Tumor budding in cervical cancer as a prognostic factor and its possible role as an additional intermediate-risk factor.

OBJECTIVE: To evaluate the prognostic value and its possible role as an additional intermediate-risk factor of tumor budding (TB) in cervical cancer following radical hysterectomy. METHODS: In total, 136 patients with cervical cancer who underwent radical hysterectomy with pelvic and/or paraaortic lymphadenectomy were included. We assessed the status of TB in available hematoxylin and eosin-stained specimens. Univariate and multivariate analyses for predicting tumor recurrence and death were performed using TB and other clinicopathologic parameters. To evaluate additional intermediate-risk factors of TB, patients who had at least one high-risk factor were excluded, and a total of 81 patients were included. We added TB to three conventional intermediate-risk models and compared their performance with new and conventional models using the log-rank test and receiver operating characteristic analysis. RESULTS: High TB was defined as ≥5 per high-power field for disease-free survival and ≥ 8 per high-power field for overall survival. Multivariate analysis revealed that high TB was an independent prognostic factor for predicting overall survival (hazard ratio, 4.96; 95% confidence intervals, 1.06-23.29; p = .0423). The addition of TB to the conventional intermediate-risk models improved the accuracy of recurrence prediction. Among the risk models, the new model using at least two risk factors, including tumor size (≥ 4 cm), deep stromal invasion (outer one-third of entire cervical thickness), lymphovascular invasion, and high TB, was the most accurate for predicting tumor recurrence (area under the curve, 0.708, hazard ratio, 4.25; p = .0231). CONCLUSION: High TB may be a prognostic biomarker of cervical cancer. Moreover, the addition of TB to the conventional intermediate-risk models improves the stratification of tumor recurrence.

Effectiveness of adjuvant treatment for morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma: A Korean multicenter study.

AIM: To evaluate the effectiveness of adjuvant treatment for morcellated, uterus-confined leiomyosarcoma in a multicenter setting. METHODS: We identified patients with International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma primarily treated with surgery between 2003 and 2016. Among them, patients who underwent one of the following morcellation methods were included: (i) power morcellation; (ii) intracorporeal morcellation using scalpels or electrocautery; and (iii) vaginal morcellation. Patients' survival outcomes were compared according to the implementation of adjuvant treatment. RESULTS: From 13 institutions, 55 patients were included; 31 for adjuvant treatment group and 24 for surgery only group. The clinicopathological characteristics including the mass size, morcellation methods, extent of surgery, and mitotic count were similar between the groups. In the adjuvant treatment group, 67.7%, 19.4% and 12.9% of patients received chemotherapy, chemoradiation and radiation, respectively. After a median follow-up of 50.5 months, the adjuvant treatment and surgery only groups showed similar overall survival (5-year rate, 92.0% vs 90.4%; P = 0.959). No significant difference in progression-free survival was observed between the two groups (3-year rate, 46.1% vs 78.2%; P = 0.069). On multivariate analyses, adjuvant treatment did not affect progression-free survival (adjusted HR, 2.138; 95% CI, 0.550-8.305; P = 0.273). The adjuvant treatment group showed a trend towards more common distant metastasis, compared to the surgery only group (25.8% vs 4.2%; P = 0.062). The incidences of pelvic, retroperitoneal, and abdominal recurrences were not different between the groups. CONCLUSION: Despite its frequent use in clinical practice, adjuvant treatment did not improve the survival outcomes of patients with morcellated, International Federation of Gynecology and Obstetrics stage I uterine leiomyosarcoma.

Prevalence, survival outcomes, and clinicopathologic factors associated with negative high risk human papillomavirus in surgical specimens of cervical cancer with pretreatment negative DNA genotype test.

