Multidirectional Traction Method Using SURGICEL NU-KNIT and Surgical Suture in Robot-assisted Laparoscopic Surgery for Endometrial Cancer.

OBJECTIVE: To describe a novel approach to robot-assisted laparoscopic total hysterectomy (RH) for endometrial cancer that minimizes cancer sell spillage and develops a stable surgical field. DESIGN: Demonstration of the multidirectional traction method with narrated video footage. SETTING: Many reports have indicated that RH for endometrial cancer has the same or superior short-term results compared with conventional laparoscopic hysterectomy (LH), and the long-term prognosis is the same [1,2]. However, there are no randomized controlled trials of RH versus LH, and some previous reports [3] have suggested that RH has a worse prognosis than LH, so the long-term prognosis should be considered with caution. Factors that may affect the long-term prognosis include the use of uterine manipulators [4] and compression of the uterine body with robotic forceps without tactile sensation [3]. However, to the best of our knowledge, no surgical technique capable of avoiding these factors has been established yet. Herein, we report a multidirectional traction method using SURGICEL NU-KNIT (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan), a local hemostatic agent, and surgical sutures. INTERVENTION: Cut 2-0 Prolene (Ethicon; Johnson & Johnson Medical Ltd., Tokyo, Japan) with straight needles (ST-70) thread to 35 cm, stick a 1 × 2 cm piece of SURGICEL NU-KNIT, and make knots Fig. 1. This implement is used to puncture the incisional margins of the peritoneum and then the abdominal wall to bring the thread to the surface of the body, where it is grasped with forceps and fixed. By repeating this operation, multidirectional traction can be obtained Fig. 2. A manipulating suture is also attached to the uterus to minimize the compression of the uterine body with robotic forceps. CONCLUSION: The multidirectional traction method allows for reproducible stable surgical field development and minimizes cancer cell spillage by reducing uterine grasping by robotic forceps without the use of uterine manipulators.

Intra-operative tumor spillage in minimally invasive surgery for endometrial cancer and its impact on recurrence risk.

OBJECTIVE: The prognostic impact of intra-operative tumor spillage (ITS) during minimally invasive surgery (MIS) for endometrial cancer (EC) is not well studied. The objective of this study was to determine if there is an association between ITS and EC recurrence. METHODS: We performed a case-control study of patients with a laparoscopic or robot-assisted hysterectomy with EC on final pathology between 2017 and 2022 and compared those with (case) and without (control) a subsequent EC recurrence. Electronic medical records were reviewed for demographic, intra-operative and pathologic details, and recurrence status. ITS was defined as uterine perforation with a manipulator, presence of extra-uterine tumor after colpotomy or specimen delivery, exposure of uncontained specimen into peritoneum, and/or pathology/operative reports noting specimen fragmentation. Conditional logistic regression was used to determine odds ratios for the association of cancer recurrence with ITS. We adjusted for >50% myoinvasion, tumor size, and adjuvant treatment. RESULTS: 1057 patients underwent MIS for EC. Approximately 8% (n = 86) developed recurrent cancer and 172 patients were selected as controls. Twenty percent of recurrent cases (17/86) had ITS compared with 4% of nonrecurrent controls (7/172). When adjusted for tumor size, deep myoinvasion, and adjuvant treatment, patients with ITS had a 5.6 times increased odds (aOR 5.63, 95% CI 1.52-20.86) of recurrence compared to patients without ITS. CONCLUSIONS: In patients with EC, we found an association between ITS and cancer recurrence. These findings warrant further investigation to determine if adjuvant therapy or surgical technique should be altered to improve outcomes.

Survival after minimally invasive radical hysterectomy without using uterine manipulator for early-stage cervical cancer: A systematic review and meta-analysis.

