改良的腹式广泛性子宫颈切除术治疗早期子宫颈癌的临床观察

目的探讨改良的腹式广泛性宫颈切除术在早期宫颈癌手术治疗中的可行性和安全性.方法 2002年10月至2004年9月,对13例Ⅰ期宫颈癌患者,施行腹式盆腔淋巴结切除术,快速冰冻病理检查证实无淋巴结转移后,行改良的腹式广泛性宫颈切除术,保留子宫体,并保持子宫动静脉的完整性.术后随访,观察其复发情况,对其中要求生育者随访其生育情况.结果 13例患者均成功地施行了改良的腹式广泛性宫颈切除术,平均手术时间158 min（135～185 min）,术中平均出血量120 ml（100～180 ml）.术后无并发症发生,平均住院时间9.7 d.随访1～24个月,无一例复发;5例有生育要求者中3例已成功妊娠,1例孕34周早产,另1例现孕16周,第3例现孕8周,妊娠经过良好.结论改良的腹式广泛性宫颈切除术安全、可行,对要求保留生育功能的早期宫颈癌患者更适宜.     

宫颈癌微创手术治疗历史、现状及反思

1987年法国人Dargent等首先完成了腹膜外淋巴结切除加经阴道的Schauta式广泛性子宫切除术，同年美国人Rich报道了世界首例腹腔镜下全子宫切除术成功，1989年法国人Querleu等人完成世界第一例腹腔镜辅助经阴道广泛子宫切除术。1990年法国人Canis报道了完全腹腔镜下广泛子宫切除术，2年后的1992年美国人Nezhat也报道了完全腹腔镜下广泛性子宫切除术获得成功。至此，拉开了宫颈癌腹腔镜手术治疗的帷幕，并在欧洲和美国推广。1993年德国人Possover率先报道了腹腔镜辅助保留神经的经阴道广泛性子宫切除术，1994年Dargent报道了腹腔镜辅助的经阴道广泛性宫颈切除术以保留生育功能。2000年6月国内首例宫颈癌腹腔镜下淋巴结切除术完成，我们同年10月报道了腹腔镜下次广泛性子宫切除术顺利实施。     

早期宫颈癌保留生育功能手术5例临床分析

目的:为保留早期宫颈癌患者的生育功能,实施广泛宫颈切除及盆腔淋巴结清扫术。方法:对2003年4月至2004年4月收治的要求保留子宫的5例早期宫颈癌患者采用经腹腔镜辅助的广泛宫颈切除及盆腔淋巴结清扫术。结果:5例患者在术中及术后均无并发症发生,术后1个月恢复正常月经,随访未发现复发癌。结论:早期子宫颈癌实施腹腔镜辅助的广泛宫颈切除及盆腔淋巴结清扫术可以保留患者的生育功能。     

保留生育功能的根治性宫颈切除术6例临床分析

目的:探讨早期宫颈浸润癌患者根治性宫颈切除术保留生育功能的可行性.方法:2004年10月至2008年5月,我们对6例分期为Ⅰ A2～Ⅰ B1期的宫颈癌患者实施盆腔淋巴结清扫术及根治性宫颈切除术.结果:6例手术患者均获成功,随访未发现复发癌,有2例患者分别妊娠1次,但均于妊娠中期流产.结论:早期宫颈癌患者实施根治性宫颈切除术及腹腔镜盆腔淋巴结清扫术(或腹膜外盆腔淋巴结清扫术)能够保留患者的生育功能.     

