Robotic nerve-sparing radical hysterectomy.

AIM: The aim of this paper was to describe the robotic nerve-sparing technique and review the most recent data in the literature on this surgical approach. METHODS: Presentation of anatomical aspects regarding the nerve-sparing technique, besides discussion of the surgical steps as performed in our institution. RESULTS: Robotic-assisted nerve-sparing radical hysterectomy is a feasible approach for the treatment of cervical cancer patients, with remarkable advantages in terms of ergonomy, articulated movements and image magnification. All these features contribute for identification and preservation of the pelvic innervation, reducing the risk of surgical sequelae. CONCLUSION: Robotic nerve-sparing technique can be incorporated as a standard care without compromising radicality.

Correlation between the extent of intraperitoneal disease and nodal metastasis in node-positive ovarian cancer patients.

AIMS: To investigate correlations between extent of disease (ED), frequency and location of nodal metastases in node-positive EOC patients. METHODS: Data were collected from 116 consecutive patients who underwent systematic lymphadenectomy during primary surgery. Patients were grouped in ED1 (disease confined in pelvis), ED2 (disease extended to abdomen), and ED3 (distant metastases). Univariate and multivariate analysis were performed for overall survival and progression-free survival (PFS). RESULTS: Correspondence analysis revealed associations between ED1 and negative nodes, ED2 and positive aortic/pelvic nodes, and ED3 and positive external and common iliac nodes. The most representative group for nodal metastases in ED1 was aortic nodes (77.8%). The number of positive pelvic nodes increased with ED; the RR was 0.58 for ED2 and 0.25 for ED3 (p = 0.004). The RR for positive external iliac nodes was 0.66 in ED2 and 0.31 in ED3 (p = 0.002); the RR for positive common iliac nodes was 0.76 and 0.17, respectively (p = 0.001). Multivariate analysis revealed that aortic nodal metastasis was associated with PFS (p = 0.03; HR, 1.95). CONCLUSION: Distribution and percentage of nodal metastases varied with ED. The risk of pelvic nodal metastasis, increased with ED. Location of positive nodes was correlated with PFS.

Comparison of robotic-assisted vs conventional laparoscopy for extraperitoneal paraaortic lymphadenectomy.

OBJECTIVE: To evaluate the perioperative outcomes of robotic-assisted extraperitoneal paraaortic lymphadenectomy for locally advanced cervical cancer and to compare to a previous series of patients from our institution undergoing the same procedure by conventional laparoscopy. METHODS: 17 patients with locally advanced cervical cancer (FIGO stages IB2, IIA2 and IIB-IVA) underwent pretherapeutic extraperitoneal paraaortic lymphadenectomy by robotic-assisted laparoscopy. Perioperative outcomes including age, BMI, FIGO stage, operating time, blood loss, complications and length of hospital stay were compared to a series of 83 patients from our institution undergoing the same procedure by conventional laparoscopy. RESULTS: The median values for operating time and hospital days for the robotic-assisted and conventional laparoscopy groups were 150 vs. 150 min and 2 vs 2 days, respectively. In the robotic group, blood loss was lower (90 vs 20 ml, p<0.05) and more aortic nodes were removed (14 vs 17 nodes, p<0.05). Docking time was 7 min (range 3-15). There were no intraoperative complications. There were no differences for postoperative complications (17.6% vs 8.4%). CONCLUSION: Robotic-assisted and conventional laparoscopy provide similar perioperative outcomes other than lower blood loss and higher number of aortic nodes removed (both without clinical impact) in robotic patients for the performance of extraperitoneal paraaortic lymphadenectomy in patients with locally advanced cervical cancer. We believe that robotic surgery is an additional tool to perform the same surgical procedure. HIGHLIGHTS: Robotic-assisted and conventional laparoscopic extraperitoneal paraaortic lymphadenectomy provide similar perioperative outcomes.

Defining the optimal lymphadenectomy cut-off value in epithelial ovarian cancer staging surgery utilizing a mathematical model of validation.