BACKGROUND: Minimally invasive radical hysterectomy has been reported to increase the risk of cancer relapse and death compared with open surgery in women with early-stage cervical cancer. The use of a uterine manipulator is considered one of the risk factors. OBJECTIVES: To investigate whether women with early-stage cervical cancer treated with minimally invasive radical hysterectomy without using uterine manipulator have oncological outcomes similar to those of open surgery. SEARCH STRATEGY: Searches were performed in MEDLINE, Embase and CENTRAL from their inception until 31 March 2022. SELECTION CRITERIA: Inclusion criteria were: (1) randomised controlled trials or observational cohort studies published in English, (2) studies comparing minimally invasive radical hysterectomy without using a uterine manipulator with open radical hysterectomy in women with early-stage cervical cancer, and (3) studies comparing survival outcomes. DATA COLLECTION AND ANALYSIS: Two authors independently conducted data extraction and assessed study quality. We calculated the hazard ratios (HR) and the 95% confidence intervals (CI) using the inverse variance approach for survival outcome. MAIN RESULTS: Six observational studies with 2150 women were included. The minimally invasive surgery group had a significantly higher risk of cancer relapse compared with open surgery group (HR 1.55, 95% CI 1.15-2.10). CONCLUSIONS: Minimally invasive radical hysterectomy without using a uterine manipulator resulted in an inferior recurrence-free survival compared with open radical hysterectomy in the treatment of women with early-stage cervical cancer.

Does the Use of a Uterine Manipulator or Intracorporeal Colpotomy Confer an Inferior Prognosis in Minimally Invasive Surgery-Treated Early-stage Cervical Cancer?

STUDY OBJECTIVE: To identify whether the use of a uterine manipulator (UM) or intracorporeal colpotomy conferred inferior short-term survival among patients treated for early-stage cervical cancer. DESIGN: Retrospective cohort study. SETTING: Tertiary university-based hospital. PATIENTS: 1169 patients with stage IB1 to IB2 cervical cancer. INTERVENTIONS: All patients underwent minimally invasive radical hysterectomy and pelvic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: A total of 1169 patients diagnosed with preoperative stage IB1 to IB2 cervical cancer were primarily treated with surgery from 2018 to 2019. The eligible patients had a median age of 48 years (range, 23-76 years), and the median follow-up time was 34 months (range, 3.57-50.87 months). The 2-year overall survival rate of the patients with pathologic stage IB1 and IB2 was 99.8% and 98.8%, respectively, according to the 2018 International Federation of Gynecology and Obstetrics staging system. Univariable analysis revealed that the UM group had a 7.6-times higher risk of death than that of the manipulator-free group (p = .006), but multivariable analysis clarified that only tumor size (p = .016; hazard ratio, 2.285; 95% confidence interval, 1.166-4.479) and parametrial involvement (p = .003; hazard ratio, 3.556; 95% confidence interval, 1.549-8.166) were independent risk factors for overall survival. There was no statistically significant difference in survival between patients who underwent intracorporeal and protective colpotomy. CONCLUSION: Short-term survival outcomes in women undergoing minimally invasive radical hysterectomy for treatment of early-stage cervical cancer did not differ when a UM was avoided or when a protective colpotomy was performed.

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.

Influence of uterine manipulator use on the incidence of lymphovascular propagation in the treatment of endometrial cancer.

BACKGROUND: Endometrial cancers are among the epithelial malignancies of the lining of the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI) is considered a risk factor for the course of the disease. MATERIAL AND METHODS: We evaluated 170 female patients. Our primary objective was to find any difference in the incidence of LVSI in female patients treated with and without an intrauterine manipulator. In addition, we analyzed the effect of the type of intrauterine manipulator used on the incidence of LVSI, tumor grading, myometrial invasion, and the method of obtaining primary histology with regard to the incidence of LVSI. RESULTS: Using a manipulator during surgery was not associated with LVSI (with a manipulator vs. without, 11.5 vs. 21.7%; OR 1.8; 95% CI 0.73-4.39; p = 0.199). However, the method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (p-value = 0.011). CONCLUSIONS: In our study, we did not confirm the effect of a uterine manipulator on the possible increase of LVSI positive cases. The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Trail registration: Trail is registered in ClicincalTrails.gov with identifier: NCT05261165.

Comparative study of tumor-free laparoscopic and open surgery in the treatment of early-stage cervical cancer. / æ— ç˜¤åŒ–è ¹è ”é•œæ‰‹æœ¯ä¸Žå¼€è ¹æ‰‹æœ¯æ²»ç–—æ—©æœŸå®«é¢ˆç™Œçš„å¯¹æ¯”ç ”ç©¶ï¼ˆè‹±æ–‡ï¼‰.

