Radioguided Occult Lesion Localization for Gynecologic Tumor Relapses: Development of a Technique.

PURPOSE OF THE REPORT: Excision of peritoneal or nodal isolated recurrences frequently involves performing a surgery on a previously operated area, which is more difficult to achieve with minimally invasive approaches. Our aim was to describe the technical aspects, feasibility, and complications derived from the application of the radioguided occult lesions localization (ROLL) in gynecologic oncology recurrence excision. PATIENTS AND METHODS: All consecutive patients bearing localized relapses of a gynecologic tumor that were considered candidates for surgical excision were assessed to undergo a ROLL procedure. Radiotracer ( 99m Tc-albumin macroaggregate) injection of the lesions was performed by ultrasonography or CT guidance. Relapses were localized using a gamma probe by minimally invasive surgery when located in the abdomen, or percutaneously when located in the groin. Intraoperative and early (up to postoperative day 30) complications were prospectively recorded. RESULTS: A total of 8 patients underwent the procedure. The median age was 59 years (range, 35-87 years). Four patients had abdominal relapses, whereas 4 patients presented groin relapses. The mean operative time was 120 minutes (range, 30-190 minutes), whereas the median estimated blood loss was 5 mL (range, 0-150 mL). All the targeted lesions were successfully removed. No intraoperative complications were reported. One postoperative complication (inguinal lymphocele) was recorded. CONCLUSIONS: ROLL surgery constitutes a new approach for isolated recurrences in gynecological tumors.

Robot-assisted Extraperitoneal Para-aortic Lymphadenectomy Is Associated with Fewer Surgical Complications: A Post Hoc Analysis of the STELLA-2 Randomized Trial.

STUDY OBJECTIVE: To evaluate if extraperitoneal para-aortic lymphadenectomy (PALND) using a robot-assisted approach was associated with fewer complications than all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robot-assisted transperitoneal) without compromising lymph node yield, operative time, or length of stay. DESIGN: Post hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2). SETTING: Three academic referral hospitals. PATIENTS: Two hundred and three eligible patients from the STELLA-2 trial were included. INTERVENTIONS: The patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopic or robot-assisted) for surgical staging of endometrial or ovarian cancer. The minimally invasive approaches were not subjected to randomization. MEASUREMENTS AND MAIN RESULTS: The primary end point was evaluated through a composite variable that included at least 1 of the following events: blood loss ≥500 mL during PALND, any intraoperative complication related to PALND, severe postoperative complication (Clavien-Dindo ≥grade IIIA), impossibility of completing the procedure, or conversion to laparotomy. Of the 203 patients analyzed, 68 were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R). A reduced trend in complications was observed in the extraperitoneal robot-assisted arm when considering the primary end point (X-L: 25.0%, T-L: 24.2%, X-R: 5.7%, T-R: 28.9%; p = .073). In a multivariable analysis, age (odds ratio [OR] 1.05; 95% confidence interval [CI], 1.00-1.09), body mass index (OR 1.09; 95% CI, 1.03-1.16), and waist-to-hip ratio (OR 1.66; 95% CI, 1.12-2.47) were found to independently increase the risk of PALND complications, whereas the extraperitoneal robotic approach (OR 0.13; 95% CI, 0.02-0.64) was an independent protective factor for complication occurrence. CONCLUSION: Robot-assisted extraperitoneal PALND is associated with fewer surgical complications, without compromising lymph node retrieval, operative time, or length of stay. Robot-enhanced 3D visualization, surgeon ergonomics, or hemostatic precision could explain our results.

Surgical complications comparing extraperitoneal vs transperitoneal laparoscopic aortic staging in early stage ovarian and endometrial cancer.

OBJECTIVE: To determine whether the extraperitoneal approach for paraaortic staging lymphadenectomy results in a lower rate of surgical complications compared to the transperitoneal approach, without compromising oncological outcomes. METHODS: Prospective randomized multicenter study of patients with early endometrial or ovarian cancer undergoing paraaortic lymphadenectomy in 2010-2019. Patients were randomized to minimally invasive surgery (laparoscopy or robotic-assisted) using an extraperitoneal or a transperitoneal approach. The primary end point measure was a composite outcome that included developing one or more of the following surgical complications: bleeding during paraaortic lymphadenectomy ≥500 mL, any intraoperative complication related to paraaortic lymphadenectomy, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure, or conversion to laparotomy. RESULTS: There were 103 patients in the extraperitoneal group and 100 in the transperitoneal group. Differences in the composite outcome (transperitoneal 26.0% vs, extraperitoneal 18.4%; P = 0.195) were not found. Differences in the operative time, conversion to laparotomy, intraoperative bleeding, or survival were not observed. A higher number of lymph nodes were retrieved through the extraperitoneal approached (median, interquartile range [IQR] 12 [7-17] vs, 14 [10-19]: P = 0.026). Older age and greater body mass index (BMI) or waist-to-hip ratio (WHR) increased the risk for surgical complications independently of the laparoscopic approach. CONCLUSIONS: The extraperitoneal approach did not show differences regarding surgical and oncological parameters compared with the transperitoneal approach, although the number of aortic nodes retrieved was higher. The decision to use one or another laparoscopic route is a matter of the surgeon preference. Trial registration ClinicalTrials.gov.identifier: NCT02676726.

