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。     

Type B Laparoscopic Radical Trachelectomy With Pelvic Lymphadenectomy for Early Cervical Cancer

Study Objective

To demonstrate the technique of laparoscopic radical trachelectomy (LRT) and laparoscopic pelvic lymphadenectomy for early cervical cancer.

腹腔镜根治性宫颈切除术治疗早期宫颈癌的妊娠结局

目的：评估早期年轻宫颈癌患者在腹腔镜下保留生育功能的根治性宫颈切除术（LRT）后的妊娠结局。方法：回顾性分析2006年4月—2013年12月武汉大学人民医院收治的早期宫颈癌患者行LRT的临床资料,妊娠结局的数据从患者的病历记录和电话回访中获得。结果：纳入22例成功行LRT的患者,中位年龄32岁（22～40岁）,LRT后的平均随访时间是28个月（3～82个月）。手术后所有患者均恢复月经,其中20例月经规律（90.9%）,2例月经不规律（9.1%）。5例患者出现宫颈管狭窄（22.7%）,主要表现为月经规律但经量减少,出现痛经。些患者采取了宫颈管扩张术。12例患者在术后试图妊娠,其中7例妊娠了11次（其中3次流产,6次早产和2次足月产）。12例患者中的7例生产了6例健康婴儿。LRT术后的妊娠率是58.3%（7/12）。自然流产率和活产率分别是27.3%（3/11）和72.7%（8/11）,早产率是54.5%（6/11）。结论：LRT术后患者的妊娠率和活产率是很有前途的;然而其早产率也明显增高;宫颈狭窄发生比例较低。     

Sexual Functioning and Vaginal Changes after Radical Vaginal Trachelectomy in Early Stage Cervical Cancer Patients: A Longitudinal Study

IntroductionRadical vaginal trachelectomy (RVT) offers low complication rate, good survival, and possibility for future childbearing for young women with early stage cervical cancer. However, the literature on quality of life (QOL) and sexual functioning in patients undergoing RVT is scarce.AimThe aims of this study were to prospectively assess sexual function after RVT and to compare scores of sexual function in patients operated by RVT and radical abdominal hysterectomy (RAH) with those of age‐matched control women from the general population.MethodsEighteen patients with early stage cervical cancer operated with RVT were prospectively included and assessed preoperatively, and 3, 6, and 12 months postoperatively using validated questionnaires. RAH patients were included consecutively and assessed once at 12 months postsurgery, while an age‐matched control group of 30 healthy women was assessed once.Main Outcome MeasureSexual dysfunction total score as measured by the Female Sexual Function Index (FSFI) was the main outcome measure.ResultsDuring the 12 months posttreatment, RVT patients tended to have persistent sexual dysfunction as measured by FSFI (mean overall score <26.55 at each assessment) and Female Sexual Distress Scale (mean overall score > 11). Sexual worry (P < 0.001) and lack of sexual desire (P = 0.038) were more frequently reported among patients in both treatment groups compared with control women. Sexual activity increased significantly during the observation time for the RVT group (P = 0.023) and reached that of healthy women. Global Health Status score improved over time for the RVT group but never reached that of healthy control women (P = 0.029).ConclusionsOur data suggest that patients treated with RVT for early stage cervical cancer experience persistent sexual dysfunction up to one year post surgery influencing negatively on their QOL. Froeding LP, Ottosen C, Rung‐Hansen H, Svane D, Mosgaard BJ, and Jensen PT. Sexual functioning and vaginal changes after radical vaginal trachelectomy in early stage cervical cancer patients: A longitudinal study. J Sex Med 2014;11:595‐604.     

Robotic Radical Trachelectomy after Supracervical Hysterectomy for Cut-Through Endometrial Adenocarcinoma Stage IIB: A Case Report

We report on a patient with a cut-through endometrial malignancy after supracervical hysterectomy treated by radical trachelectomy and staging via a robotic approach.A 58-year-old patient with incidental finding of a stage IIB G1 endometrial adenocarcinoma after a supracervical hysterectomy underwent robotic radical trachelectomy, bilateral pelvic lymphadenectomy, and ileal resection with anastomosis. The operative time was 360 minutes, and blood loss was 100 mL. The pathology report revealed no evidence of residual disease. The patient remains disease-free 18 months after her robotic procedure. Robotic radical trachelectomy and pelvic lymphadenectomy appear to be feasible and safe for the treatment of endometrial malignancy discovered after supracervical hysterectomy. We suggest use of the terms partial radical trachelectomy for fertility preservation procedures and radical trachelectomy after subtotal hysterectomy for the complete radical removal of the cervix.     