OBJECTIVES: Laparoscopic surgery for cervical cancer has the advantages of little blood loss and rapid recovery, but its therapeutic effect is still controversial. This study aims to analyze the surgical procedure and clinical efficacy of tumor-free laparoscopic radical hysterectomy without a uterine manipulator for early-stage cervical cancer, and to explore the indications of laparoscopic surgery for cervical cancer. METHODS: This study was a retrospective study. The data of patients who underwent radical hysterectomy for early-stage cervical cancer admitted to Hunan Provincial Maternal and Child Health Care Hospital from July 2019 to December 2021 were collected. According to 2018 the International Federation of Gynecology and Obstetrics (FIGO) clinical staging, all patients were in IA1 with lymphovascular invasion, IA2, and IB1 stage. Among them, 45 patients underwent tumor-free laparoscopic radical hysterectomy without a uterine manipulator (laparoscopy group) and 16 patients underwent open surgery (open surgery group). Patients were followed up for 12-41 months. The differences between the 2 groups in terms of operative time, bleeding volume, extent of surgical resection, surgical complications, and prognosis were compared and analyzed. RESULTS: Compared to the open surgery group, the laparoscopy group had significantly shorter operation time and less intraoperative blood loss (both P<0.001). There were no significant differences between the 2 groups in terms of the length of excised uterosacral ligaments, cardinal ligaments, vagina, and the number of excised lymph nodes (all P>0.05). The incidence of postoperative complications did not differ significantly between the groups (P>0.05). No death or recurrence occurred in the 2 groups during the follow-up period. The overall survival rate and disease-free survival rate were both 100%. CONCLUSIONS: For early-stage cervical cancer with a diameter ≤2 cm, tumor-free laparoscopic radical hysterectomy without a uterine manipulator is safe and feasible, and the short-term outcomes is no less than that of open surgery.

Change in the trend of surgical treatment and staging of lymph nodes in endometrial cancer - results of the Oncogynecology Center, Department of Gynecology and Obstetrics, University Hospital Brno and Masaryk University in the years 2012-2021.

INTRODUCTION: In the last decade, the view of endometrial cancer has shifted enormously, and the surgical approach or lymph node staging has changed significantly. We are presenting these changes with the University Hospital Brno Oncogynecology centers results in the years 2012-2021 in the actual national and European guidelines context. METHODS: The retrospective unicentric observational study, national and European guidelines review. RESULTS: In the observation period, 715 endometrial cancer patients were treated in our clinic, and 636 of them underwent surgical treatment (89%). Concerning lymph node staging, firstly, there is a clear trend of expanding lymphadenectomy to the paraaortic area, followed by the sentinel node bio-psy introduction in the years 2018-2019, and finally, the complete transition to this method as the main staging procedure in 2021, when this examination was performed in 73% of surgeries, even with high-risk cancers limited to the uterus. Within the sentinel node bio-psy expansion, a gradual decrease in laparotomy approach (maximum 41% in 2016, 18% in 2021), and blood loss (2012-2019 median 100 mL, with a decrease to 50 mL in 2020-2021) was evident. A hospitalization length stabilized at a median of 5-6 days. CONCLUSIONS: Surgical treatment of endometrial cancer has become a minimally invasive procedure for the majority of patients, the average blood loss and hospitalization length have decreased. Sentinel node bio-psy has become the preferred lymph node staging method.

Factors associated with an increased risk of recurrence in patients diagnosed with high-grade endometrial cancer undergoing minimally invasive surgery: A study of the society of gynecologic oncology of Canada (GOC) community of practice (CoP).

BACKGROUND: Minimally invasive surgery (MIS) is a standard surgical approach for comprehensive surgical staging in women with endometrial cancer. As rates and complexity of MIS are steadily increasing, it is important to identify potential risk factors which may be associated with this approach. This study evaluates the impact of local factors on the risk of disease recurrence. METHODS: A retrospective cohort study was conducted of patients diagnosed with high grade endometrial cancer (HGEC) who underwent MIS between 2012 and 2016 at eight Canadian centers. Data was collected from medical records. The 75th percentile was calculated for estimated uterine volume and weight. All recurrences were categorized into two groups; intra-abdominal vs. extra-abdominal. To search for significant covariates associated with recurrence-free survival a Cox proportional hazard model was performed. RESULTS: A total of 758 patients were included in the study. Intra-uterine manipulator was used in 497 (35.8%) of patients. Vaginal lacerations were documented in 9.1%. Median follow-up was 30.5 months (interquartile range 20-47). There were 157 who had disease recurrence (20.71%), including 92 (12.14%) intra-abdominal and 60 (7.92%) extra-abdominal only recurrences. In univariate analysis myometrial invasion, LVI, stage, uterine volume and weight > 75th percentile and chemotherapy were associated with increased risk of intra-abdominal recurrence. In multivariable analysis only stage, and specimen weight > 75th percentile (OR 2.207, CI 1.123-4.337) remained significant. Uterine volume, and weight were not associated with increased risk of extra-abdominal recurrences. CONCLUSION: For patients diagnosed with HGEC undergoing MIS, extracting a large uterus is associated with a significantly increased risk for intra-abdominal recurrence.

