Comparison of midline and Pfannenstiel incision for radical hysterectomy with pelvic and paraaortic lymphadenectomy in cervical carcinoma

AIM: To compare Pfannenstiel and midline incisions with respect to efficacy and early postoperative surgical site complications in patients with early stage cervical carcinoma. METHODS: Patients with cervical carcinoma who underwent radical hysterectomy during 1995-2004 are retrospectively reviewed. There were 40 patients in the Pfannenstiel group and 71 patients in the midline group. Patients' age, type of incision, operative time, hospitalization length, postoperative surgical site complications, pre and postoperative Hb levels, number of extracted pelvic and paraaortic lymph nodes were the variables collected from the patients' files and oncology follow-up forms. RESULTS: Mean age (53.5+/-6.96 vs 55.9+/-10.5, P=0.2) and preoperative Hb levels of patients (12.52+/-1.48 vs 12.94+/-1.34, P=0.17) were not statistically different in midline and Pfannenstiel groups, respectively. Operative time (141.8+/-36 vs 135.8+/-31 min), number of extracted lymph nodes in pelvic (23.05+/-9.7 vs 23.5+/-8.07) and paraaortic areas (3.17+/-1.68 vs 2.66+/-1.15) were not significantly different among the midline and Pfannenstiel groups, respectively (P>0.05). Although postoperative incisional complications were more common in the midline group, this difference did not reach a significant level (11.3% vs 7.5%, P=0.52). Duration of hospitalization was not significantly different between the midline and Pfannenstiel groups, respectively (6.3+/-2.69 vs 6.2+/-2.72 days, P=0.21). Multivariate analysis revealed postoperative Hb levels to be significantly different among the groups (P=0.017, OR=1.59, 95% CI: 1.08-2.35). CONCLUSION: Pfannenstiel incision can be used for radical hysterectomy with pelvic and paraaortic lymphadenectomy in selected patients with cervical carcinoma, without any negative influence on optimal resectability of tumor and surgical morbidity.     

Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies

OBJECTIVE: Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. METHODS: Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). RESULTS: After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9-21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. CONCLUSION: By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.     

Multivariate analysis of histopathologic prognostic factors for invasive cervical cancer treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy

BACKGROUND: The aim of this study was to identify the independent histopathologic prognostic factors for patients with cervical carcinoma treated with radical hysterectomy including paraaortic lymphadenectomy. METHODS: A total of 187 patients with stage IB to IIB cervical carcinomas treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy were retrospectively analyzed. The median follow-up period was 83 months. Cox regression analysis was used to select independent prognostic factors. RESULTS: Using multivariate Cox regression analysis, lymph node (LN) status (negative vs. metastasis to pelvic nodes except for common iliac nodes vs. common iliac/paraaortic node metastasis), histopathologic parametrial invasion, lymph-vascular space invasion (LVSI), and histology of pure adenocarcinoma were found to be independently related to patients' poor survival. For patients who had a tumor histologically confined to the uterus and have neither parametrial invasion nor lymph node metastasis, LVSI was the most important prognostic factor, and histologic type, depth of cervical stromal invasion, and tumor size were not related to survival. The survival of patients with a tumor extending to parametrium or pelvic lymph node(s) was adversely affected by histology of pure adenocarcinoma. When the tumor extended to common iliac or paraaortic nodes, patients' survival became quite poor irrespective of LVSI or histologic type of pure adenocarcinoma. Patients' prognosis could be stratified into low risk (patients with a tumor confined to the uterus not associated with LVSI: n = 80), intermediate risk (patients with a tumor confined to the uterus associated with positive LVSI, and patients with squamous/adenosquamous carcinoma associated with pelvic lymph node metastasis or parametrial invasion: n = 86), and high risk (patients with pure adenocarcinoma associated with pelvic lymph node metastasis or parametrial invasion, and patients with common iliac/paraaortic node metastasis: n = 21) with an estimated 5-year survival rate of 100 +/- 0 (mean +/- SE)%, 85.5 +/- 3.9%, and 25.1 +/- 9.7%, respectively. CONCLUSIONS: LN status, parametrial invasion, LVSI, and histology of pure adenocarcinoma are important histopathologic prognostic factors of cervical carcinoma treated with radical hysterectomy and systematic retroperitoneal lymphadenectomy. Prognosis for patients with cervical carcinoma may be stratified by combined analysis of these histopathologic prognostic factors. Postoperative therapy needs to be individualized according to these prognostic factors and validated for its efficacy using randomized clinical trials.     

Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection.

We report the first case of a laparoscopic radical hysterectomy and paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.     

妇科腹腔镜手术中结扎束血管闭合系统与双极电凝止血的对比研究

目的：比较结扎束血管闭合系统（简称结扎束）与双极电凝在妇科腹腔镜手术中应用的效果及安全性。方法：对180例妇科腹腔镜手术的患者进行回顾性分析（包括输卵管切除术、输卵管及卵巢切除术、子宫全切术）,90例使用结扎束血管闭合系统（LigaSure血管闭合系统）闭合卵巢和子宫血管,另90例使用普通双极电凝钳凝固闭合卵巢和子宫血管,比较2组手术时间、术中出血量、术后恢复情况及近期术后并发症的发生情况。结果：2组术后住院时间及排气时间差异无统计学意义（P＞0.05）,手术时间及术中出血量差异有统计学意义,结扎束组少（短）于双极电凝组（均P＜0.05）;术后最高体温结扎束组低于双极电凝组（P＜0.05）。结论：结扎束血管闭合系统较双极电凝更安全,更有效地闭合血管,减少出血量及缩短手术时间,减少术后发热。     

Laparoscopic-assisted radical parametrectomy including pelvic and/or paraaortic lymphadenectomy in women after prior hysterectomy-three cases

BACKGROUND: Radical abdominal surgery in patients who have previously undergone a hysterectomy is a surgical challenge. This type of surgery for invasive cervical cancer after a hysterectomy or vaginal stump metastasis traditionally requires a major laparotomy; however, a minimal-access approach is now being applied to this type of procedure. CASE: A laparoscopic-assisted radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy was performed on two patients presenting invasive cervical cancer diagnosed after a simple hysterectomy and one patient with recurred endometrial cancer in the vaginal stump. All three patients had an excellent clinical outcome and made a rapid recovery with no major complications, even though two cases involved a bladder laceration. CONCLUSION: A laparoscopic radical parametrectomy including a pelvic and/or paraaortic lymphadenectomy is a viable technique for women with invasive cervical cancer or recurrent endometrial vaginal cancer after a prior hysterectomy.     

"Schauta sine utero": technique and results of laparoscopic-vaginal radical parametrectomy

OBJECTIVES: Radical parametrectomy or radical cervical stump exstirpation is indicated in selected oncologic situations. We evaluated whether radical parametrectomy without or with cervical stump exstirpation can be performed by a combined laparoscopic-vaginal approach. METHODS: Between November 2001 and Dezember 2002 six patients with unexpected cervical cancer (n = 3) after simple hysterectomy, histologically confirmed vaginal recurrence of endometrial cancer (n = 1), or cervical stump recurrence of endometrial cancer after supracervical hysterectomy (n = 2) underwent radical parametrectomy. After cystoscopic placement of bilateral ureteral stents laparoscopic paraaortic and pelvic lymphadenectomy was performed. The vascular part of the cardinal ligament and the bladder pillar were transsected laparoscopically. According to a LARVH type III procedure vaginal vault or cervical stump with parametrial and paravaginal structures was removed transvaginally. RESULTS: In all patients R0 resection could be achieved (n = 4) or no residual tumor was detected (n = 2). There were no intraoperative complications. One patient developed acute kidney failure on postoperative day 1, with spontaneous recovery after 12 days. The median drop of hemoglobin on postoperative day 5 was 2.15 mmol/L (1.3-3.2) and no patient needed transfusion. Restitution of bladder function took 4.3 days on average. The mean operation time was 424 min (385-452). CONCLUSIONS: Radical parametrectomy can be performed by a combined laparoscopic-vaginal technique without complications. Together with laparoscopic paraaortic and pelvic lymphadenectomy, it is a valid alternative to open surgery in selected oncologic patients.     

