.87 mm, and 59.60 mm for the arterial CMOR. The morphological patterns we identified were classified in three types (I-III). The model of CMOR serves as a useful tool for the learning and investigation of the CMOR. In the future, the digital anatomical data can be beneficial to illustrating the operation approach and decreasing the surgical complications.

[Technique of pelvic and paraaortic lymphadenectomy]

OBJECTIVE

Overview of classification, anatomical conditions, methods and complications of pelvic and paraaortic lymph-node dissection.

DESIGN

Review article.

SETTING

Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Medical Faculty, Charles University, Prague.

MATERIALS AND METHODS

Lymphadenectomy is classified according to its extent into sentinel lymph-node biopsy, debulking, sampling and systematic procedure and according to approach into extraperitoneal or transperitoneal procedure. The most complex variant is systematic pelvic and paraaortic lymph-node dissection, which requires removal of fatty-lymphatic tissue from anatomically strictly defined areas. Procedure can be performed from laparotomy, laparoscopically or robotically.

RESULTS

The main objective criterium of systematic procedure is the number of harvested nodes. The most common complications comprise bleeding and lymphocele formation.

CONCLUSIONS

Pelvic and paraaortic lymphadenectomy represent basic component of surgical management in majority of gynecological cancers. The knowledge of extent, different techniques and ability to solve complications represents essential skill in gynecological oncology.

Predictive factors for lymph node positivity in patients undergoing extended pelvic lymphadenectomy during robot assisted radical prostatectomy

Introduction:

Pelvic lymphadenectomy during radical prostatectomy (RP) improves staging and may provide a therapeutic benefit. However, there is no clear consensus on the selection criteria for subjecting patients to this additional procedure. With a growing adoption of robot assisted radical prostatectomy (RARP) in India, it has become imperative to study the incidence and predictive factors for lymph node involvement in our patients.

Materials and Methods:

From February 2010 to February 2014, 452 RARP procedures were performed at our institution. A total of 100 consecutive patients from July 2011 to August 2012 were additionally subjected to a robotic extended pelvic lymphadenectomy (EPLND). Lymph node positivity rates and lymph node density were analyzed on the basis of preoperative prostate specific antigen (PSA), Gleason score, clinical stage, D’Amico risk category and magnetic resonance imaging (MRI) findings. Multivariate analysis was performed to ascertain factors associated with lymph node positivity in our cohort.

Results:

The mean age of the patients was 65.5 (47–77) years and the body mass index was 26.3 (16.3–38.7) kg/m². The mean console time for EPLND was 45 (32–68) min. A median of 17 (two to 40) lymph nodes were retrieved. Seventeen patients (17%) had positive lymph nodes (median of 1, range 1–6). Median lymph node density in these patients was 10%. When stratified by PSA, Gleason score, clinical stage, D’Amico risk category and features of locally advanced disease on MRI, a trend towards increasing incidence of lymph node positivity was observed, with an increase in adverse factors. However, on multivariate analysis, clinical stage > T2a was the only significant factor impacting lymph node positivity in our cohort.

Conclusions:

A significant proportion of men undergoing RARP in India have positive lymph nodes on EPLND. While other variables may also have a potential impact, a higher clinical stage predisposes to an increased incidence of lymph node metastases.

Delayed complication of pelvic lymphocele: Ileal conduit obstruction

Radical cystectomy is the standard treatment for muscle invasive bladder cancer. Lymphocele is a common sequalae of pelvic lymphadenectomy. We report an unusual presentation of pelvic lymphocele developing after radical cystectomy reconstructed with an ileal conduit where the patient developed obstruction of the ileal conduit loop due to external pressure of the lymphocele. Catheter drainage of the conduit relieved the symptoms and a computerized tomography scan showed a large lymphocele causing acute angulation and resultant obstruction of the ileal conduit. The patient was treated with percutaneous drainage of the lymphocele and remains symptom-free on follow-up at 1 year.

Tailoring Pelvic Lymphadenectomy for Patients with Stage IA2, IB1, and IIA1 Uterine Cervical Cancer

Purpose: The purpose of this study was to assess the risk factors for pelvic lymph node metastasis (PLNM) in patients with early-stage uterine cervical cancer.

Methods: A total of 192 patients with early-stage uterine cervical cancer (FIGO stage IA2, IB1, and IIA1) receiving radical hysterectomy with pelvic lymphadenectomy were included in the statistical analysis.