Impact of uterine manipulator on oncological outcome in endometrial cancer surgery.

BACKGROUND: There are limited data available to indicate whether oncological outcomes might be influenced by the uterine manipulator, which is used at the time of hysterectomy for minimally invasive surgery in patients with endometrial cancer. The current evidence derives from retrospective studies with limited sample sizes. Without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience. OBJECTIVE: To evaluate the use of the uterine manipulator on oncological outcomes after minimally invasive surgery, for apparent early-stage endometrial cancer. STUDY DESIGN: We performed a retrospective multicentric study to assess the oncological safety of uterine manipulator use in patients with apparent early-stage endometrial cancer, treated with minimally invasive surgery. The type of manipulator, surgical staging, histology, lymphovascular space invasion, International Federation of Gynecology and Obstetrics stage, adjuvant treatment, recurrence, and pattern of recurrence were evaluated. The primary objective was to determine the relapse rate. The secondary objective was to determine recurrence-free survival, overall survival, and the pattern of recurrence. RESULTS: A total of 2661 women from 15 centers were included; 1756 patients underwent hysterectomy with a uterine manipulator and 905 without it. Both groups were balanced with respect to histology, tumor grade, myometrial invasion, International Federation of Gynecology and Obstetrics stage, and adjuvant therapy. The rate of recurrence was 11.69% in the uterine manipulator group and 7.4% in the no-manipulator group (P<.001). The use of the uterine manipulator was associated with a higher risk of recurrence (hazard ratio, 2.31; 95% confidence interval, 1.27-4.20; P=.006). The use of uterine manipulator in uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics [FIGO] I-II) was associated with lower disease-free survival (hazard ratio, 1.74; 95% confidence interval, 0.57-0.97; P=.027) and higher risk of death (hazard ratio, 1.74; 95% confidence interval, 1.07-2.83; P=.026). No differences were found regarding the pattern of recurrence between both groups (chi-square statistic, 1.74; P=.63). CONCLUSION: In this study, the use of a uterine manipulator was associated with a worse oncological outcome in patients with uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics I-II) who underwent minimally invasive surgery. Prospective trials are essential to confirm these results.

Introduction of gasless laparoscopic surgery as a minimally invasive procedure for endometrial cancer and its usefulness from the viewpoint of the learning curve.

BACKGROUND: We investigated the usefulness of gasless laparoscopic surgery (GLS) using a subcutaneous abdominal wall lifting method for endometrial cancer. METHODS: We studied 105 patients with early endometrial cancer who underwent GLS (55) or open surgery (50). A uterine manipulator was used in all GLS cases. We compared operative time, blood loss, number of lymph nodes removed, hospital stay, perioperative complications, cases converted to laparotomy, and recurrence and survival rates. We also studied the learning curve and proficiency of GLS. RESULTS: The GLS group had significantly longer operative time (265 vs. 191 min), reduced blood loss (184 vs. 425 mL), shorter hospital stay (9.9 vs. 17.6 days), and fewer postoperative complications (1.8 vs. 12.0%) than the open group. No case was converted to laparotomy. Disease-free and overall survival rates at 4 years postoperatively (GLS vs. open groups) were 98.0 versus 97.8 and 100 versus 95.7%, respectively, and there was no significant difference between the groups. Regarding the learning curve for GLS, two different phases were observed in approximately 10 cases. Operator 2, who was not accustomed to laparoscopic surgery, showed a significant reduction in operative time in the later phase 2. CONCLUSIONS: GLS for endometrial cancer results in less bleeding, shorter hospital stay, and fewer complications than open surgery. Recurrence and survival rates were not significantly different from those of open surgery. This technique may be introduced in a short time for operators who are skilled at open surgery but not used to laparoscopic surgery.

Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups.

PURPOSE: Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created. METHODS: Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS. RESULTS: 30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]). CONCLUSION: DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.

Laparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB: description of the technique, our experience and results after the era of LACC trial.