广泛宫颈切除术在宫颈癌保留生育功能治疗中的价值评估及手术要点

保留生育功能的根治性宫颈切除术是早期宫颈癌治疗的标准选择之一,目前有经腹、经阴道、腹腔镜和机器人辅助的根治性宫颈切除术手术方式,在技术要点、切除术范围等各有特色。无论何种术式,只要掌握适应证、操作规范,手术并发症低、肿瘤安全性和妊娠率都满意。但应根据所熟悉的技术、现有的设备、肿瘤大小等选择不同术式。     

早期宫颈癌宫颈广泛性切除术的研究进展

宫颈癌是最常见的妇科恶性肿瘤之一,随着宫颈癌发病群体的年轻化,越来越多的宫颈癌患者有保留生育功能的需求。宫颈广泛性切除术已成为国际妇产科联盟（International Federation of Gynecology and Obstetrics,FIGO）分期ⅠA2期、ⅠB1期宫颈癌患者保留生育功能的标准手术方式,在肿瘤直径>2 cm的新辅助化疗后的宫颈癌患者及妊娠合并宫颈癌患者中也有应用。宫颈广泛性切除术范围广、难度大、手术时间长,术后并发症发生率较高。手术入路、术中操作和淋巴结评估方式都可能对肿瘤预后及妊娠结局产生不同的影响。因此,寻求宫颈广泛性切除术后肿瘤学预后与生育功能之间的平衡,在保证肿瘤切除范围的同时减少不必要的组织切除与损伤,缩短手术时间,降低并发症发生概率,可以使更多接受宫颈广泛性切除术的宫颈癌患者获益。     

根治性子宫颈切除术和腹腔镜下淋巴结切除术在早期子宫颈癌治疗中的应用

目的 探讨根治性子宫颈切除术和腹腔镜下淋巴结切除术,在早期子宫颈癌治疗中的可行性和效果。方法2001年8月至2003年5月,对12例Ⅰ a期至Ⅰ b2期的子宫颈癌患者,施行腹腔镜下盆腔淋巴结切除术,切除的盆腔淋巴结经病理学检查证实无淋巴结转移者,随即行根治性子宫颈切除术,保留子宫体。结果 12例患者均在腹腔镜下完成盆腔淋巴结切除术,淋巴结检查均为阴性;根治性子宫颈切除术均经阴道完成,平均手术时间142 min(115—178 min),术中出血量约180 ml(120—230 ml)。术后无感染及出血,平均住院时间6.7 d。经随访3—28个月,1例患者妊娠,无一例肿瘤复发。结论 对于未生育且强烈要求保留生育功能的早期子宫颈癌患者,行腹腔镜下盆腔淋巴结切除术和根治性子宫颈切除术是可行的;手术创伤小,术后患者恢复快。     

小于35岁子宫颈癌患者213例治疗与预后分析

目的分析小于35岁妇女宫颈癌的临床表现、诊断和治疗的特点。方法回顾分析1986年1月至2006年7月收治的年轻妇女宫颈癌213例的临床资料。结果年轻妇女宫颈癌占全部宫颈癌的比例呈逐年上升的趋势;其临床表现主要为接触性阴道出血(59.62%)。0期、Ⅰ期、Ⅱ期、Ⅲ期、Ⅳ期患者的5年生存率分别为100%、79.51%、43.25%、31.71%、0。13例宫颈原位癌行宫颈锥切术,1例宫颈原位癌行LEEP术,术后均无肿瘤复发。27例宫颈癌在广泛性子宫切除手术同时行卵巢移位术,术后无1例卵巢发生癌转移。21例(12例Ⅰb2期,9例Ⅱb早期)经术前介入化疗(新辅助化疗)后行广泛性子宫切除及盆腔淋巴结清扫术,5年生存率为76.25%。5例术前放疗后行广泛性子宫切除及盆腔淋巴结清扫术,5年生存率为60.00%。两者无统计学差异(P>0.05)。结论应对筛查年轻妇女宫颈癌予以重视,对有接触性阴道出血的年轻妇女应予高度警惕。治疗年轻妇女宫颈癌时应注意保留早期患者的生育功能、卵巢功能及性功能,对局部晚期患者可用术前新辅助化疗,以提高手术切除率,改善患者的生活质量。     