Potential strategies for prevention of tumor spillage in minimally invasive radical hysterectomy.

OBJECTIVE: The publication of a prospective [1] and several retrospective [2,3] studies describing a worse prognosis in patients affected with early-stage cervical cancer who underwent a minimally invasive radical hysterectomy has raised a high concern in what measures should be undertaken in order to revert these results. Potential strategies [4] to prevent tumor spillage have been previously proposed. METHODS: In this video, we describe nine strategies that should be addressed in future trials regarding this procedure. RESULTS: These strategies are: 1. Fallopian tubes should be coagulated prior to start the surgery. 2. All sentinel lymph nodes and lymphadenectomy specimens should be obtained without lymph nodes fragmentation. 3. All surgical specimens should be extracted within a containment bag. 4. Uterine manipulators must never be used. 5. Prior to vaginal section, a closed knotted ligature should be placed around the vagina, proximal to the section line, and the remaining vaginal cavity profusely washed. 6. Once the vagina is opened, the surgical specimen should be extracted vaginally within a specimen retrieval bag. 7. After surgery, the pelvic cavity is profusely washed with physiological serum, and the vagina should be washed with iodopovidone diluted to 10% [5]. 8. Port-site metastasis prevention measures should be performed. 9. Every action made to prevent tumor spillage should be recorded in the surgical report. CONCLUSION: As there is a biological rationale in these measures that would prevent tumor spillage and seeding, there is a need of prospectively exploring them within appropriate studies in order to determine their own oncological outcome.

Technetium-99m-indocyanine green versus technetium-99m-methylene blue for sentinel lymph node biopsy in early-stage endometrial cancer.

INTRODUCTION: The low accuracy of pre-operative imaging techniques for prediction of nodal status strengthens the relevance of sentinel lymph node (SLN) biopsy in endometrial cancer, although the optimal method for its detection is still under investigation. The increasing use of indocyanine green (ICG) has aroused concern about its enhanced visualization of lymphatic channels, which could lead to a specimen that is thought to be nodal tissue not subsequently yielding a lymph node on pathologic analysis ('empty node packet'). Our main objective was to compare the overall and bilateral detection rates for SLN biopsy using two combined techniques: technetium-99m-ICG (Tc-99m-ICG) versus technetium-99m-methylene blue (Tc-99m-MB). Our secondary aim was to compare the 'empty node packet' rates between the two cohorts. METHODS: A prospective, non-randomized, single-center trial including patients diagnosed with endometrial cancer (any grade or histology) in pre-operative early stage, and operated on between February 2017 and July 2019. All tracers were injected intracervically. Pelvic and aortic lymphadenectomy were performed on patients at intermediate or high risk of recurrence pre-operatively. All SLNs were sent for intra-operative frozen section and afterwards processed following an ultrastaging protocol. RESULTS: Eighty-four patients were included, 58% (n=49) in the Tc-99m-MB group and 42% (n=35) in the Tc-99m-ICG group. Overall detection rate was 93% and was not statistically different between the two groups. A better bilateral detection rate was observed among Tc-99m-ICG patients (69% vs 41%, p=0.012). The 'empty node packet' rate was 4% in the Tc-99m-ICG cohort and 0% in the Tc-99m-MB cohort (p=0.032). DISCUSSION: Tc-99m-ICG is a feasible, safe technique for SLN biopsy in early-stage endometrial cancer, and appears to be superior in terms of bilateral detection to Tc-99m-MB. The addition of Tc-99m to ICG could decrease the rate of 'empty node packets' and better define the anatomic location of SLNs in patients with endometrial cancer.

Clinical management of early-stage cervical cancer: The role of sentinel lymph node biopsy in tumors ≤2 cm.