Electrosurgical bipolar vessel sealing versus conventional clamping and suturing for total abdominal hysterectomy: a randomized trial

STUDY OBJECTIVE: To compare the effects of bipolar vessel sealing versus conventional clamping and suturing in women undergoing total abdominal hysterectomy. DESIGN: A randomized controlled trial was performed. Patients were randomized to vessel sealing or conventional surgery. Postoperative pain was the primary outcome. An intention-to-treat analysis was performed (Canadian Task Force classification I). SETTING: Two Dutch teaching hospitals. PATIENTS: A total of 57 women undergoing abdominal hysterectomy for benign conditions. MEASUREMENTS AND MAIN RESULTS: During the first 3 postoperative days, patients operated on using vessel sealing had statistically significantly lower pain scores. The amount of blood loss, surgery time, complication risk, and duration of hospitalization were similar between both groups. Patients in the vessel-sealing group resumed their normal daily activities on average 8 days earlier as compared with the conventional group. Postoperative pelvic floor function was similar in both groups. CONCLUSION: The use of vessel sealing during abdominal hysterectomy for benign conditions appears to be associated with reduced postoperative pain and faster recovery.     

Ogilvie's syndrome of colonic pseudo-obstruction: A complication of radical hysterectomy with pelvic and paraaortic lymphadenectomy

Ogilvie's syndrome of colonic pseudo-obstruction has been reported in a wide variety of systemic disorders including blunt and surgical trauma but apparently not as a complication of radical hysterectomy with pelvic and paraaortic lymphadenectomy. Its occurrence following extensive paraaortic dissection in this case but no report so far of its occurrence after routine radical hysterectomy supports the most commonly proposed etiology of disturbed splanchnic nerve supply to the colon as a cause. Colonic pseudo-obstruction following radical hysterectomy with pelvic and paraaortic lymphadenectomy is reported and the etiology, diagnosis, and management are discussed to highlight the condition so that possible associated morbidity/mortality may be avoided.     

Laparoscopic-assisted vaginal hysterectomy with laparoscopic pelvic and paraaortic staging for early endometrial cancer

While abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy is still considered the gold standard for the surgical treatment of endometrial cancer, the laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic lymphadenectomy has been performed in FIGO stage I endometrial cancer in selected centers for about a decade. Clinical studies have shown that the frequency of intra- and postoperative complications, the pelvic and paraaortic lymph node yield, and—more importantly—the overall survival, are similar both with the laparoscopic-assisted vaginal approach and the abdominal approach in stage I disease. Blood loss and duration of hospital stay may even be reduced with the LAVH. In summary, provided there is compliance with established oncologic guidelines, LAVH with pelvic and paraaortic lymphadenectomy can probably be performed in patients with endometrial cancer FIGO stage I without safety loss.     

Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer

OBJECTIVE: The aim of this work was to examine three types of radical vaginal hysterectomy with different degrees of radicality, performed in order to reduce surgical complications and sequelae in different indications, and to test the feasibility of a new simple and quick technique for extraperitoneal pelvic lymphadenectomy to be used in combination with radical vaginal hysterectomy for treatment of cervical cancer. In this way the advantages of vaginal surgery (e.g.: unnecessary general anaesthesia, reduced surgical trauma, applicability to obese and poor surgical risk patients, fast time-saving procedure) can be preserved. METHODS: We compared retrospectively the long-term results of radical vaginal and radical abdominal operations in a large series of stage IB-IIA cervical cancer patients treated at our institution in Florence from 1968 to 1983. Furthermore, we analysed the results of our experience from 1995 to 1998, when we performed extraperitoneal pelvic lymphadenectomy, followed by radical vaginal hysterectomy, on 48 patients affected by cervical cancer. Extraperitoneal pelvic lymphadenectomy was performed through two small abdominal incisions (6-7 cm). Twenty-two patients (45%) were obese (BMI>30 kg/m2) and 20 were poor surgical risks. FIGO stage was: IB1 in 18 cases, IB2 in eight, IIA in six, IIB in 12, IIIB in four. Neoadjuvant chemotherapy was given in 12 cases and preoperative irradiation was given in ten. General and regional anaesthesia were used in 30 (62.5%) and in 18 (37.5%) cases, respectively. RESULTS: As for past experience, in stage IB the five-year survival of 356 patients who underwent radical vaginal hysterectomy and that of 288 who had radical abdominal hysterectomy with pelvic lymphadenectomy were 81% and 75%, respectively (p<0.05). Surgical complications were fewer with no mortality in the first group. In stage IIA, survival rates were 68% for radical vaginal hysterectomy and 64% for radical abdominal hysterectomy, in 76 and 64 cases, respectively (p=n.s.). As for the more recent experience, median operative time for extraperitoneal pelvic lymphadenectomy was 20 minutes for each side (range 15-36). In each patient a median of 26 lymph nodes were removed (range 16-48). Positive nodes were found in 12 cases (25%). Median operative time for radical vaginal hysterectomy was 40 minutes (range 30-65). Extraperitoneal pelvic lymphadenectomy complications included: lymphocyst, five cases (10%) and retroperitoneal hematoma, one (2%); all occurred at the beginning of the experience. Radical vaginal hysterectomy complications included: ureteral stenosis, one (2%) and uretero-vaginal fistula, one (2%). All complications occurred in patients who received radiotherapy or chemotherapy preoperatively. Median hospital stay was ten days (range 6-20). CONCLUSIONS: The results of our work demonstrate that our technique for extraperitoneal pelvic lymphadenectomy shows a good applicability to cervical cancer patients submitted to radical vaginal hysterectomy, which has a high rate of cure for stage IB and IIA as shown by our past experience. The procedure of extraperitoneal pelvic lymphadenectomy was quick, easy, and safe, and its realization was not detrimental to the advantages of radical vaginal hysterectomy. Our experience supports the continued use of this combined extraperitoneal and vaginal approach in the treatment of cervical cancer. Moreover, the three classes of radical vaginal hysterectomy allow tailoring the type of the operation to the clinical and physical characteristics of the patients.     

Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer

OBJECTIVE: To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer. METHODS: We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006. RESULTS: Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function. CONCLUSION: Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.     

Comparison of laparoscopic and conventional surgery in the treatment of early cervical cancer

STUDY OBJECTIVE: To compare efficacy, results, and complications of laparoscopic-assisted radical hysterectomy (LARH) and pelvic lymphadenectomy with abdominal radical hysterectomy (ARH) and pelvic lymphadenectomy in management of early (stages 1a2, 1b) invasive cervical carcinoma. DESIGN: Prospective cohort study (Canadian Task Force classification II-2). SETTING: University-affiliated hospital. PATIENTS: Sixty women enrolled for radical hysterectomy as most appropriate primary treatment. INTERVENTION: Radical hysterectomy performed by laparoscopy or laparotomy. MEASUREMENTS AND MAIN RESULTS: Thirty patients each underwent LARH and ARH. The groups did not differ in terms of age, weight, disease stage, operating time, and hospital stay. Mean blood loss was 962 +/- 543 ml for ARH and 450 +/- 284 ml for LARH. No laparoscopic procedure was converted to laparotomy. There was no significant difference in intraoperative and postoperative complications. There was no significant difference in recurrence rates. CONCLUSION: LARH with pelvic lymphadenectomy does not increase recurrence rates and morbidity when performed by experienced endoscopists and oncologists.     

Learning curve and surgical outcome for robotic-assisted hysterectomy with lymphadenectomy: case-matched controlled comparison with laparoscopy and laparotomy for treatment of endometrial cancer