同位素标记白蛋白和异硫蓝染料联合注射用于术中识别早期宫颈癌前哨淋巴结

广泛性子宫切除及盆腔淋巴结清扫术是治疗早期宫颈癌的标准术式,但发生盆腔淋巴结转移的患者约10%～15%,说明盆腔淋巴结清扫不仅对大部分患者无益,反而有并发淋巴囊肿、淋巴水肿等风险。前哨淋巴结是指最早接受肿瘤淋巴引流的淋巴结,也是最早发生转移的淋巴结,前哨淋巴结组织学检查阴性预示其他淋巴结无转移。因此检测前哨淋巴结的转移状况可避免对患者实施过度治疗。为研究联合应用异硫蓝和放射性同位素标记法识别宫颈癌前哨淋巴结的可行性。对24例I期宫颈癌患者和1例IIa期患者术前1d在宫颈4个象限肿瘤周围分别注射99m锝标记的白蛋白,然…     

腹腔镜手术治疗宫颈癌应用现状及进展

目前宫颈癌的手术方式已经从传统的开腹手术、阴式手术逐步发展到腹腔镜以及机器人辅助的腹腔镜手术,手术范围也从传统的广泛性子宫切除发展到保留神经的广泛性子宫切除和保留生育功能的广泛性宫颈切除。本文重点介绍目前国内外宫颈癌腹腔镜微创手术的应用现状及进展。     

Fertility-sparing radical abdominal trachelectomy for cervical carcinoma: technique and review of the literature

OBJECTIVES: Radical trachelectomy has emerged as a reasonable fertility-sparing operation for selected patients with stage I cervical cancer. The purpose of this report is to describe our technique of radical abdominal trachelectomy, a fertility-sparing operation in women with cervical cancer, and review the current literature on this procedure. METHODS: A review of a prospectively maintained database of all fertility-sparing radical trachelectomy procedures performed at our institution. RESULTS: Between 11/01 and 3/06, we performed a total of 42 fertility-preserving radical trachelectomies with pelvic lymphadenectomy for women with invasive cervical cancer. We had previously reported on 2 pediatric abdominal trachelectomies, which are excluded from this report. Five of the remaining 40 cases had undergone a radical abdominal trachelectomy, and 35 cases were performed laparoscopically with a radical vaginal approach. The characteristics of the 5 adult patients who underwent abdominal radical trachelectomy included stage IB1 disease in all cases, a mean age of 36 years (range, 33-39), and a mean estimated blood loss of 280 ml (range, 50-400); 1 patient with squamous cell carcinoma needed completion radical hysterectomy at the time of trachelectomy due to disease extending into the endometrium, and 1 patient needed postoperative chemoradiation due to a positive parametrial lymph node. The remaining 3 patients resumed normal menstruation postoperatively. All patients remain disease-free at the time of this report. The only remaining uterine blood supply in these patients are the utero-ovarian vessels. There were no postoperative complications, and transurethral Foley catheters were removed in all cases within 2 weeks. CONCLUSIONS: Radical abdominal trachelectomy with pelvic lymphadenectomy is a feasible operation for selected women with stage I cervical cancer who desire to preserve reproductive function. Menstruation and reproductive function may be preserved after bilateral uterine vessel ligation. The procedure expands the inclusion criteria of radical vaginal trachelectomy to patients with distorted cervicovaginal anatomy in which the vaginal approach may not be feasible.     

Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation and subsequent pregnancy in the treatment of early invasive cervical cancer

BACKGROUND: Recently, pregnancies in patients after radical vaginal trachelectomy and laparoscopic pelvic lymphadenectomy have been reported. Radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation has been previously described; however, subsequent outcome and pregnancy has not. METHODS: Three patients with cervical carcinoma, 1 with stage IA1 with lymph-vascular space invasion and 2 with stage IA2, were treated with radical abdominal trachelectomy and pelvic lymphadenectomy with uterine conservation. RESULTS: All patients underwent the planned procedure with no significant intraoperative or postoperative complications. All patients had return to normal menstrual function. One patient had a successful pregnancy delivered at 39 weeks by cesarean section and is now subsequently pregnant with a second pregnancy. CONCLUSION: Radical abdominal trachelectomy is a technically feasible operation that uses operative techniques familiar to the American-trained gynecologic oncologist and results in wider parametrial resection than radical vaginal trachelectomy. In young patients desiring to retain fertility, successful pregnancies after radical abdominal trachelectomy are possible. Intraoperative and postoperative complications are likely to be lower with an abdominal versus a vaginal approach. Long-term survival of patients treated with radical trachelectomy for early invasive cervical cancer are yet to be determined.     