OBJECTIVE: To evaluate the experience with sentinel lymph node (SLN) biopsy in patients with early-stage cervical cancer at our hospital, and to analyze factors influencing the rate of false negatives. STUDY DESIGN: This study was carried out at the Vall d'Hebron Hospital (Barcelona, Spain) between September 2000 and October 2016. All patients underwent SLN biopsy and systematic and bilateral pelvic lymphadenectomy, followed by radical hysterectomy. SLNs were analyzed by the pathologist by staining with hematoxylin-eosin and immunohistochemistry. RESULTS: Patients (N = 128) had been diagnosed with early-stage cervical cancer (FIGO-2009 stages 1A2, IB1, and IIA1). The combined SLN detection rate (99-technecium and a blue dye) was 98.4%, bilateral in 76% of the patients. Positive SLNs were found in 19 patients (14.8%). Sensitivity of detection was 79.2% (CI95, 57.9-92.9), false negative rate 20.8% (CI95, 7.1-42.2), and negative predictive value 95.4% (CI95, 89.6-98.5). False negative cases were observed in 5 patients with tumors >2 cm and presenting lymphovascular space invasion. Micrometastases were detected during SLN ultrastaging in 3 patients (2.3%). The median follow-up was 8.24 years and the 5-year overall survival (OS) was 88.4% (CI95, 80.9-93.1). CONCLUSION: SLN mapping and biopsy in early-stage cervical cancer is feasible and has high sensitivity to detect patients with initial metastases. The risk of false negatives could be lower in certain groups of patients, such as those with tumors ≤2 cm and no lymphovascular space invasion, but future studies will be required to test this hypothesis.

Radical Hysterectomy: Efficacy and Safety in the Dawn of Minimally Invasive Techniques.

STUDY OBJECTIVE: To analyze the effect that the introduction of minimally invasive procedures has had on surgical and oncologic outcomes when compared with conventional open radical hysterectomy (ORH) in a national reference cancer after 17 years of experience in radical hysterectomy. DESIGN: A prospective controlled study (Canadian Task Force classification II-2). SETTING: A university teaching hospital. PATIENTS: All patients who underwent radical hysterectomy as primary treatment for cervical cancer in our institution between May 1999 and June 2016, with a total of 188 patients. INTERVENTIONS: Patients underwent ORH or minimally invasive surgery (MIS) (i.e., laparoscopic or robotically assisted radical hysterectomy). MEASUREMENTS AND MAIN RESULTS: Seventy-six patients underwent ORH, 90 laparoscopic radical hysterectomy, and 22 robotically assisted radical hysterectomy. Blood loss and hospital stay were inferior in the MIS group (p <.0001). The laparotomic group presented shorter operation times (p = .0001). With a median follow-up of 112.4 months, a total of 156 patients (83%) were alive and free of disease at the time of the data analysis. Overall survival was higher in the MIS group when compared with the ORH group (91 vs 78.9, p = .026). There were no differences regarding recurrence rates between the surgical approaches. CONCLUSION: With 1 of the largest follow-up periods in the literature, this study provides added evidence that MIS could become the preferable surgical approach for early-stage cervical cancer since it appears to reduce morbidity without affecting oncologic results.

Vaginal Intraepithelial Neoplasia: Clinical Presentation, Management, and Outcomes in Relation to HIV Infection Status.

OBJECTIVES: The data available on vaginal intraepithelial neoplasia (VAIN) and infection by HIV are scarce. We therefore aimed to review the clinical presentation, management, and survival outcomes of VAIN in this group of women. MATERIALS AND METHODS: This is an observational cohort study of women diagnosed with VAIN for a 23-year period. Clinical characteristics and outcomes were analyzed according to women's HIV infection status. Disease-free and progression-free survival were compared between groups. RESULTS: Twenty-two of 87 women were HIV positive (25.3%) compared with the HIV-negative group, HIV-positive women were younger (median age = 39 vs 57 years, p < .001) and more frequently smokers (p < .001). They also presented with multifocal and multicentric disease more often (p = .004 and p = .033, respectively) in relation to infection by human papillomavirus. All HIV-positive women were receiving antiretroviral treatment. The median time from the diagnosis of HIV to the development of VAIN was 14 years (range = 1-22 years). There were no significant differences in survival outcomes between groups. CONCLUSIONS: HIV-positive women are at an increased risk of developing VAIN and frequently present at a younger age with multifocal and multicentric disease. Vaginal intraepithelial neoplasia lesions can develop many years after the initial diagnosis of HIV infection reason why prolonged surveillance is essential to enable prompt diagnosis and treatment.