OBJECTIVE: The aim of this study was to detect high risk human papillomavirus in cervical cancer with a pretreatment negative high risk human papillomavirus DNA genotype test and to evaluate clinicopathologic characteristics and survival outcomes according to high risk human papillomavirus status. METHODS: We investigated high risk human papillomavirus status in surgical specimens from 30 cases of cervical cancer using polymerase chain reaction. Polymerase chain reaction primers were set to detect the presence of the common L1 and E7 regions of human papillomavirus types 16, 18, 31, 33, 45, 52, and 58. We analyzed the following clinicopathologic parameters to evaluate their relationships with high risk human papillomavirus status: age, histology, stage, tumor size, invasion depth, lymphovascular invasion, and recurrent status. RESULTS: Among 30 cases with a pretreatment negative DNA genotype test, high risk human papillomavirus was detected in 12 (40.0%), whereas 18 (60.0%) were negatives. Of 12 high risk human papillomavirus positive cases, 10 (33.3%) were positive for the L1 region, 6 (20.0%) of the 7 types were positive for the E7 region, and 4 (13.1%) were positive for both L1 and E7 regions. According to a multiple logistic regression model, tumor size (odds ratio 7.80; 95% confidence interval 1.476 to 41.216; P=0.0097) and stage (odds ratio 7.00; 95% confidence interval 1.293 to 37.910; P=0.0173) were associated with negative high risk human papillomavirus DNA status. Kaplan-Meier survival plots showed that negative high risk human papillomavirus status was associated with worse disease free survival in contrast with positive high risk human papillomavirus status (P=0.0392). CONCLUSIONS: Negative high risk human papillomavirus was found in 60% of cervical cancers with a pretreatment negative DNA genotype test. Moreover, the negative high risk human papillomavirus group was associated with worse survival outcome.

Transmembrane G protein-coupled receptor 30 gene polymorphisms and uterine adenomyosis in Korean women.

To compare the genetic distributions of 14G protein-coupled receptor 30 (GPR30) single-nucleotide polymorphisms (SNPs) between women with and without uterine adenomyosis. The study population comprised 69 Korean women. Uterine tissues from the adenomyosis and non-adenomyosis groups were used for DNA extraction. Pre-designed PCR/Sanger or Sequencing Primer and TaqMan® SNP Genotyping Assays were used for the SNP genotyping of the GPR30 gene. Immunohistochemical staining was performed to confirm the GPR30 expression. Differences in genotype and allele frequencies between the two groups were calculated using Fisher's exact test. The rs3802141 CT genotype was more common in the control group (p = .02), and the rs4266553 CC genotype was more common in the adenomyosis group (p = .02). The C allele of the SNP rs4266553 was more common in the adenomyosis group (p = .02). GPR30 expression was confirmed in 69 individuals in both groups. GPR30 gene polymorphism is presumed to affect the risk of adenomyosis with limited sample size. Further large-scale study is needed to explain the genetic influence of GPR30 gene polymorphism.

Prognostic value of pre-treatment human papilloma virus DNA status in cervical cancer.

OBJECTIVE: Although the relationship between human papilloma virus (HPV) and cervical cancer is well established, the prognostic value of HPV status has not been determined, largely because previous studies have yielded conflicting results. This study aimed to investigate the prognostic value of pre-treatment HPV DNA for predicting tumor recurrence in cervical cancer. METHODS: The study included 248 eligible patients who provided cervical cell specimens for HPV genotyping before surgery or concurrent chemoradiotherapy (CCRT). Of these 248 patients, 108 were treated with radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage IB1-IIA cervical cancer, and 140 were treated with CCRT for FIGO stage IB2-IV cervical cancer. RESULTS: HPV 16 and 18 were the two most common HPV types detected, with prevalence rates of 52.4% and 12.5%, respectively. The pre-treatment HPV DNA test showed that 18.5% of cervical cancers were HPV negative. Multivariate analysis showed that HPV negativity was associated with poorer disease-free survival (DFS) than HPV-positive status (hazard ratio [HR], 3.97; 95% confidence interval [CI], 1.84-8.58; p=0.0005), and patients with HPV 16-positive cancers had better DFS (HR, 0.41; 95% CI, 0.23-0.72; p=0.0019). In the surgery group, only HPV 16 positivity was significantly correlated with DFS (HR, 0.34; 95% CI, 0.12-0.96; p=0.0416). In the CCRT group, only HPV negativity was significantly correlated with DFS (HR, 3.75; 95% CI, 1.78-7.90; p=0.0005). CONCLUSIONS: Pre-treatment HPV DNA status may be a useful prognostic biomarker in cervical cancer. The presence of HPV 16 DNA was associated with better DFS, and HPV negativity was associated with worse DFS. However, larger sample sizes and more comprehensive studies are required to verify our findings.

Comparison of the Long-Term Oncological Outcomes Between the Initial Learning Period of Robotic and the Experienced Period of Laparoscopic Radical Hysterectomy for Early-Stage Cervical Cancer.