Laparoscopic abdominal radical trachelectomy

BACKGROUND: Radical trachelectomy is a fertility preserving alternative for young women with early stages of cervical cancer. Currently, a technique of abdominal radical approach is used in a few centres. With growing availability of laparoscopy, a novel technique of laparoscopic radical trachelectomy might be an alternative. CASE: Presented is one case of laparoscopic pelvic lymphadenectomy with radical trachelectomy in young woman with IB cervical cancer. No intraoperative or postoperative complications occurred. Operation time reached 250 min, estimated blood loss was 250 ml. Limited follow-up of 9 months was uneventful and patient indicates normal menstrual pattern and satisfactory sexual intercourse. CONCLUSION: Laparoscopic abdominal radical trachelectomy with pelvic lymphadenectomy might be an alternative technique in the treatment of early stages cervical cancer in patients who desire future pregnancy. The procedure is in principle identical to the standard abdominal radical hysterectomy. Centres practising laparoscopic radical hysterectomy can adopt the technique without any special surgical training.     

Laparoscopic sentinel lymph nodes identification followed by trachelectomy in early stage cervical cancer

The status of regional lymph nodes is the main prognostic factor in diagnosis and treatment of early stage of the cervical cancer. If the first node that drains a tumor site (sentinel node) is not metastatic, other lymph nodes should also be free of the disease. Detection using blue dye and laparoscopic removal of the sentinel lymph nodes let to avoid radical hysterectomy with pelvic limphadenectomy and it is especially useful in young women who want to preserve fertility. We describe a case of a 33- year old woman with invasive cervical cancer who underwent laparoscopic sentinel lymph nodes detection followed by trachelectomy. Thus histopatological examination confirmed no metastasis in removed sentinel lymph nodes, trachelectomy as a minimally invasive procedure was performed.     

Isolated recurrence at the residual uterine cervix after abdominal radical trachelectomy for early cervical cancer

BACKGROUND: We report an isolated recurrence at the residual cervix shortly after abdominal radical trachelectomy for cervical cancer. CASE: A 34-year-old woman underwent radical abdominal trachelectomy and pelvic lymphadenectomy for FIGO stage IB1 squamous cell cervical cancer. The tumor measured 10 mm in maximum diameter with 4 mm of invasion. Histology showed lymph vascular space involvement with no infiltration of adjacent structures and no pelvic lymph node metastases. Tumor-free resection margins exceeded 15 mm. At the 6-month follow-up examination, cervical cytology showed cells suspicious for recurrent cervical cancer. Abdominal hysterectomy was performed and histology showed an isolated 3-mm recurrence in the residual cervix. The patient is free of disease 8 months after hysterectomy. CONCLUSION: Recurrence at the residual cervix is a potential risk of abdominal trachelectomy for early cervical cancer. Patients should be counseled accordingly and followed closely.     

机器人手术在妇科恶性肿瘤手术治疗中的应用

机器人技术的出现使外科微创手术进入新的发展阶段。在妇科恶性肿瘤手术治疗中机器人也逐步得到应用,其主要应用于宫颈癌的广泛性全子宫切除和盆腔淋巴清扫术,此外机器人根治性宫颈切除术、晚期宫颈癌分期手术及复发性宫颈癌的盆腔脏器切除术也有相关报道;子宫内膜癌和卵巢癌的机器人分期手术也日趋增多。目前,机器人手术多是回顾性病例报告,缺乏随机对照、大样本比较性研究,其适应证和手术效果还需要大量临床探索,以作出全面的评价。     

Conservative surgical methods for FIGO stage IA2 squamous cervical carcinoma and their role in preserving women's fertility