Nerve-Sparing Technique during Laparoscopic Radical Hysterectomy: Critical Steps.

STUDY OBJECTIVE: To show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1]) for the treatment of early cervical cancer. DESIGN: A surgical video article (Canadian Task Force classification III). SETTING: A university hospital (University Hospital of Barcelona, Barcelona, Spain). PATIENTS: Nerve-preserving radical hysterectomy is performed in a patient with Fédération Internationale de Gynécologie et d'Obstétrique stage 1B1 cervical cancer with deep stromal invasion. INTERVENTIONS: Three steps are fundamental for the removal of the cérvix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2]. 1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection. 2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament. 3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein. CONCLUSION: Nerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure.

Prospective Randomized Trial Comparing Transperitoneal Versus Extraperitoneal Laparoscopic Aortic Lymphadenectomy for Surgical Staging of Endometrial and Ovarian Cancer: The STELLA Trial.

BACKGROUND: There is an ongoing debate on which approach, transperitoneal or extraperitoneal, is superior for the performance of laparoscopic aortic lymphadenectomy (LPA-LND) for the surgical staging of gynecologic cancer. A prospective randomized trial (STELLA trial) was designed to compare the perioperative outcomes and node retrieval of extraperitoneal versus transperitoneal aortic lymphadenectomy by laparoscopy or robot-assisted laparoscopy. METHODS: Patients with endometrial or ovarian carcinoma requiring aortic lymphadenectomy for surgical staging were randomized to an extraperitoneal or transperitoneal approach by laparoscopy or robot-assisted laparoscopy between June 2012 and July 2014. RESULTS: A total of 60 patients were entered into the study, 48 with endometrial cancer (80 %) and 12 with ovarian cancer (20 %). Thirty-one patients (51.6 %) were randomly assigned to the extraperitoneal group and 29 to the transperitoneal group (48.3 %). The means LPA-LND operating time was 90 min in both group (p = 0.343). The mean (range) blood loss was 105 (10-400) mL for extraperitoneal versus 100 (5-1000) mL for transperitoneal group (p = 0.541). There were no differences in the number of collected lymph nodes between the two groups [median (range) for extraperitoneal 12 (4-41) vs. 13 (4-29) for transperitoneal (p = 0.719)]. CONCLUSIONS: The extraperitoneal and transperitoneal approaches for laparoscopic and robotic aortic lymphadenectomy provide similar perioperative outcomes and nodal yields. TRIAL REGISTRATION: The STELLA trial is registered at the US National Institutes of Health (ClinicalTrials.gov) #NCT01810874.

Vulvar intraepithelial neoplasia: clinical presentation, management and outcomes in women infected with HIV.

OBJECTIVE: Immunocompromised patients are at increased risk of developing preinvasive lesions of the lower genital tract. There are a limited number of studies on vulvar intraepithelial neoplasia (VIN) in HIV-positive women. We aimed to review the clinical presentation of VIN, management and survival outcomes in this group of patients. DESIGN: Observational cohort study. METHODS: Data was collected from women diagnosed with VIN at the Hospital Vall d'Hebron between September 1994 and October 2011. The main outcome measures were recurrence-free survival (RFS) and progression-free survival (PFS). Risk factors for recurrence and progression were assessed using univariate and multivariate analyses. RESULTS: Thirty-seven out of 107 women were HIV positive (34.6%). The median follow-up time was 32 (range 12-179) months. Compared with the HIV-negative group, HIV-positive women were younger (median age 37 vs. 44 years, P = 0.003) and presented with multifocal and multicentric disease more frequently (63.6 vs. 22.2% and 84.8 vs. 43.3%, respectively, P < 0.0001). RFS and PFS were lower in the HIV-positive group (42.4 vs. 71.4% P = 0.043 and 69.7 vs. 95.2% P = 0.006, respectively). RFS was significantly associated to multicentric and multifocal disease on multivariate analysis. PFS was associated to HIV infection on univariate analysis. CONCLUSION: HIV-positive women are at increased risk of developing VIN and frequently present at a younger age with multifocal and multicentric disease. They have shorter RFS and PFS compared with HIV-negative women. Close surveillance of the lower genital tract is mandatory to enable early recognition and treatment of any suspicious lesions. Close follow-up after treatment of VIN is essential to exclude early recurrence or progression.

Nerve sparing technique in robotic-assisted radical hysterectomy: results.

