Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study.

PURPOSE: To analyze the survival outcomes of patients in a Brazilian cohort who underwent minimally invasive surgery (MIS) compared with open surgery for early stage cervical cancer. METHODS: A multicenter database was constructed, registering 1280 cervical cancer patients who had undergone radical hysterectomy from 2000 to 2019. For the final analysis, we included cases with a tumor ≤ 4 cm (stages Ia2 to Ib2, FIGO 2018) that underwent surgery from January 2007 to December 2017. Propensity score matching was also performed. RESULTS: A total of 776 cases were ultimately analyzed, 526 of which were included in the propensity score matching analysis (open, n = 263; MIS, n = 263). There were 52 recurrences (9.9%), 28 (10.6%) with MIS and 24 (9.1%) with open surgery (p = 0.55); and 34 deaths were recorded, 13 (4.9%) and 21 (8.0%), respectively (p = 0.15). We noted a 3-year disease-free survival (DFS) rate of 88.2% and 90.3% for those who received MIS and open surgery, respectively (HR 1.32; 95% CI: 0.76-2.29; p = 0.31) and a 5-year overall survival (OS) rate of 91.8% and 91.1%, respectively (HR 0.80; 95% CI: 0.40-1.61; p = 0.53). There was no difference in 3-year DFS rates between open surgery and MIS for tumors ≤ 2 cm (95.7% vs. 90.8%; p = 0.16) or > 2 cm (83.9% vs. 85.4%; p = 0.77). Also, the 5-year OS between open surgery and MIS did not differ for tumors ≤ 2 cm (93.1% vs. 93.6%; p = 0.82) or > 2 cm (88.9% vs. 89.8%; p = 0.35). CONCLUSIONS: Survival outcomes were similar between minimally invasive and open radical hysterectomy in this large retrospective multicenter cohort.

Brazilian Society of Surgical Oncology consensus on fertility-sparing surgery for cervical cancer.

OBJECTIVE: Several controversies remain on conservative management of cervical cancer. Our aim was to develop a consensus recommendation on important and novel topics of fertility-sparing treatment of cervical cancer. METHODS: The consensus was sponsored by the Brazilian Society of Surgical Oncology (BSSO) from March 2020 to September 2020 and included a multidisciplinary team of 55 specialists. A total of 21 questions were addressed and they were assigned to specialists' groups that reviewed the literature and drafted preliminary recommendations. Further, the coordinators evaluated the recommendations that were classified by the level of evidence, and finally, they were voted by all participants. RESULTS: The questions included controversial topics on tumor assessment, surgical treatment, and surveillance in conservative management of cervical cancer. The two topics with lower agreement rates were the role of minimally invasive approach in radical trachelectomy and parametrial preservation. Additionally, only three recommendations had <90% of agreement (fertility preservation in Stage Ib2, anti-stenosis device, and uterine transposition). CONCLUSIONS: As very few clinical trials have been developed in surgery for cervical cancer, most recommendations were supported by low levels of evidence. We addressed important and novel topics in conservative management of cervical cancer and our study may contribute to literature.

Study of biomolecular and clinical prognostic factors in patients with cancer of the vulva undergoing surgical treatment.

INTRODUCTION: Cancers of the vulva account for 3% to 5% of all cancers of the female genital. This study was conducted to evaluate clinical, pathological, and molecular prognostic factors in patients with cancer of the vulva. METHODS: Patients with squamous cell carcinoma of the vulva who had undergone surgical treatment at the Department of Pelvic Surgery and Gynecology Service, Aristides Maltez Hospital, between June 1993 and June 2011 were selected. Clinical, epidemiological, pathological, and molecular characteristics related to the prognosis of these patients were evaluated in relation to the prognosis. In the molecular evaluation, we studied the expression of p53 and matrix metalloproteinase 2 by immunohistochemistry. RESULTS: Seventy-five patients were eligible for the study. In multivariable analysis, factors related to survival were as follows: tumor size larger than 4 cm (P = 0.014), an invasion depth greater than 2 mm (P = 0.023) and matrix metalloproteinase 2 expression in more than 50% of the tumor cells (P = 0.046). With the use of the relative risks of the factors identified in the multivariable analysis, a point count was developed for a prognostic classification (the score classifies patients into 3 categories). CONCLUSIONS: A tumor size larger than 4 cm, an invasion depth greater than 2 mm, and metalloproteinase 2 expression in more than 50% of the tumor cells seem to be related to lower overall survival rate in patients with cancer of the vulva undergoing surgical treatment. A classification of the patient's prognosis can be performed using a point count based on these relative risks.

Laparoscopic surgical staging of locally advanced cervix cancer (IB2 to IVA): initial experience.

INTRODUCTION AND OBJECTIVES: Cervical cancer incidence worldwide is about 500,000 new cases per year with most of them being detected at a locally advanced stage. Many studies have shown the need to look for extra-pelvic disease when planning appropriate therapy. We performed surgical staging by laparoscopy in 43 cases of cervical cancer at stages IB2 to IVa and evaluated our initial results. MATERIALS AND METHODS: Between February 2008 and May 2010, we selected 43 patients with histologically confirmed cervical cancer at stages IB2 to IVA with a Karnosfsky index>70. We classified the tumors according to the FIGO (International Federation of Gynecology and Obstetrics) stage and performed tomographic evaluations of the abdomen to select patients without signs of peritoneal or para-aortic tumor spread. We performed a laparoscopic evaluation of the peritoneal cavity and para-aortic lymph nodes by an extra-peritoneal route. We did not use tweezers or disposable energy seals. RESULTS: The mean surgical time was 130.8min. The mean blood loss was 111.5ml. There was no conversion to laparotomy for any case. We describe a case with peritoneal implants that was classified as IVB. We removed an average of 16.4 lymph nodes; nine cases had para-aortic lymph node metastases. CONCLUSION: Laparoscopic surgical staging diagnosed 23.3% of cases with peritoneal spread of the tumor or extra-pelvic lymph node metastases. In this study, we could better define the lymph node status through laparoscopic surgical staging and could therefore recommend more suitable adjuvant therapy for patients with locally advanced cervical cancer.

Gangrena de Fournier pós-hemorroidectomia / Fournier's gangrene post-hemorrhoidectomy

A fascite necrotizante do períneo e regiäo escrotal é uma entidade rara, caracterizada por extensa necrose da pele e tecido celular subcutâneo, tendo sido descrita em 1883 por Jean Alfred Fournier. A hemorroidectomia, apesar de ser procedimento operatório que ocorre em regiäo contaminada por resíduos fecais, muito raramente evolui para complicaçöes sépticas graves e necrotizantes. Neste trabalho apresentamos um caso de gangrena de Fournier que ocorreu em um doente alcoólatra e desnutrido, submetido a hemorroidectomia Miligan-Morgan em unidade ambulatorial. O desbridamento cirúrgico associado à colostomia derivativa, à antibioticoterapia ampla e à oxigeniterapia hiperbárica foram fatores determinantes para o sucesso terapêutico. Neste artigo discutimos as principais causas ou fatores envolvidos na gênese do processo infeccioso necrotizante pós-hemorroidectomia, realçando a necessidade de diagnóstico e terapêutica precoces