Results: Thirty-six patients (18.8%) developed PLNM, and the incidences of PLNM in patients with stage IA2, stage IB2, and stage IIA1 were 0% (0/6), 13.9% (20/144), and 38.1% (16/42), respectively. The most common location of PLNM was the obturator lymph node. Univariate analysis showed that stage IIA1 (p < 0.001), tumor size greater than 3 cm (p = 0.019), deep-full thickness stromal invasion (p < 0.001), and lymphovascular invasion (p = 0.001) were associated with PLNM. Multivariate analysis showed that deep or full-thickness stromal invasion and lymphovascular invasion were significantly and independently associated with PLNM (p < 0.05 for both). The incidence of PLNM was 34.9% and 28.7% in patients with deep-full thickness stromal invasion and lymphovascular invasion, respectively, but that was only 5.7% and 9.2% in patients with superficial-middle stromal invasion and absence of lymphovascular invasion, respectively.

Conclusion: Patients with superficial-middle stromal invasion and without lymphovascular invasion may be avoided pelvic lymphadenectomy in stage IA2, IB1, IIA1 uterine cervical cancer.

Distribution pattern of lymph node metastases and its implication in individualized radiotherapeutic clinical target volume delineation of regional lymph nodes in patients with stage IA to IIA cervical cancer

BACKGROUND

To study the distribution pattern of lymph node metastases of stage IA to IIA cervical cancer and to clarify the individualized clinical target volume delineation of regional lymph nodes (CTVn).

METHODS

A total of 665 cases with International Federation Gynecology and Obstetrics stage IA to IIA cervical cancer who underwent radical hysterectomy and pelvic lymphadenectomy were retrospectively reviewed. The clinicopathological factors related to lymph node metastases were analyzed using logistic regression analysis.

RESULTS

Pelvic lymph node metastases were found in 168 of 665 patients resulting in a metastasis rate of 25.3%. Binary logistic regression analysis showed that age, lymph vascular space involvement, and deep stromal invasion statistically influenced pelvic lymph node metastases (p = 0.017, < 0.001, < 0.001, respectively). Pathological morphology type, lymph node metastases of the obturator, the external iliac and internal iliac, and the para-aortic had a strong influence on lymph node metastases of the common iliac (p = 0.022, 0.003, < 0.001, 0.009, respectively). Tumor size and lymph node metastases of the common iliac were significantly related to lymph node metastases of the para-aortic (p = 0.045, < 0.001, respectively). Lymph node metastases of the obturator, the external iliac and internal iliac were strongly correlated to lymph node metastases of the circumflex iliac node distal to the external iliac node (CINDEIN; p = 0.027, 0.024, respectively).

CONCLUSIONS

Factors related to lymph node metastases should be comprehensively considered to design and tailor CTVn for radiotherapy of cervical cancer. Selective regional irradiation including the correlated lymphatic drainage regions should be performed.

Laser CO2 treatment for vulvar lymphedema secondary to gynecological cancer therapy: A report of two cases and review of the literature

Vulvar lymphedema is an uncommon and disabling side-effect of pelvic lymphadenectomy and pelvic radiotherapeutic treatment for invasive genital cancer. Lymphorrhea, a complication of lymphedema, may be extremely distressing for patients due to the requirement to wear sanitary towels and as the pain and loss of elasticity of the vulvar skin and mucosa can cause discomfort during coitus. Surgical treatments of lymphorrhea and vulvar lymphedema secondary to gynecological cancer treatments remain controversial and are not currently considered to be the standard therapy. The present study reports two cases of vulvar lymphedema complicated by vulvar lymphorrhea in females who had undergone treatment for cervical and endometrial cancer, respectively; a review of the literature is also included. In the two present cases, vulvar lymphedemas were refractory to standard treatments, including decongestive therapy, manual lymph drainage, elastic bandaging, low-stretch bandaging, exercises and skin care. Laser CO₂ excision and vaporization of the whole skin and mucosal tissue of the vulva was successfully performed to treat the lymphorrhea and improve quality of life. Thus, the present two cases indicated that laser CO₂ surgery may present an additional therapy for the treatment of genital lymphedema that is refractory to other treatments.