Laparoscopic Nerve-Sparing Radical Trachelectomy: Surgical Technique and Outcome

Study ObjectiveTo assess the feasibility of the laparoscopic approach in fertility-preserving and radical surgery of cervical cancer in young patients.DesignRetrospective study (Canadian Task Force classification I).SettingHospital Son Llatzer, Palma de Mallorca, Spain.PatientsNine women with early cervical cancer.InterventionLaparoscopic nerve-sparring radical trachelectomy.Measurements and Main ResultsData for 9 consecutive women undergoing laparoscopic nerve-sparing radical trachelectomy because of FIGO IA2 (n = 2) or FIGO IB1 (n = 7) infiltrating cervical carcinoma of the squamous type (n = 6) or adenocarcinoma (n = 3) were analyzed. Resection of the pericervical ligaments was laparoscopically performed, preserving innervation of the bladder and the arterial supply of the uterus. The laparoscopic approach enabled completion of the operation via the vaginal route without difficulties. The mean duration of surgery was 270 minutes. No relevant perioperative complications occurred. Two women became pregnant: 1 underwent an elective cesarean section delivery at week 38, and hysterectomy was performed 6 months later; and the other woman was pregnant at the time of this writing. Mean duration of follow-up was 28 months. Six patients currently have regular menses without evidence of disease. One patient had a central recurrence at 14 months, which was treated using surgery and radiochemotherapy, and she was free of disease at the last follow-up.ConclusionsLaparoscopic nerve-sparring radical trachelectomy may be an alternative in fertility-preserving surgery for cervical cancer in centers in which specialization in radical vaginal surgery is lacking. The procedure enables preservation of autonomic innervation of the urinary bladder and the arterial supply of the uterus.     

Oncologic and Surgical Outcomes of Robotic Versus Open Radical Hysterectomy for Cervical Cancer

Objective

In view of the recent controversy concerning the use of minimally invasive radical hysterectomy as primary treatment for early stage cervical cancer, this study compared the survival and perioperative outcomes in a cohort of patients who underwent radical hysterectomy either by laparotomy or by robotics.

Surgical and Oncologic Outcomes of Radical Abdominal Trachelectomy Versus Hysterectomy for Stage IA2-IB1 Cervical Cancer

Study Objective: To compare the surgical and oncologic outcomes between abdominal radical trachelectomy (ART) and radical hysterectomy (RH) for stage IA2-IB1 cervical cancer.Design: A retrospective cohort study (Canadian Task Force classification II-2).Setting: Shandong Cancer Hospital, Shandong, China.Patients: Three hundred twenty-nine patients with IA2-IB1 cervical cancer.Interventions: All patients underwent ART or RH.Measurements and Main Results: All patients were divided into ART (n?=?143) and RH (n?=?186) groups according to the surgical approach. Additionally, oncologic and fertility outcomes were compared for different tumor pathologies and sizes in ART patients. The ART group had similar case characteristics as the RH group, except that the ART group had a longer surgical time. During a similar follow-up period, there were 4 (2.9%) recurrences and 3 (2.2%) patients who died from recurrence in the ART group compared with 8 (4.6%) recurrences and 4 (2.3%) patients who died from recurrence in the RH group (p?=?.444 and p?=?.999, respectively). In the ART group, squamous cell carcinoma (SCC) patients had a 5-year overall survival and pregnancy rate similar to those of non-SCC patients (98.1% vs 96.8%, p?=?.999; 33.3% vs 26.7%, p?=?.873), and patients with tumors ≤2 cm and 2 to 4 cm experienced a similar 5-year overall survival rate (97.0% vs 98.6%, p?=?.999), except patients with tumors ≤2 cm had a higher pregnancy rate (45.2% vs 17.2%, p?=?.020).Conclusion: ART seems to have similar surgical and oncologic outcomes to RH, except ART has a longer surgical time. Both non-SCC patients and stage IA2-IB1 patients with 2- to 4-cm tumors can undergo ART safely. Patients with tumors ≤2 cm have a higher pregnancy rate than patients with 2- to 4-cm tumors.     