OBJECTIVE: Since 1985 International Federation of Gynecology and Obstetrics includes pelvic and aortic lymphadenectomy as part of the surgical staging in epithelial ovarian cancer (EOC). There is no consensus on the overall number of nodes needed in a systematic lymphadenectomy. The aim of this study is to calculate the optimal cut-off value using a mathematical modeling approach. METHODS: Data was collected retrospectively, from 1996 to 2000, of 120 consecutive Mayo Clinic patients with EOC and positive nodes. All patients was underwent pelvic and/or aortic lymphadnectomy during surgical staging. To mathematically predict the probability of a positive node in EOC patients we used a predictive mathematical model (PMM). The mathematical analysis consisted: creation of a new PMM according to our purposes, application of PMM to describe the experimental data in order to build the polynomial regression curves in each lymphatic area and determine the optimal point for each curve. RESULTS: The mean number of lymph nodes and metastatic nodes removed were 35 and 7.8, respectively; the mean percentage of positive nodes was 28.3%. The optimal point of each fitting curves were: 7 nodes for unilateral aortic nodal sampling (at least 3 infrarenal or 5 inframesenteric) and 15 nodes for unilateral pelvic lymphadenectomy (at least 5 external iliac). CONCLUSIONS: We can mathematically predict the probability to obtain a positive node in EOC surgical staging. Our results have shown the need to obtain at least 22 lymph nodes between pelvic and aortic lymphadenectomy.

Location of aortic node metastases in locally advanced cervical cancer.

BACKGROUND: To assess the location of aortic node metastasis in patients with locally advanced cervical cancer undergoing extraperitoneal aortic lymphadenectomy to define the extent of the aortic lymphadenectomy. MATERIAL AND METHODS: Between August 2001 and December 2010, 100 consecutive patients with primary locally advanced cervical cancer underwent extraperitoneal laparoscopic aortic and common iliac lymphadenectomy. The location of aortic node metastases, inframesenteric or infrarenal was noted. RESULTS: The mean number±standard deviation (SD) of aortic nodes removed was 15.9 ± 7.8 (range 4-62). The mean number ± SD of inframesenteric (including common iliac) nodes removed was 8.8 ± 4.5 (range 2-41) and the mean number ± SD of infrarenal nodes removed was 7.8 ± 4.1 (range 2-21). Positive aortic nodes were observed in 16 patients, and in 5 (31.2%) of them the infrarenal nodes were the only nodes involved, with negative inframesenteric nodes. CONCLUSION: Inframesenteric aortic nodes are negative in the presence of positive infrarenal nodes in about one third of patients with locally advanced cervical cancer and aortic metastases.

Robotic surgery for endometrial cancer: comparison of perioperative outcomes and recurrence with laparoscopy, vaginal/laparoscopy and laparotomy.

INTRODUCTION: Comparison of perioperative outcomes and recurrence in patients undergoing primary surgical treatment for endometrial cancer by robotics, laparoscopy, vaginal/laparoscopy, or laparotomy approaches. METHODS: Prospective analysis of 67 patients undergoing robotic surgery for endometrial cancer between March 2004 and December 2007. Comparison was made with similar patients operated between November 1999 and December 2006 by laparoscopy (37 cases), laparotomy (99 cases) and vaginal/laparoscopy approach (vaginal hysterectomy, bilateral adnexectomy/laparoscopic lymphadenectomy) (47 cases) and matched by age, body mass index (BMI), histological type and International Federation of Gynecologists and Obstetricians (FIGO) staging. RESULTS: Mean operating times for patients undergoing robotic, laparoscopy, vaginal/laparoscopy or laparotomy approach were 181.9, 189.5, 202.7 and 162.7 min, respectively (p = 0.006); mean blood loss was 141.4, 300.8, 300.0 and 472.6 ml, respectively (p <0.001); mean number of nodes was 24.7, 27.1, 28.6, and 30.9, respectively (p = 0.008); mean length of hospital stay was 1.9, 3.4, 3.5 and 5.6 days, respectively (p < 0.001). There were no significant differences in intra- or postoperative complications among the four groups. The conversion rate was 2.9% for robotics and 10.8% for the laparoscopy group (0.001). There were no differences relative to recurrence rates among the four groups: 9%, 14%, 11% and 15% for robotics, laparoscopy, vaginal/laparoscopy, and laparotomy, respectively. CONCLUSION: Robotics, laparoscopy and vaginal/laparoscopy techniques are preferable to laparotomy for suitable patients with endometrial cancer. Robotics is preferable to laparoscopy due to a shorter hospital stay and lower conversion rate and preferable to vaginal/laparoscopy due to a reduced hospitalization.