OBJECTIVE: Until recently, the treatment of choice for stage IA2 squamous cervical cancer has been radical hysterectomy with pelvic node dissection. However, many of these cases occur in younger women, for whom the preservation of fertility is desirable. More conservative methods have emerged as alternative treatment modalities for these women, as they may allow for future fertility, without having a considerable adverse effect on cure rates. The objective of this review is to present the published data on these methods (radical vaginal, abdominal or laparoscopic trachelectomy and laparoscopic pelvic lymphadenectomy, deep cold-knife excision and lymphadenectomy, ovarian transposition and radiotherapy) and comment on their clinical role. METHOD: A detailed literature search was done in MEDLINE (1966-2003), EMBASE (1974-2003) and CINAHL (1982-2003) for data on cure rates, survival and reproductive outcome of radical vaginal trachelectomy as well as other conservative treatment options. RESULTS: The recurrence rates after radical trachelectomy range from 0% to 8% and are comparable to reported results from series of patients treated with radical hysterectomy. There are over 35 reported live births out of approximately 210 women who had this operation. However, the rates of second trimester losses and preterm deliveries due to cervical weakness are high. Data from the other methods are limited. CONCLUSION: Vaginal radical trachelectomy is currently the fertility-sparing procedure with the most available data supporting its use. Although these results are encouraging, there is lack of level I evidence (i.e. randomized controlled trials) comparing safety and survival rates between conservative and radical methods. Therefore, these techniques should be used by fully trained operators, with the understanding that this is not the standard treatment at present.     

Robot-assisted abdominal laparoscopic radical trachelectomy

BACKGROUND: Radical trachelectomy in conjunction with pelvic lymphadenectomy is an established method to preserve fertility in early cases of cervical cancer. The radical trachelectomy is usually performed vaginally despite the initial use of laparoscopy for the lymphadenectomy. The complexity of a laparoscopic abdominal trachelectomy may explain this dual approach. Here we describe the surgical technique of a robot-assisted laparoscopic radical trachelectomy with lymphatic mapping using a radiotracer and without a vaginal approach. CASES AND SURGICAL TECHNIQUE: Two nulliparous women with early cervical cancer underwent a laparoscopic radical trachelectomy and pelvic lymphadenectomy with the assistance of the da Vinci robot (Intuitive Surgical Inc, Sunnyvale, CA). After the sentinel lymph nodes were found negative on frozen section, the parametria, paracolpia and sacrouterine ligaments were dissected sparing the main branches of the uterine arteries. Following ligation of the descending branches of the uterine arteries the cervix and the vagina were transsected using monopolar diathermia and the vagina was sutured to the remaining cervix. Finally, a permanent cerclage was placed. Time for surgery was 387 and 358 min respectively. No perioperative complications were noted and the postoperative period was uneventful in both cases. CONCLUSIONS: Robot-assisted laparoscopic abdominal trachelectomy is a feasible alternative to a combined laparoscopic and vaginal approach.     

New concepts for staging and therapy of cervix cancer by endoscopic surgery]

Non-invasive staging of cervical cancer according to FIGO is out-dated. In contrast to clinical staging exact histopathologic evaluation of tumor extension and tumor biology can be achieved via laparoscopic evaluation. Invasive endoscopic staging is advantageous and should be integrated into the diagnostic armamentarium of gynecologic oncologists and radiotherapists. Through magnification and blood-less surgery minute anatomical structures can be identified laparoscopically. Thus, fibers of autonomic nerves can be visualized and parasympathetic fibres can be preserved. Conservation of these neural structures leads to significant reduction of postoperative morbidity of bladder and rectum. The concept of the sentinel lymph node is also valid for the uterine cervix. Selected biopsy of the sentinel node and identification of single tumor cells leads potentially to higher oncologic safety and may reduce morbidity associated with radical lymphadenectomy. In early stage cervical cancer fertility may be preserved by radical trachelectomy which is combined with laparoscopic parametric and pelvic lymphadenectomy. Following radical trachelectomy a pregnancy rate of 40% is achieved, the recurrence rate following conventional radical hysterectomy is identical.