达芬奇机器人手术系统在宫颈癌广泛子宫切除手术中学习曲线的研究

目的:评估达芬奇机器人手术系统在实施宫颈癌广泛子宫切除手术的不同阶段的手术效果,探讨腹腔镜妇科医师缩短达芬奇机器人手术系统学习曲线的要点。方法:分析2010年3月至2014年4月由同组医师完成的50例达芬奇机器人手术系统在宫颈癌广泛子宫切除手术患者的临床资料。按手术先后次序分A组(15例)、B组(15例)、C组(20例),比较各组的手术效果。结果:3组间实施保留盆腔自主神经、行腹主动脉旁淋巴结切除术例数及手术时间的比较,差异均有统计学意义(P0.05),其中B组和C组明显优于A组,差异均有统计学意义(P0.05);3组术后恢复自主排尿时间比较,差异有统计学意义(P0.05),其中C组术后排尿时间最短,与A组比较,差异有统计学意义(P0.05)。3组术中出血量、术后住院时间、盆腔淋巴结切除数、围手术期并发症发生率及手术频度的比较,差异均无统计学意义(P0.05)。结论:有丰富腹腔镜宫颈癌手术经验的手术团队,经过30例的学习曲线,可掌握达芬奇机器人手术系统用于宫颈癌广泛子宫切除手术。     

Robotic Radical Hysterectomy for Cervical Cancer: A Population-Based Study of Adoption and Immediate Postoperative Outcomes in the United States

Study Objective

To compare the use of robotic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH) in the United States, with secondary outcomes of perioperative complications, hospital length of stay (LOS), immediate postoperative mortality, cost and a subanalysis compared with laparoscopic radical hysterectomy (LRH).

Frozen Hope: Fertility Preservation for Women With Cancer

Young women diagnosed with cancer have the option of preserving their fertility by using assisted reproductive technology (ART) techniques prior to undergoing cancer treatment. This article presents a composite case of a young woman with cancer who had many unanswered emotional and ethical questions about her future as a parent. Fertility preservation techniques, including preimplantation genetic diagnosis (PGD), and related patient education are described. Current literature regarding reproductive counseling for cancer survivors is reviewed. Resources for providing psychosocial support for decisions about fertility preservation are lagging behind the rapid pace of scientific advancements in cancer treatment and ART. As more young women are surviving cancer and taking steps to preserve fertility, there is great need for the provision of psychologic support services and the establishment of ethical guidelines to aid them on this path. Women's health care providers can provide support to cancer survivors facing fertility and parenting issues by becoming knowledgeable about the long‐term aspects of decision making and developing educational materials and guidelines for these patients.     

Robotic Radical Hysterectomy After Concomitant Chemoradiation in Locally Advanced Cervical Cancer: A Prospective Phase II Study

Study Objective

To assess the feasibility of total robotic radical surgery (TRRS) in patients with locally advanced cervical cancer (LACC) who receive chemoradiation therapy (CT/RT).

结合典型病例谈年轻子宫内膜癌患者生育功能的保留

随着全球女性生育年龄的推迟,年轻子宫内膜癌患者保留生育功能越来越受到重视,是近年来国内外研究的热点及重点.大多数早期的年轻子宫内膜癌多为雌激素依赖型,具有病变局限、进展缓慢、分化及预后较好、对性激素治疗反应良好等特点,高效、大剂量、长期应用孕激素是子宫内膜癌患者保留生育功能治疗成功的关键,安全有效的全面评估尤为重要,介...     

Perioperative Outcomes of 3-Arm Versus 4-Arm Robotic Radical Hysterectomy in Patients with Cervical Cancer

Study Objective

To investigate and compare surgical outcomes of the 3 versus 4 robotic arm approaches for robotic surgery in patients with cervical cancer.

Robotic Radical Hysterectomy for Cervical Adenocarcinoma after Preoperative Brachytherapy in 10 Steps

Study ObjectiveMinimally invasive surgery decreases postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer. However, a randomized trial and large retrospective data question its safety after observing lower rates of survival than open surgery [1,2]. The causes of this higher recurrence rate are not definitely established but may result from cancer exposure to the peritoneum during vaginal section and cancerous cells’ spillage enhanced by pneumoperitoneum or a uterine manipulator. The aim of this surgical video was to present a standardized step-by-step approach for robotic RH according to the recent recommendations from the ARCAGY–Group of National Investigators for the Study of Ovarian and Breast Cancers surgeon's group [3].DesignStep-by-step video demonstration of the technique.SettingTertiary center specialized in gynecologic oncology and minimally invasive surgery.InterventionsA 48-year-old woman was diagnosed with a stage IB2 endocervical adenocarcinoma (International Federation of Gynecology and Obstetrics 2018) with a tumor size of 27 mm. Surgery was planned after preoperative pulsed dose rate uterovaginal brachytherapy. Surgery was performed following 10 reproducible steps:? Pelvic sentinel node identification according to the SENTICOL-III trial? Right infundibulopelvic and round ligaments transection? Right uterine vessels transection? Parametrectomy? Right uterosacral ligament transection? Bladder mobilization? Identical left dissection? Rectovaginal space development? Colpectomy by vaginal route after complete pneumoperitoneum exsufflation? Robotic vaginal cuff closure and pelvic inspectionThorough robotically assisted vaginal cuff closure was carried out as a comparative study suggesting that abdominal closure may decrease vaginal complications and dehiscence [3].ConclusionNo international recommendations for the RH approach have yet been endorsed. Patients must be clearly informed about the benefit-risk ratio of the surgical route. If a minimally invasive RH is still decided, the patient should be referred to experienced centers, and precautionary measures must be implemented [4]. Colpotomy by vaginal route without pneumoperitoneum is recommended. Uterine manipulators have to be strictly avoided. Preoperative brachytherapy has been reported in experienced centers in France with favorable histologic response with high rates of pathologic complete response (near 70%) and seems particularly worthwhile for tumor sizes ranging from 2 to 4 cm or presenting with lymphovascular invasion [5].     