OBJECTIVES: To compare the long-term oncological outcomes, complication rates, and recurrence patterns of robotic radical hysterectomy (RRH) with laparoscopic radical hysterectomy (LRH) for the treatment of early-stage cervical cancer. METHODS: Between January 2008 and December 2013, 65 consecutive patients underwent RRH during the learning period, and 60 consecutive patients underwent LRH during the experienced period. RESULTS: Both groups were similar with respect to clinicopathologic characteristics. The mean operative time in the RRH group was significantly longer than that in the LRH group (277.8 ± 57.3 vs 199.6 ± 45.0 minutes; P < 0.0001). Postoperative complication rates were significantly higher in the RRH group than in the LRH group (47.7% vs 27.1%; P = 0.0188). No difference in the estimated disease-free survival rates was observed between the 2 groups (P = 0.3152); however, the estimated overall survival of RRH was lower than that of LRH with marginal significance (P = 0.0762). There was no significant difference in terms of recurrence pattern between the 2 groups (P = 0.7041). However, peritoneal recurrences occurred only in the RRH group. CONCLUSIONS: Despite RRH being performed by an experienced laparoscopic oncologist, RRH showed inferior long-term oncological outcomes and postoperative complication rates compared with those of LRH during the learning period.

Comparison of robotic-assisted versus laparoscopy for transperitoneal infrarenal para-aortic lymphadenectomy in patients with endometrial cancer.

AIM: This study was conducted to evaluate the clinical feasibility of robotic-assisted transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) in patients with endometrial cancer. METHODS: From June 2006 to October 2016, we retrospectively analyzed 42 patients who underwent laparoscopic (n = 16) or robotic-assisted (n = 26) staging operations, including TIPAL for endometrial cancer. Perioperative data including age; body mass index; operation duration; the number of lymph nodes retrieved and the ratio of time to lymph node retrieval during pelvic, infrarenal para-aortic and total lymphadenectomy; estimated blood loss and postoperative complications were compared. RESULTS: The operative duration of pelvic (21.7 ± 5.31 vs 30.7 ± 10.8 min; P = 0.002), and total (62.6 ± 14.0 vs 87.0 ± 30.4 min; P = 0.010) lymphadenectomy was significantly shorter in the robotic-assisted than the laparoscopic group, whereas there was no statistical difference in the duration of infrarenal para-aortic lymphadenectomy. By contrast, the number of infrarenal para-aortic lymph nodes retreived was significantly higher (29.4 ± 10.7 vs 23.3 ± 9.16; P = 0.016) in the robotic-assisted group. Consequently, the ratio of time to number of lymph nodes retrieved during infrarenal (1.51 ± 0.49 vs 2.62 ± 1.34; P = 0.002) and total (1.43 ± 0.48 vs 2.15 ± 0.93; P = 0.014) lymphadenectomy was lower in the robotic-assisted compared to the laparoscopic group. CONCLUSIONS: The robotic-assisted approach took less time per infrarenal para-aortic and total lymph nodes retrieved compared to the conventional laparoscopic approach. Robotic-assisted TIPAL could be feasible and effective for the staging and treatment of patients with endometrial cancer.

Late solitary pelvic metastasis of hepatocellular carcinoma mimicking alpha-fetoprotein-producing gynaecologic tumour.

Extrahepatic spread of hepatocellular carcinoma (HCC) is uncommon; and, pelvic metastasis, in particular, is extremely rare. A 71-year-old woman was admitted for evaluation of pelvic solitary solid mass. She had undergone a left lobectomy 28 years previously. Magnetic resonance imaging of the abdomen and pelvis demonstrated a heterogeneous mass in the right pelvic cavity, whereas no space-occupying lesions or ascites were detected in the liver. CA 125 levels were within normal limits; however, serum alpha-fetoprotein levels were markedly elevated. She underwent laparoscopic pelvic mass excision, total hysterectomy, and bilateral salpingo-oophorectomy. Histopathologic findings and immunochemical staining results indicated metastatic HCC. Herein, we report an unusual case of a patient with solitary recurrence in the pelvic cavity 28 years after initial diagnosis and treatment.

Conservative Treatment for Patients with Carcinoma in Situ-Positive Margins After a Loop Electroexcisional Procedure: Is It Safe?