PURPOSE: The aim of this study is to evaluate surgical data and oncological outcome of laparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB, over the last 8 years. METHODS: This retrospective study includes 32 patients with cervical cancer Figo stage (2009) IB who underwent laparoscopic nerve-sparing radical hysterectomy without using any kind of uterine manipulator. Patients were eligible if they had squamous cell carcinoma, adenocarcinoma, or adeno-squamous carcinoma, and no para-aortic lymph node involvement by imaging or after frozen section. The median value and range were assessed for operative outcomes and relapse rate and disease-free survival rate were evaluated using the Kaplan-Meier method. RESULTS: In the study, 32 patients were included and among them 27 women were stage IB1 (18 cases with tumor size 2-4 cm) and 5 women stage IB2 (Figo stage 2009). The median age of patients was 50.5 years (range 31-68) and median body mass index (B.M.I) was 25.3 kg/m2 (range 19-33.5 kg/m2). The average operating time was 228 min (range 147-310 min) and median hospital stay was 2.7 days (range 2-7 days). Approximate blood loss was 188 ml (range 120-300 ml). After a median follow-up of 37 months, we had 2 recurrences out of 32 cases and no death. Especially for patients with Figo stage (2009) IB1, the recurrence rate was 3.7% (1/27). The 3-year PFS was 93.7% and the number at risk 23 (71.8%) and especially for the IB1 stage (2009) women, the 3-year PFS was 96.1% and the number at risk 21 (77.7%). The 3-year OS was 100% with no. at risk 71.8%. CONCLUSIONS: Laparoscopic nerve-sparing radical hysterectomy without uterine manipulator is feasible and safe surgical procedure for cervical cancer with acceptable surgical and oncological outcomes in the hands of well-trained and experienced laparoscopic surgeons. Our retrospective study reveals better oncological outcome compared to other studies on the minimally invasive approach, where uterine manipulator was routinely used and no vaginal sealing of the tumor was made.

Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer.

BACKGROUND: We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer. METHODOLOGY: Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage. RESULTS: All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6-14). All drains and urethral catheters were removed after a median of 7 days (range 5-11) and 16 days (range 12-21), respectively. A median of 26 (range 20-32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease. CONCLUSION: We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.

The use of the V-Care laparoscopic uterine manipulator to facilitate total abdominal hysterectomy: a novel approach and case-series.

Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach. During abdominal surgery, access to the pelvis can be challenging on occasion, and there may be a higher incidence of intraoperative complications. We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.Impact StatementWhat is already known on the subject? Hysterectomy remains mostly performed via the abdominal route in the United Kingdom, despite advances in minimal access techniques and increased training in laparoscopic hysterectomy. The use of uterine manipulators remains a key component of the laparoscopic approach.What do the results of this study add? We describe the use of a laparoscopic uterine manipulator during total abdominal hysterectomy as a novel approach to facilitate the procedure by improving surgical exposure, reducing dissection, while safeguarding vital structures and maintaining vaginal length.What are the implications of these findings for clinical practice and/or future research? The proposed technique is safe, easily reproducible and could be widely adopted. This approach may be considered as an option in morbidly obese women or those women with anticipated complex pelvic pathology.

Total laparoscopic hysterectomy - clinical comparison of the method using two types of uterine manipulators.

AIM OF THE STUDY: Comparison of two types of uterine manipulators used in total laparoscopic hysterectomy (TLH) and clinical evaluation of the method in patients in a two-year group supplemented by subjective evaluation. DESIGN: Prospective observational study. SETTING: Department of Gynecology and Obstetrics, Masaryk University, Faculty of Medicine and University Hospital Brno. MATERIAL AND METHODS: A group of patients operated in the years 2018-2019 by the TLH method using one of two types of uterine manipulators - Karl Storz HOHL (group No. 1) vs. plastic ring of Koh's manipulator (group No. 2). We compared surgical time (min), blood loss (ml), perioperative complications, length of hospital stay (days), early and late complications. We were interested in the possible influence of BMI, uterine on these parameters. Subjective evaluation of the method by patients took place before the procedure and 12 weeks after the operation with a standardized questionnaire. RESULTS: A total of 134 patients were enrolled in the study (75 in group 1 vs. 59 in group 2). The monitored parameters: age, BMI, operative time, blood loss and length of hospitalization did not differ statistically significantly. When comparing the individual groups with different manipulators, the total number of complications (mild difficulties, serious complications) was without statistical significance (p = 0.58), but the spectrum of symptoms was different in both groups. More than a third of the patients in the group were obese. There were more serious complications than non-obese ones, the performance was longer, however, for a small number it was statistically insignificant (p = 0.11). In patients with uterine surgery, we recorded more adhesiolysis. We did not show that previous surgery on the uterus was associated with a higher incidence of complications (p = 0.6). We did not notice any statistically significant difference in the subjective evaluation (p = 0.3). CONCLUSION: TLH is the dominant method of uterine removal in our workplace. In a group of 134 women, we did not show a statistically significant difference in the monitored parameters. The HOHL manipulator has proved to be more user-friendly due to its technical parameters and better clarity of the operating field. Subjective evaluation of the method was positive in patients.