Metastatic and recurrent adenocarcinoma of the uterine cervix: a long-term survival of 16 years.

PURPOSE OF INVESTIGATION: Recurrent metastatic adenocarcinoma of the cervix is associated with an extremely poor prognosis. Treatment options for recurrent disease are limited and cure is extremely rare. CASE REPORT: We report a case of a 43-year-old patient with Stage IB adenocarcinoma of the cervix. She had multiple metastatic recurrence episodes salvaged with several radical surgeries, external and intraoperative irradiation, and chemotherapy over a survival period of 16 years. CONCLUSION: We conclude that long-term multi-modal salvage treatment may achieve longer survival in rare cases with recurrent metastatic adenocarcinoma of the cervix.

Robotic surgery in gynecology.

Robotic technology is nothing more than an enhancement along the continuum of laparoscopic technological advances and represents only the beginning of numerous more forthcoming advances. It constitutes a major improvement in the efficiency, accuracy, ease, and comfort associated with the performance of laparoscopic operations. Instrument articulation, downscaling of movements, absence of tremor, 3-D image, and comfort for the surgeon, assistant and scrub nurse are all new to the practice of laparoscopy. In our hands, robotic operative times for simple and radical hysterectomy are shorter than those obtained by conventional laparoscopy. Robotic technology is preferable to conventional laparoscopic instrumentation for the surgical treatment of gynecologic malignancies and most operations for benign disease of certain complexity such as hysterectomy myomectomy, and invasive pelvic endometriosis.

Laparoscopic treatment of endometrial cancer: five-year recurrence and survival rates.

PURPOSE: To evaluate the 5-year recurrence and survival of patients with clinical Stage I endometrial cancer treated by the laparoscopic approach. METHODS: Retrospective review of 56 patients with clinical Stage I endometrial cancer treated laparoscopically. The mean follow-up was 6.4 (4.8-9.6) years. The International Federation of Obstetricians and Gynecologists (FIGO) surgical staging was: I, 45 (80.4%); II, three (5.4%); III, six (10.7%); and IV, two (3.6%). RESULTS: For patients with surgical Stage I (n = 45), the 5-year recurrence rate was 4.9% and the 5-year cause-specific survival was 94.7%. Factors univariately associated with survival were grade (p = .017), depth of myometrial invasion (p = .018), node metastasis (p = .013), and surgical stage according to FIGO (p = .097). CONCLUSION: The laparoscopic approach provided 5-year survival and recurrence rates similar to those previously attained by laparotomy in our institution.

Mucinous adenocarcinoma in an ovarian remnant.

The ovarian remnant syndrome, a complication of bilateral salpingo-oophorectomy, is progressively receiving more attention in the gynecological surgery literature. The syndrome is manifested by pelvic pain and a palpable or sonographic finding of a pelvic mass. However, in rare cases, patients can present with large masses and radiographic suggestion of malignancy. We present the case of a 76-year-old white female, 23 months after bilateral salpino-oophorectomy at the same institution, complaining of 3.5 months of right flank and abdominal pain. Clinical and radiological evidence of a right ovarian remnant was discovered. Subsequent laparoscopic resection was consistent with a well-encapsulated mucinous adenocarcinoma in a right ovarian remnant. Curiously, this patient had no history of endometriosis, dense pelvic adhesions, pelvic inflammatory disease, or difficulty encountered during the original hysterectomy. This is the seventh published case report in the international literature about carcinoma developing in an ovarian remnant. However, this case differs in that the patient had no preexisting gynecologic conditions at the time of hysterectomy and bilateral salpingo-oophorectomy to account for residual ovarian tissue. Additionally, the oophorectomy was performed vaginally, in contrast to multiple previous case reports.

Harvesting autologous fascia lata for pelvic reconstructive surgery: techniques and morbidity.

OBJECTIVE: To determine donor site morbidity associated with harvesting of fascia lata. STUDY DESIGN: We reviewed medical records and evaluated responses to mailed questionnaires from all patients who underwent fascia lata harvesting during a 54-month period. Data were collected about immediate complications and long-term morbidity related to the donor site. RESULTS: The study comprised 71 patients. Immediate postoperative complications were limited to 1 (1%) hematoma that required drainage, 2 (3%) seromas, and 5 (7%) cases of cellulitis that required oral antibiotics. Questionnaire response rate was 77%, with a mean follow-up of 25 months. Of the responders, 22 (40%) reported mild symptoms, 3 (5%) reported clinically significant symptoms related to the donor leg, and 7 (13%) expressed dissatisfaction because of unacceptable cosmesis (n = 5), leg discomfort (n = 5), or both. CONCLUSION: There was little immediate postoperative morbidity. Although many patients may be expected to report long-term symptoms related to the donor leg, these symptoms are generally mild, and the incidence of patient dissatisfaction is relatively low.