Role of pelvic and para-aortic lymphadenectomy in endometrial cancer: current evidence

The aim of the present review is to summarize the current evidence on the role of pelvic and para-aortic lymphadenectomy in endometrial cancer. In 1988, the International Federation of Obstetrics and Gynecology recommended surgical staging for endometrial cancer patients. However, 25 years later, the role of lymph node dissection remains controversial. Although the findings of two large independent randomized trials suggested that pelvic lymphadenectomy provides only adjunctive morbidity with no clear influence on survival outcomes, the studies have many pitfalls that limit interpretation of the results. Theoretically, lymphadenectomy may help identify patients with metastatic dissemination, who may benefit from adjuvant therapy, thus reducing radiation-related morbidity. Also, lymphadenectomy may eradicate metastatic disease. Because lymphatic spread is relatively uncommon, our main effort should be directed at identifying patients who may potentially benefit from lymph node dissection, thus reducing the rate of unnecessary treatment and associated morbidity. This review will discuss the role of lymphadenectomy in endometrial cancer, focusing on patient selection, extension of the surgical procedure, postoperative outcomes, quality of life and costs. The need for new surgical studies and efficacious systemic drugs is recommended.

Robotic radical hysterectomy following neoadjuvant chemotherapy in FIGO stage IIIB cervical cancer: a case report

BACKGROUND

The management of advanced cervical cancer is challenging. The administration of neoadjuvant chemotherapy (NACT) followed by radical hysterectomy has proved to be safe in selected cases. Nevertheless, data on the use of minimally invasive surgery is lacking with this clinical application.

METHODS

A 31 year-old woman was diagnosed with a FIGO stage IIIB squamous cell cervical carcinoma. During multidisciplinary consultation it was decided that she should receive NACT, followed by robotic hysterectomy.

RESULTS

After three cycles of TIP (paclitaxel, ifosfamide and cisplatin), the patient achieved a complete clinical and radiological response. She underwent robotic type III/C2 radical hysterectomy with bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy. No complications were recorded. The complete response was confirmed at pathological examination. Two additional cycles of adjuvant chemotherapy were administered, and the patient is currently without evidence of disease at 18 months of follow-up.

CONCLUSIONS

In selected patients, robotics is a viable option to accomplish radical hysterectomy, including cases of advanced cervical cancer. Further experiences are needed to confirm our findings.

Clinical outcome observation of preoperative concurrent chemoradiotherapy/radiotherapy alone in 174 Chinese patients with local advanced cervical carcinoma

OBJECTIVE

To study outcomes of concurrent chemoradiotherapy (CCRT) or radiotherapy (RT) alone followed by radical surgery in patients with local advanced cervical cancer.

METHODS

A retrospective approach was carried out in 174 Chinese patients with International Federation of Obstetricians and Gynaecologists stage IB2-IIIB cervical carcinoma. A total of 121 patients were treated with CCRT, while the remaining 53 patients received RT alone, and the regimen of chemotherapy was weekly cisplatin (40 mg/m2). Pathological response, overall survival (OS), progression-free survival (PFS), and complications were analyzed.

RESULTS

The median age was 45 years and the mean primary tumor diameter was 4.8 ± 1.0 cm. Pathological complete response (CR) was achieved in 53 patients (30.5%). The CR rate was relatively higher in the CCRT group (31.4% vs 28.3%, P = 0.724), particularly when tumor diameter was less than 5 cm (38.2% vs 30.8%, P = 0.623). With median follow-up of 24 months, patients with CR had improved 3-year OS (100% vs 83.6%, P = 0.018) and 3-year PFS (93.1% vs 83.2%, P = 0.035) compared to patients with residual disease. CCRT was associated with significantly improved 3-year PFS (92.0% vs 76.5%, P = 0.032) compared to RT alone in patients with tumor diameter less than 5 cm. Thirty-seven patients (21.3%) experienced more than grade 2 toxicity, and one patient (0.6%) developed grade 3 uronephrosis. Data thus indicated that pathologic response, tumor size, and lymph-node involvement were highly correlated with clinical outcomes of the local advanced cervical disease.

CONCLUSION

Preoperative CCRT achieved outcomes superior to RT alone, depending on the pathologic response, tumor size and lymph-node involvement as major prognostic factors.

Radical cystectomy for bladder cancer: A single center experience

We present the outcomes of a large series of patients treated with radical cystectomy and pelvic lymphadenectomy for transitional cell carcinoma of bladder.