Uterine manipulator requirement in laparoscopic surgery of Ectopic Pregnancy.

OBJECTIVE: The advantages of laparoscopic surgery used in the treatment of ectopic pregnancy is well-known; however, the efficacy of uterine manipulators remains unknown. In this study, we aimed to investigate the efficacy of uterine manipulators in the laparoscopic treatment of ectopic pregnancy. METHODS: Overall, 118 patients who underwent laparoscopy due to ectopic pregnancy in Department of Obstetrics and Gynaecology at Tepecik Education and Research Hospital between January 2010 and January 2018 and who met the inclusion criteria were included in the study. Groups of patients undergoing surgery with or without the use of a uterine manipulator were compared in terms of demographic data, operative and postoperative results. RESULTS: No difference was noted between the groups in terms of age, parity, body mass index, smoking, side of ectopic pregnancy mass, previous operations and pregnancy type. However, the size of ectopic pregnancy mass measured by ultrasonography was significantly larger (p = 0.006) and the operation time was significantly shorter (p<0.001) in the group where uterine manipulators were not used than in the uterine manipulator group. CONCLUSION: We concluded that not using a uterine manipulator in laparoscopic procedures for ectopic pregnancy did not increase operative complications and that operation time was higher in procedures using uterine manipulators.

Laparoscopic radical hysterectomy with transvaginal closure of vaginal cuff - a multicenter analysis.

OBJECTIVE: Laparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy. METHODS: Between August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator. RESULTS: A total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2-86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1-288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery. CONCLUSION: The combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

A multipurpose uterine/vaginal manipulator for laparoscopic urogynecologic procedures.

INTRODUCTION AND HYPOTHESIS: The use of an appropriate uterine manipulator is key to various laparoscopic gynecologic procedures. Adequate uterine manipulation is important for total or supracervical laparoscopic hysterectomies, laparoscopic sacrocolpopexy as well as laparoscopic repair of vaginal vault prolapse. While several uterine manipulators are available to choose from, their use may be specific to certain procedures and their cost may vary as well. METHODS: This video aims to provide an introduction to a multipurpose, reusable uterine/vaginal manipulator that can be used for laparoscopic supracervical hysterectomy, laparoscopic sacrocolpopexy, laparoscopic hysteropexy as well as laparoscopic repair of vaginal vault prolapse. RESULTS: The video highlights the user-friendly, easy-to-clean, reusable, multipurpose uterine/vaginal manipulator. CONCLUSIONS: The manipulator is designed for an efficient combination of laparoscopic urogynecologic procedures and supracervical hysterectomy.

Laparoscopic Radical Hysterectomy with Enclosed Colpotomy and without the Use of Uterine Manipulator for Early-Stage Cervical Cancer.

It was reported recently that minimally invasive radical hysterectomy was associated with worse prognosis than the open abdominal counterpart for the management of early-stage cervical cancer. Uterine manipulator and intracorporeal open colpotomy may be the 2 main suspects responsible for the inferiority. We hypothesize that minimally invasive radical hysterectomy with enclosed colpotomy and without the use of a uterine manipulator will improve survival. Thus, laparoscopic radical hysterectomy with abdominal uterine manipulation and enclosed colpotomy was performed in women with early-stage cervical cancer. The round ligament, the ovary ligament, and the fallopian tube were sutured together for the abdominal manipulation of the uterus. Meanwhile, the upper vagina was ligated before colpotomy to avoid tumor spillage. There were no intraoperative and postoperative complications. The abdominal uterine manipulation and enclosed colpotomy technique, which are both safe and feasible in this study, provide a relatively tumor-free approach for minimally invasive radical hysterectomy. Further investigation of oncologic outcomes in larger prospective studies are needed to confirm our hypothesis.