BACKGROUND: This work assessed the role of robotic-assisted lapararoscopic radical hysterectomy in the treatment of early invasive cervical cancer with special regard to nerve sparing technique. METHODS: Between October 2009 and June 2011, a total of 14 non-consecutive patients underwent early cervical cancer surgery at the authors' institution. Patients with FIGO stage IA2 or IB1 with a tumor size less than or equal to 2 cm underwent radical hysterectomy type B1 and patients with FIGO stage IB1 with a tumor mass bigger than 2 cm underwent a radical hysterectomy using a C1 type technique. RESULTS: Three type B1 and 11 type C1 radical hysterectomies with robotic-assisted laparoscopy were performed using Da Vinci®. The median operation time was 260 min (range 150-300 min). The median follow-up after surgery was 13.7 months (range 1-23 months). During this time, three patients reported anorectal dysfunction while none reported sexual or bladder dysfunction. All patients remain without evidence of disease except one with high risk factors for recurrence. They all are alive. CONCLUSIONS: Laparoscopic robotic-assisted radical hysterectomy with nerve sparing technique is an attractive surgical approach for early invasive cervical cancer. Robotic technology allows a stereoscopic visualization of blood vessels and autonomic nerve supplies (sympathetic and parasympathetic branches) to the bladder and rectum making nerve sparing a safe and feasible procedure.

Change in clinical management of sentinel lymph node location in early stage cervical cancer: the role of SPECT/CT.

OBJECTIVE: The aim of this study was to investigate the feasibility of the sentinel lymph node (SLN) identification with SPECT/CT lymphoscintigraphy imaging in the early stage invasive cervical cancer in patients undergoing radical hysterectomy and pelvic lymphadenectomy. METHODS: Between March 2007 and June 2009, a prospective consecutive study was designed for SLN mapping. Twenty-two patients with cervical cancer FIGO stage IB1 (n=20) or stage IIA1 (n=2) underwent SLN identification with preoperative SPECT/CT and planar images (technetium-99m colloid albumin injection around the tumor) and posterior intraoperative detection with both blue dye and a handheld or laparoscopic gamma probe. Complete pelvic lymphadenectomy was performed in all cases by open (n=2) or laparoscopic (n=20) surgery. RESULTS: In the present series, a total of 35 SLN were detected with planar images and 40 SLN were identified and well located by SPECT/CT lymphoscintigraphy (median 2.0 nodes per patient). In 5/22 patients (22.7%) SPECT/CT procedure improves the number of localized SLN. Intraoperatively, 57 SLNs were identified, with a median of 3 SLNs per patient by gamma probe (a total of 53 hot nodes) and a median of 2 nodes per patient after blue dye injection (a total of 42 blue nodes). Microscopic nodal metastases (eight nodes, corresponding to four patients) were confirmed in 18.18% of cases; all these lymph nodes were previously detected as SLN. The remaining 450 nodes, including SLNs, following complete pelvic lymphadenectomy, were histologically negative. CONCLUSIONS: Sentinel lymph node detection is improved by SPECT/CT imaging because of the increased number of SLN detected and the better tridimensional anatomic location, allowing easier intra-operative detection with gamma probe and showing, in this series, a 100% negative predictive value.

Pretherapeutic extraperitoneal laparoscopic staging of bulky or locally advanced cervical cancer.

BACKGROUND: To assess the safety, feasibility, and impact on survival of extraperitoneal para-aortic lymphadenectomy in the staging of patients with bulky or locally advanced cervical cancer. MATERIALS AND METHODS: Between August 2001 and October 2009, 87 consecutive patients (median age 5 years) with bulky or locally advanced cervical cancer underwent extraperitoneal laparoscopic infrarenal aortic and common iliac dissection as a pretherapeutic staging procedure. Data on pathologic findings, details of surgery, postoperative complications, and disease status at follow-up were collected. RESULTS: The median operating time was 150 min (range 60-255 min). The mean (± standard deviation) para-aortic nodal yield was 15.5 ± 8.1 (range 4-62). In none of the patients, conversion to the transperitoneal approach or laparotomy was necessary. Histological examination revealed metastasis in 13 patients (macroscopic disease 10, microscopic disease 3). After a median follow-up of 33.4 months (range 13.3-65.9 months), 73.6% of patients were free of disease and 1.1% were alive with disease, 19.5% died from cervical cancer, and 3.3% died from other causes. After a follow-up of 3 years, no deaths or recurrences were documented, with an overall survival rate of 74.8% (95% CI 62.8%-83.4%) and disease-free survival of 86% (95% CI 74.7%-92.5%). There were no significant differences in overall survival and disease-free survival between patients with positive and negative para-aortic lymph nodes. CONCLUSION: The extraperitoneal laparoscopic para-aortic lymphadenectomy for pretherapeutic surgical staging in cervical cancer is a safe and feasible procedure that should be considered as a tool to identify lymph node positive patients who require extended-field radiation and/or chemotherapy.