OBJECTIVE: To investigate the clinical significance of and appropriate treatments for carcinoma in situ (CIS)-positive margin after a loop electroexcisional procedure (LEEP) in the management of squamous carcinoma in situ (SCIS), adenocarcinoma in situ (ACIS), and microinvasive carcinoma (MIC). STUDY DESIGN: We analyzed 232 patients who underwent a hysterectomy for CIS-positive margin. We investigated the relationship between residual lesions after hysterectomy and clinical parameters, including age, LEEP method, histologic grade of conized cervix, location of the positive margin after LEEP, results of endocervical curettage (ECC), and size of the conized specimen. RESULTS: Age, LEEP method, proximal endocervical margin positivity, and ECC positivity differed significantly between patients with residual lesions and those with no residual lesions. In a comparison between groups with residual disease of a higher or lower grade than MIC, age, LEEP method, ECC positivity, and histologic grade of conized cervix were significantly different. Age, histologic grade of conized cervix, and ECC positivity were clinical parameters significantly contributing to invasive residual lesion in multivariate regression analysis. There were no residual invasive (MIC or advanced invasive cancer) lesions observed in women <50 years old who had SCIS conized lesions after hysterectomy. CONCLUSION: Conservative treatment with close follow-up or reconization for women <50 years old who have conized SCIS lesions without ECC positivity is acceptable. However, this study does not present sufficient evidence for the conservative treatment of conized ACIS or MIC lesions with CIS-positive margins.

Long-Term Efficacy of Laparoscopic or Robotic Adenomyomectomy with or without Medical Treatment for Severely Symptomatic Adenomyosis.

BACKGROUND/AIMS: To determine the long-term efficacy of laparoscopic or robotic adenomyomectomy with or without gonadotropin-releasing hormone (GnRH) for the treatment of severely symptomatic adenomyosis. METHODS: Between August 2008 and May 2011, we prospectively observed 33 patients who underwent laparoscopic or robotic adenomyomectomy with uterine artery ligation for the treatment of symptomatic adenomyosis. Seventeen patients (52%) received 3-course GnRH agonist treatment after the adenomyomectomy. RESULTS: The mean operating time was 147.4 ± 52.0 min, and the mean blood loss was 36.1 ± 37.4 ml. Postoperative complications occurred in 5 patients, including 4 cases of febrile morbidity, 1 case of ileus and 1 case of pelvic abscess. Patients had statistically significant symptom relief during the 3-year follow-up period. Four of the 33 patients (12%) showed symptom relapse; 3 patients showed a relapse with dysmenorrhea and 1 patient showed a relapse with menorrhagia. There were no significant differences in terms of therapeutic outcomes between surgical-only and surgical-medical treatment. CONCLUSION: Laparoscopic or robotic adenomyomectomy was feasible and safe for women with severely symptomatic adenomyosis who requested uterine preservation. Moreover, this procedure provided long-term symptom control, regardless of postoperative GnRH agonist administration.

Total vaginal and single-port total laparoscopic hysterectomy for uterine benign diseases.

OBJECTIVE: This study aimed to review the surgical outcomes and health-related quality of life (HRQOL) of total vaginal (TVH) and single-port total laparoscopic hysterectomy (SP-TLH) for uterine benign diseases. STUDY DESIGN: This study included 121 patients who had undergone TVH or SP-TLH for uterine benign diseases between April 2011 and July 2012. Surgical outcomes, complications, and HRQOL were reviewed in the two groups. Preoperative and postoperative HRQOL data from the 36-item Short Form questionnaire (SF-36) were recorded for all patients. RESULTS: TVH was performed more often for the patients who had fewer previous operations (p = 0.32). In the TVH, there were fewer combined surgical procedures (p < 0.01), shorter operation times (p < 0.01), shorter vaginal stump suture times (p = 0.03) and lower complication rates (p < 0.01) than in SP-TLH. Overall, all SF-36 scales improved after surgery, except for the Social Functioning scale. There was no significant difference in any of the scales between the two groups. CONCLUSIONS: TVH has equivalent effects on HRQOL as SP-TLH. SP-TLH is preferred for the cases with complicated and combined procedures.

Role of SUVmax and GLUT-1 Expression in Determining Tumor Aggressiveness in Patients With Clinical Stage I Endometrioid Endometrial Cancer.