腹腔镜下盆腔淋巴结切除+阴式广泛宫颈切除术治疗早期宫颈癌16例临床效果及妊娠结局的观察分析

目的:探讨年轻宫颈癌保留生育功能患者行腹腔镜下盆腔淋巴结切除+阴式广泛宫颈切除术(VRT)后的临床效果及妊娠结局。方法:选择2011年1月至2015年12月就诊于宁夏医科大学总医院行腹腔镜下盆腔淋巴结切除+VRT的早期宫颈癌患者16例(VRT组),同期30例早期宫颈癌行腹腔镜下广泛子宫切除术+盆腔淋巴结切除术(LRH)患者作为对照(LRH组),对比观察两种手术的的临床效果;随访16例患者的累积妊娠率及妊娠结局。结果:两组在年龄、临床分期、病理分化程度、淋巴血管间隙受侵、鳞癌抗原表达、手术时间、术后发热率、术后并发症以及术后复发等指标上差异无统计学意义(P0.05)。VRT组术中出血量、术后住院天数明显优于LRH组(P0.05)。16例腹腔镜下盆腔淋巴结切除+VRT术后1年妊娠12例,累积妊娠次数15次;1年足月产4例次(33.3%),流产11例次(73.3%)。结论:对年轻宫颈癌患者,腹腔镜下盆腔淋巴结切除+VRT手术可达到与广泛子宫切除术+盆腔淋巴结切除术同样临床效果,同时可保留生育功能,但需提高妊娠率及生殖预后。     

改良腹式与全腹腔镜广泛宫颈切除术治疗早期宫颈癌的比较

目的:比较改良腹式广泛宫颈切除术(MART)与全腹腔镜广泛宫颈切除术(TLRT)在早期宫颈癌保留生育功能治疗中的技术异同性、临床治疗效果和妊娠结局。方法:收集2002年10月至2014年7月46例早期宫颈癌并接受MART或TLRT手术患者的临床资料和随访结果,并进行对比。结果:46例患者均完成预期手术,其中MART组27例,TLRT组19例。TLRT组术中出血量及住院时间明显少于MART组(P0.05),MART组在手术时间、切除宫旁组织长度、子宫动脉损伤率方面明显优于TLRT组(P0.05)。两组切除淋巴结数、腹腔引流量及膀胱功能障碍发生率等比较,差异无统计学意义(P0.05)。术后随访两组均无复发,MART组妊娠率(38.10%)与TLRT组(53.85%)比较,差异无统计学意义(P0.05)。结论:MART和TLRT两种手术方式均可有效治疗早期宫颈癌并实现患者保留生育功能的愿望。MART术式切除宫旁范围较TLRT相对较广,TLRT在减少术中出血及对盆腔脏器的干扰方面有其微创的优势。选择手术方式应个体化。     

根治性宫颈切除术治疗年轻早期宫颈鳞癌21例临床分析

目的:探讨对年轻早期宫颈鳞癌患者实施根治性宫颈切除术的价值。方法:对21例23～40岁早期宫颈鳞癌患者实施根治性宫颈切除+盆腔淋巴结切除术,术后从生殖、生理、肿瘤复发3个角度对其进行临床追踪随访,随访时间2～5年。结果:21例患者中19例完成随访,5例要求生育的患者4例妊娠,其中1例妊娠6月引产,2例孕早期流产,1例异位妊娠。19例患者术后均有月经来潮,3例卵巢储备功能下降。术后随访2～5年,无一例患者复发。结论:对年轻早期宫颈鳞癌患者实施根治性宫颈切除保留子宫体的手术是安全的、可行的,明显提高了术后患者的生活质量,且有足月妊娠的可能。