Extraperitoneal laparoscopic approach for diagnosis and treatment of aortic lymph node recurrence in gynecologic malignancy.

OBJECTIVE: To estimate the safety and feasibility of extraperitoneal laparoscopic approach for the diagnosis and treatment of paraaortic lymph node recurrence in gynecologic cancers. MATERIAL AND METHODS: Between December 2002 and September 2009, 15 patients underwent extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected isolated lymph node recurrence in the Gynecologic Oncology Unit of Hospital Vall d'Hebron. The suspected diagnosis of recurrence was performed with computed tomography scanning, 18F-fluorodeoxyglucose positron emission tomography scanning, or magnetic resonance imaging. RESULTS: The median age of patients was 63 years (range 42-75). The median body mass index was 28.5 Kg/m(2) (range 18-38). The median operative time was 157.5 minutes (range 120-240). The median blood loss was 70 mL (range 30-150). The mean nodal yield was 7.7 +/- 5.3 (range 1-16). The median hospital stay was 2 days (range 2-13). There was 1 conversion to laparotomy. There was only 1 postoperative complication, a lymphorrhea that was resolved with drainage. Recurrence was confirmed in the pathologic study in 13 of the 15 patients. CONCLUSION: The extraperitoneal laparoscopic surgical approach is a feasible and safe procedure for the diagnosis of paraaortic lymph node recurrences of gynecologic cancers. The previous abdominal surgeries or treatment with chemotherapy or radiotherapy and high body mass index are not a problem. The low complication rate, low blood loss and low hospitalization allow a rapid recovery of the patients, which in turn, allows the rapid onset of adjuvant therapy. Complete debulking of suspicious lymphadenopathy offers an exact diagnosis of malignancy, and it may have a therapeutic benefit in the case of being positive.

Total laparoscopic radical hysterectomy for cervical cancer in prolapsed uterus.

PURPOSE: The association between cervical cancer and uterine prolapse is rare and sparsely represented in literature, despite the high incidence of the latter. The suitable treatment in this clinical situation is not defined. The objective of this article is to review published cases about this clinical condition. METHODS: We report a case of cervical cancer in prolapsed uterus treated with radical hysterectomy performed totally by laparoscopic approach, and review other case reports published about this clinical condition. RESULTS: We present the first case reported in literature in our knowledge of cervical cancer in prolapsed uterus treated with radical hysterectomy performed totally by laparoscopic approach. Treatments previously reported are vaginal hysterectomies with adjuvant radiotherapy or concomitant chemo-radiotherapy. CONCLUSIONS: Radical hysterectomy can be correctly performed totally by laparoscopic approach even when cervical cancer is associated with severe uterine prolapse.

Usefulness of extraperitoneal laparoscopic paraaortic lymphadenectomy for lymph node recurrence in gynecologic malignancy.

OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected lymph node recurrence of gynecological cancers. DESIGN: Descriptive study. SETTING: Unit of Gynecologic Oncology of an acute-care teaching hospital in Barcelona, Spain. POPULATION: Between December 2002 and October 2007, eight women underwent extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected lymph node recurrence, detected by magnetic resonance image (MRI), computed tomography (CT) scan or 18F-fluorodeoxyglucose positron emission tomography (PET) scanning. The suspicious nodes were removed through an extraperitoneal laparoscopic approach. RESULTS: The median age of patients was 66.5 years (range: 54-74). The median operating time was 157.5 minutes (range: 120-240). The median blood loss was 112.5 mL (range: 50-150). The mean nodal yield was 9.4+/-4.72 (range: 1-16). There were no intraoperative or postoperative complications. The median hospital stay was two days. Histological examination revealed metastasis in seven of eight patients. CONCLUSIONS: The extraperitoneal laparoscopic paraaortic lymphadenectomy for lymph node recurrence of gynecological cancers is a safe and feasible procedure which should be considered where there is isolated involvement of retroperitoneal lymph nodes. This procedure is a minimally invasive technique that allows an excellent approach to the paraaortic lymph nodes.