OBJECTIVE: The aim of this study was to determine the role of (18)F-fluorodeoxyglucose positron emission tomography/computed tomography in estimating tumor aggressiveness in patients with clinical stage I endometrial cancer and the correlation between aggressiveness and expression of glucose transporter 1 (GLUT-1). METHODS: F-fluorodeoxyglucose positron emission tomography/computed tomography was performed on 43 patients with clinical stage I endometrioid endometrial cancer. (18)F-fluorodeoxyglucose uptake was quantified by calculating the maximum standardized uptake value (SUV(max)) and GLUT-1 expression status based on immunohistochemistry. RESULTS: The mean (SD) SUV(max) of the primary tumor was 8.55 (5.04). The mean SUV(max) and GLUT-1 expression in stage IB and stage IC were significantly higher than that in stage IA (P = 0.001; P = 0.003). The mean (SD) SUV(max) was 6.81 (4.55) in grade 1, 10.92 (4.61) in grade 2, and 15.35 (1.34) in grade 3 (grade 1 vs grade 2 and 3; P = 0.005). The mean (SD) GLUT-1 expression was 1.17 (0.94) in grade 1, 2.00 (0.94) in grade 2, and 3.00 (0.00) in grade 3 (grade 1 vs grade 2 and 3; P = 0.017). CONCLUSIONS: Tumor aggressiveness, such as myometrial invasion or tumor grade, had a positive correlation with the SUV(max) and GLUT-1 expression in patients with clinical stage I endometrioid endometrial cancer.

Single-port (OctoPort) assisted extracorporeal ovarian cystectomy for the treatment of large ovarian cysts: compare to conventional laparoscopy and laparotomy.

STUDY OBJECTIVE: To evaluate single-port assisted extracorporeal cystectomy for treatment of large ovarian cysts and to compare its surgical outcomes, complications, and cystic content spillage rates with those of conventional laparoscopy and laparotomy. DESIGN: Retrospective study (Canadian Task Force classification II-2). SETTING: University teaching hospital. PATIENTS: Twenty-five patients who underwent single-port assisted extracorporeal cystectomy (group 1), 33 patients who underwent conventional laparoscopy (group 2), and 25 patients who underwent laparotomy (group 3). INTERVENTIONS: Surgical outcomes, complications, and spillage rates in group 1 were compared with those in groups 2 and 3. MEASUREMENTS AND MAIN RESULTS: Patients characteristics and tumor histologic findings were similar in the 3 groups. The mean (SD) largest diameter of ovarian cysts was 11.4 (4.2) cm in group 1, 9.7 (2.3) cm in group 2, and 12.0 (3.4) cm in group 3. Operative time in groups 1 and 2 was similar at 69.3 (26.3) minutes vs 73.1 (36.3) minutes (p = .66); however, operative time in group 1 was shorter than in group 3, at 69.3 (26.3) minutes vs 87.5 (26.6) minutes (p =.02). Blood loss in group 1 was significantly lower than in groups 2 and 3, at 16.0 (19.4) mL vs 36.1 (20.7) mL (p < .001) and 16.0 (19.4) mL vs 42.2 (39.7) mL (p = .005). The spillage rate in group 1 was profoundly lower than in group 2, at 8.0% vs 69.7% (p < .001). CONCLUSION: Single-port assisted extracorporeal cystectomy offers an alternative to conventional laparoscopy and laparotomy for management of large ovarian cysts, with comparable surgical outcomes. Furthermore, cyst content spillage rate in single-port assisted extracorporeal cystectomy was remarkably lower than that in conventional laparoscopy.

Is Laparoscopic Incidental Appendectomy in Gynecological Diseases Related to Postoperative Intraabdominal Infection and Complications?

OBJECTIVE: To establish whether laparoscopic incidental appendectomy in gynecological diseases is related to postoperative intraabdominal infection and complications. STUDY DESIGN: This study was performed prospectively in 443 patients who underwent laparoscopic surgery without appendectomy (n = 222) or with appendectomy (n = 221). On postoperative day 1, drain fluid was cultured in all patients. All data were compared using Student's t test and χ2 test. RESULTS: Bacteria grew in cultures of 93 patients (21.0%): 38 (17.1%) in the nonappendectomy group and 55 (24.9%) in the appendectomy group (p < 0.01). There were statistical differences in the incidence of bacterial growth, postoperative complications, and post-operative laboratory changes for percentage of neutrophils (p < 0.01) and C-reactive protein (p < 0.01). Thirteen genera of bacteria grew in the drain culture. The 9 commensal organisms of the human intestine were identified in all patients, each 8 genera of bacteria in both groups. The surgical type did not affect the postoperative drain culture results. CONCLUSION: Postoperative bacterial growth and complications were increased in the laparoscopic incidental appendectomy group. Infections with bacteria from the intestine in both groups were also related to contamination during surgery and postoperative care.