Endometriosis: correlation between histologic and visual findings at laparoscopy.

OBJECTIVE: The purpose of this study was to correlate the diagnosis of endometriosis on the basis of visualization at laparoscopy with the pathologic diagnosis. STUDY DESIGN: A prospective study of 44 patients undergoing laparoscopy for the evaluation of chronic pelvic pain was carried out. All areas suggestive of endometriosis were excised and examined pathologically. Peritoneal biopsy specimens were obtained from areas of normal-appearing peritoneum to rule out microscopic endometriosis. All lesions were identified by anatomic site. Visual and histologic American Fertility Society scores were compared. The positive predictive value, sensitivity, negative predictive value, and specificity were determined for visually identified endometriosis versus the histologic correlate. RESULTS: The mean prevalence of abnormalities visually consistent with endometriosis was 36%, with 18% confirmed histologically. The positive predictive value was 45%; sensitivity, 97%; negative predictive value, 99%; and specificity, 77%; for visual versus histologic diagnosis of endometriosis. Thirty-six percent of the diagnoses were downstaged on the basis of histologic findings. CONCLUSION: A diagnosis of endometriosis should be established only after histologic confirmation.

Laparoscopic surgery for gynecologic cancers.

In conclusion, laparoscopic techniques are useful for the evaluation and treatment of selected gynecologic malignancies and provide major benefits to patients. The benefits, however, can be expected only from gynecologic oncologists well-versed in advanced laparoscopic techniques. Results must be interpreted cautiously, depending on the laparoscopic expertise of the reporting authors. Numerous questions remain unanswered, particularly those associated with long-term recurrences and survival. The use of laparoscopic procedures for gynecologic malignancies must be considered investigational until adequate long-term survival data are available.

Squamous cell carcinoma of the vulva stage IA: long-term results.

OBJECTIVE: The aim of this study was to evaluate the risk of metastases to lymph nodes and long-term results of radical and modified radical surgery in patients with a T1 squamous cell carcinoma of the vulva and

Laparoscopic radical parametrectomy and pelvic and aortic lymphadenectomy for vaginal carcinoma: A case report.

OBJECTIVE: The objective of this study was to examine the feasibility of laparoscopic radical parametrectomy after previous hysterectomy. METHODS: This was a prospective study of a patient with vaginal adenocarcinoma after previous simple hysterectomy. The technique of radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy as used for open cases for years was performed laparoscopically. RESULTS: The operating time was 270 min, the estimated blood loss was 200 mL, and the duration of hospitalization was 3 days. There were no intraoperative or postoperative complications. CONCLUSIONS: Radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy can be successfully accomplished laparoscopically.

Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy for endometrial cancer: morbidity and survival.

OBJECTIVES: Our goal was to evaluate the morbidity, recurrence, and survival of patients with clinical stage I endometrial cancer treated by laparoscopic lymphadenectomy with vaginal or laparoscopic hysterectomy and bilateral salpingo-oophorectomy. STUDY DESIGN: This article is a retrospective review of records for 56 patients. The mean follow-up among those alive at last contact was 2.4 years (range, 32 days-5.2 years). Staging according to the International Federation of Gynecology and Obstetrics (1988) was as follows: I, 45 (80.4%); II, 3 (5.4%); III, 6 (10.7%); and IV, 2 (3.6%). RESULTS: Intraoperative complications occurred in 4 patients (7.1%). Transformation to laparotomy was necessary in 7 patients. Postoperative complications were observed in 9 patients (16.1%). Pelvic irradiation was administered postoperatively to 11 patients (19.6%). Among the 45 patients with surgical stage I disease, the 3-year recurrence rate was 2.5% and the 3-year cause-specific survival was 96.0%. CONCLUSIONS: Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy provided 3-year survival and recurrence rates similar to those of the traditional abdominal approach.