Vaginal Morcellation Inside Protective Pouch: A Safe Strategy for Uterine Extration in Cases of Bulky Endometrial Cancers: Operative and Oncological Safety of the Method.

OBJECTIVE: To evaluate the operative and oncologic outcomes of an innovative technique for organ morcellation in patients scheduled for laparoscopic treatment of uterine malignancies. BACKGROUND: Endoscopy is currently considered the standard of care for the operative treatment of endometrial cancer; however, the use of minimal invasive surgery (MIS) is restricted in patients with a bulky uterus or narrow vagina. Conventional unprotected intraperitoneal uterine fragmentation is indeed contraindicated in these cases. Consequently, oncologically safe methods to render these patients eligible for MIS are urgently needed. INTERVENTION: Prospective study of women with histologically proven endometrial cancer in which uterus removal was a realistic concern owing to both organ size and proportionality. The patients underwent laparoscopic staging, including retroperitoneal lymphadenectomy, total hysterectomy, and bilateral salpingo-oophorectomy, followed by vaginal morcellation of the uterus inside a protective pouch (LapSac). RESULTS: In our series of 30 cases, we achieved successful completion in all patients, without conversion to laparotomy. No surgery-related casualty or intraoperative morbidity was observed. The mean organ size was 246 g (range, 148-420 g), and the average additional operative time related to vaginal morcellation was 16 minutes (range, 9-28 minutes). Proper histopathological staging according to 2009 FIGO staging guidelines could be performed in all specimens. Two patients (6%) presented with significant postoperative complications, 1 each with vesicovaginal fistula and vaginal vault dehiscence. Fourteen patients (46%) needed adjuvant therapy. After a median follow-up of 20 months (range, 6-38 months), the 12-month and 24-month overall survival was 100% and 73.4% (95% confidence interval, 51%-96%), respectively. Four patients with positive lymph nodes died of distant metastasis. No case of pelvic or local relapse was observed. CONCLUSION: Vaginal morcellation following oncologic principles is a feasible method that permits rapid uterine extraction and potentially avoids unnecessary laparotomies. This series suggests that the technique may be oncologically safe and also can be used in cases of uterine pathology of uncertain malignancy.

Laparoscopic extrafascial hysterectomy (completion surgery) after primary chemoradiation in patients with locally advanced cervical cancer: technical aspects and operative outcomes.

OBJECTIVE: This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis. BACKGROUND: Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial. METHODS: Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response. RESULTS: From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21-77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4-10.2 cm). Estimated blood loss was 80 mL (range, 40-150 mL), and mean operative time was approximately 104 minutes (range, 75-130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1-4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = -0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence. CONCLUSIONS: Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.

Vaginal morcellation: a new strategy for large gynecological malignant tumor extraction: a pilot study.

OBJECTIVE: Evaluate feasibility and safety of a novel technique for uterine morcellation in patients scheduled for laparoscopic treatment of gynecologic malignances. BACKGROUND: The laparoscopic management of uterine malignancies is progressively gaining importance and popularity over laparotomy. Nevertheless, minimal invasive surgery is of limited use when patients have enlarged uterus or narrow vagina. In these cases, conventional uterus morcellation could be a solution but should not be recommended due to risks of tumor dissemination. METHODS: Prospective pilot study of women with endometrial cancer in which uterus removal was a realistic concern due to both organ size and proportionality. Brief technique description: after completion of total laparoscopic hysterectomy and bilateral anexectomy, a nylon with polyurethane Lapsac® is vaginally inserted into the abdomen; the specimen is placed inside the pouch that will be closed and rotated 180° toward the vaginal vault and, posteriorly, pushed into the vaginal canal; in the transvaginal phase, the surgeon pulls the edges of the bag up to vaginal introitus and all vaginal walls will be covered; inside the pouch, the operator performs a uterus bisection-morcellation. RESULTS: In our series of 8 cases, we achieved successful completion in all patients, without conversion to laparotomy. Average operative time, blood loss and length of hospitalization were favorable. One patient presented with a vesicovaginal fistula. CONCLUSION: The vaginal morcellation following oncologic principles is a feasible method that permits a rapid uterine extraction and may avoid a number of unnecessary laparotomies. Further studies are needed to confirm the oncological safety of the technique.