Unabsorbed polylactide adhesion barrier mimicking recurrence of gynecologic malignant diseases with increased ¹8F-FDG uptake on PET/CT.

PURPOSE: To evaluate the incidence and characteristics of the unabsorbed polylactide adhesion barrier with increased (18)F-fluorodeoxyglucose ((18)F-FDG) uptake after surgeries for gynecologic malignancies. METHODS: Between September 2006 and November 2009, we reviewed the charts of 75 patients who were provided a polylactide adhesion barrier after surgery for gynecologic malignant diseases. We surveyed the cases of increased (18)F-FDG uptake on positron emission tomography/computed tomography (PET/CT), and evaluated the effectiveness of polylactide adhesion barrier using an adhesion scoring system. RESULTS: Ten patients (13.3 %) had a solitary pelvic mass with increased (18)F-FDG uptake in the follow up PET/CT. The characteristics of patients and tumors are described below. The median age was 48 years (range 19-66 years). The median tumor size was 1.9 cm (range 1.0-2.3 cm), and the median SUVmax of the pelvic mass was 5.1 (range 3.7-7.9). The median time between initial operations and second operation was 13.5 months (range 8-23 months). We performed laparoscopic excision of the pelvic mass, and the biopsy revealed foreign body reactions with the exception of 1 case, which contained tumor cells under the unabsorbed polylactide adhesion barrier. The median adhesion grade was 1 (range 0-2). CONCLUSIONS: A solitary pelvic mass found in the PET/CT with increased (18)F-FDG uptake after usage of a polylactide adhesion barrier may be an unabsorbed remnant. The adhesion barrier should be used with caution in patients with gynecologic malignant diseases.

Myomectomy with ArtiSential fully articulating laparoscopic instruments: A prospective multicenter study.

BACKGROUND: ArtiSential, a class of innovative laparoscopic instrument, has been developed to overcome the limitations of conventional laparoscopic surgery by enabling free, 360°-unrestricted movement of the wrist joint, as in robotic surgery. OBJECTIVE: The aim of the present study was to describe the initial experiences with these devices in myomectomy and to report the surgical outcomes. METHODS: A total of 77 women undergoing laparoscopic or robotic myomectomy between January 2021 and June 2022 were included in this multicenter prospective study. The ArtiSential instruments used by the surgeons were those chosen according to their respective preferences. The baseline characteristics, surgical outcomes, trocar placement options, and operator survey results were scrutinized. RESULTS: The mean age of the patients was 39.9 ± 6.3, and the mean body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters) was 22.4 ± 3.4 kg/m2; 46.8% of the patients underwent robotic surgery, while 53.2% underwent laparoscopic surgery. The number of removed myomas was 3.3 ± 3.0, the size of the largest myoma was 7.1 ± 2.3 cm, and the operative time was 130.0 ± 54.0 min. No transfusions or laparotomy conversions were required. Other than one case of ileus, there were no postoperative complications. In most cases, the instruments were inserted through the umbilicus trocar, and the fenestrated forceps, needle holder, and bipolar fenestrated forceps, in that order, were frequently employed. According to a surgeon survey, 29.9% moderately or strongly agreed that the ArtiSential devices utilized were more convenient than conventional laparoscopic instruments, while only 9.7% moderately or strongly agreed that they were more convenient than robotic instruments. CONCLUSIONS: Myomectomy as performed with an ArtiSential instrument seems to be feasible and safe. Further studies are necessary in order to comparatively assess the outcomes and potential benefits of ArtiSential, robotic, and conventional laparoscopic myomectomy.

Therapeutic effects of surgical debulking of metastatic lymph nodes in cervical cancer IIICr: a trial protocol for a phase III, multicenter, randomized controlled study (KGOG1047/DEBULK trial).

BACKGROUND: Bulky or multiple lymph node (LN) metastases are associated with poor prognosis in cervical cancer, and the size or number of LN metastases is not yet reflected in the staging system and therapeutic strategy. Although the therapeutic effects of surgical resection of bulky LNs before standard treatment have been reported in several retrospective studies, well-planned randomized clinical studies are lacking. Therefore, the aim of the Korean Gynecologic Oncology Group (KGOG) 1047/DEBULK trial is to investigate whether the debulking surgery of bulky or multiple LNs prior to concurrent chemoradiation therapy (CCRT) improves the survival rate of patients with cervical cancer IIICr diagnosed by imaging tests. METHODS: The KGOG 1047/DEBULK trial is a phase III, multicenter, randomized clinical trial involving patients with bulky or multiple LN metastases in cervical cancer IIICr. This study will include patients with a short-axis diameter of a pelvic or para-aortic LN ≥2 cm or ≥3 LNs with a short-axis diameter ≥1 cm and for whom CCRT is planned. The treatment arms will be randomly allocated in a 1:1 ratio to either receive CCRT (control arm) or undergo surgical debulking of bulky or multiple LNs before CCRT (experimental arm). CCRT consists of extended-field external beam radiotherapy/pelvic radiotherapy, brachytherapy and LN boost, and weekly chemotherapy with cisplatin (40 mg/m²), 4-6 times administered intravenously. The primary endpoint will be 3-year progression-free survival rate. The secondary endpoints will be 3-year overall survival rate, treatment-related complications, and accuracy of radiological diagnosis of bulky or multiple LNs. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT05421650; Clinical Research Information Service Identifier: KCT0007137.

Robot-assisted total preservation of the pelvic autonomic nerve with extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy for cervical cancer.

OBJECTIVE: To evaluate our short-term clinical outcomes of robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy. METHODS: Between March 2011 and June 2012, we observed prospectively 28 consecutive patients who underwent robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy, including the superior and inferior gluteal, presacral (subaortic), common iliac, and lower para-aortic nodes. RESULTS: The predominant International Federation of Gynecology and Obstetrics stage was IB1 (15 patients), followed by IB2 (5 patients), IA2 (3 patients), IIA1 (3 patients), and IIA2 (2 patients). The mean ± SD total operating time was 308.8 ± 54.9 minutes, and the mean ± SD console time was 280.0 ± 46.0 minutes. The mean ± SD blood loss was 102.7 ± 153.8 mL. The mean ± SD acquired pelvic lymph node was 27.1 ± 9.3, the mean ± SD extended lymph node was 19.2 ± 9.6, and the mean ± SD total lymph node was 46.3 ± 14.5. A total of 10 patients (35.7%) had nodal metastasis; among them, 6 patients (21.4%) had single pelvic nodal metastasis, 3 patients (10.7%) had concurrent pelvic and extended nodal metastasis, and one patient (3.6%) had single extended nodal metastasis. No intraoperative complications that required treatment occurred; however, ureterovaginal fistula was identified in 4 patients (14.3%) and ureter stricture in 4 patients (14.3%) after radiotherapy. After a median follow-up of 10 months (range, 1-16 months), there was no pelvic recurrence; however, one patient had recurrence at transposition site of ovary. CONCLUSIONS: With the advantage of delicate movement of robot instrument, robot-assisted systematic extended lymphadenectomy with total preservation of pelvic autonomic nerves did not compromise the radicality, and its surgical technique was feasible and safe. By using this approach, we could harvest more lymph nodes and have a high rate of metastatic nodes without disturbing voiding function; however, there was increased rate of urological complications. Moreover, long-term survival benefit after an extended systematic lymphadenectomy must be evaluated.

Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon's initial experience.

OBJECTIVE: The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases. METHODS: Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH. RESULTS: Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases. CONCLUSIONS: During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.

Comparative study of supracervical hysterectomy between da Vinci SP® surgical system and conventional single-site laparoscopy for uterine fibroid: single center experiences.

This study aimed to review the surgical outcomes of supracervical hysterectomy using the da Vinci SP® surgical system and conventional single-site laparoscopic surgery for uterine fibroids. This study included 79 patients who underwent supracervical hysterectomy with the da Vinci SP® surgical system and conventional single-site laparoscopy for uterine fibroid between June 2018 and April 2021. All the surgeries were performed by an experienced surgeon. Surgical outcomes and complications were reviewed in both groups. No significant difference was found between the two groups with regards to the patients' preoperative surgical conditions such as weight of the uterus, history of pelvic surgery, and pelvic adhesion. A significantly longer operation time (p < 0.01) and higher levels of C-reactive protein (p < 0.01) were found in the robotic surgery group; in particular, the uterus-out time was significantly longer (p < 0.01). No significant differences were found in other surgical outcomes such as complication rates and hospital stays. Supracervical hysterectomy using the da Vinci® SP surgical system is comparable to conventional single-site laparoscopy in uncomplicated cases. However, it requires a significantly longer operative time and has a higher inflammatory response.