Study ObjectiveTo determine the learning curve for robotic-assisted hysterectomy with lymphadenectomy for surgical treatment of endometrial cancer.DesignAn analysis of robotic-assisted hysterectomy with lymphadenectomy vs total laparoscopic hysterectomy with lymphadenectomy and laparotomy with total abdominal hysterectomy with lymphadenectomy (Canadian Task Force classification II-1).SettingSolo, experienced, minimally invasive gynecologic oncology practice in a tertiary hospital.PatientsOne hundred forty-eight patients including 56 patients who underwent robotic-assisted hysterectomy with bilateral pelvic and paraaortic lymph node dissection, 56 patients who underwent total laparoscopic hysterectomy with bilateral pelvic and paraaortic lymph node dissection, and 36 patients who underwent traditional total abdominal hysterectomy with bilateral pelvic and paraaortic lymph node dissection performed by the same surgeon for treatment of endometrial cancer.InterventionsRobotic-assisted hysterectomy with bilateral lymphadenectomy, total laparoscopic hysterectomy with bilateral lymphadenectomy, and traditional total abdominal hysterectomy with bilateral lymphadenectomy were performed. Data were categorized by chronologic order of cases into groups of 20 patients each. The learning curve of the surgical procedure was estimated by measuring operative time with respect to chronologic order of each patient who had undergone the respective procedure.Measurements and Main ResultsFor the 3 surgical procedures, data analyzed included mean age, body mass index, operative time, blood loss, lymph node retrieval, and complications. Mean (SD); 95% confidence interval [CI]) operative time for the 3 procedures was statistically significant: 162.5 (53) minutes (95% CI, 148.6–176.4]), 192.3 (55.5) minutes (95% CI, 177.6–207.0), and 136.9 (32.3) minutes (95% CI, 126.3–147.5), respectively. Analysis of operative time for robotic-assisted hysterectomy with bilateral lymph node dissection with respect to chronologic order of each group of 20 cases demonstrated a decrease in operative time: 183.2 (69) minutes (95% CI; 153.0–213.4) for cases 1 to 20, 152.7 (39.8) minutes (95% CI, 135.3–170.1) for cases 21 to 40, and 148.8 (36.7) minutes (95% CI, 130.8–166.8) for cases 41 to 56. For the groups with laparoscopic hysterectomy with lymphadenectomy and traditional total abdominal hysterectomy with lymphadenectomy, there was no difference in operative time with respect to chronologic group order of cases. There was a difference between the number of lymph nodes retrieved between robotic-assisted hysterectomy with bilateral lymphadenectomy (26.7 [12.8]; 95% CI, 23.3–30.1) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (45.1 [20.9]; 95% CI, 39.6–50.6) and traditional total abdominal hysterectomy with lymphadenectomy (55.8 [23.4]; 95% CI, 48.2–63.4). The rate of intraoperative complications for laparoscopic hysterectomy with bilateral lymphadenectomy was 12.5% (7 of 56) compared with 0 % for robotic-assisted hysterectomy with bilateral lymphadenectomy. The rate of postoperative complications was 14.3% (8 of 56), 21.4% (12 of 56), and 19.4% (7 of 36), respectively, for the 3 groups. There was less blood loss with robotic-assisted hysterectomy with bilateral lymphadenectomy (89.3 [45.4]; 95% CI, 77.4–101.2) compared with laparoscopic hysterectomy with bilateral lymphadenectomy (209.1 [91.8]; 95% CI, 185.1–233.1) and traditional total abdominal hysterectomy with lymphadenectomy (266.0 [145.1]; 95% CI, 218.6–313.4). Duration of hospitalization was shorter in the group with robotic-assisted hysterectomy with bilateral lymphadenectomy (1.6 [0.7]; 95% CI, 1.4–1.8) compared with the groups who underwent laparoscopic hysterectomy with bilateral lymphadenectomy (2.6 [0.9]; 95% CI, 2.4–2.8) or traditional total abdominal hysterectomy with lymphadenectomy (4.9 [1.9]; 95% CI, (4.3–5.5).ConclusionThe learning curve for robotic-assisted hysterectomy with lymph node dissection seems to be easier compared with that for laparoscopic hysterectomy with lymph node dissection for surgical management of endometrial cancer.     

腹腔镜与开腹手术行广泛子宫切除加盆腔淋巴结清除术的临床效果比较

目的 比较腹腔镜与开腹手术行广泛子宫切除加盆腔淋巴结清除术的临床效果。方法 回顾性分析近2年我院经腹腔镜行广泛子宫切除加盆腔淋巴结清除术的26例子宫恶性肿瘤患者(腹腔镜组)的临床资料,随机抽取近4年行开腹同类手术的27例(开腹组)作为对照。结果腹腔镜组平均手术时间为310 min,开腹组为238 min;腹腔镜组平均切除的淋巴结22个,开腹组为16个;腹腔镜组术中平均出血量为756 ml,开腹组为1129 ml,腹腔镜组平均输血量为321 m1,开腹组为746 ml,腹腔镜组平均术后排气时间为37 h,开腹组为62 h;腹腔镜组术后体温恢复正常时间平均为5 d,开腹组为8 d;腹腔镜组平均应用抗生素时间为6 d,开腹组为8 d;以上各项数据两组间比较,差异均有极显著性(P<0.01)。两组在盆腔引流液(分别为321、216 ml)、尿管拔除时间(分别为13、10d)、术后第3天的白细胞计数(分别为11 × 109/L、10 × 109/L)、术后住院日(分别为26、26 d)及住院费用(分别为25 986、22 672元)等方面比较,差异均无显著性(P>0.05)。结论 腹腔镜下广泛子宫切除及盆腔淋巴结清除术可达到开腹手术的彻底性,并具有创伤小、恢复快等优点。     

Risk factors for early and late postoperative complications of patients with endometrial cancer

OBJECTIVE: We have routinely performed staging with pelvic and/or paraaortic lymphadenectomy in patients with endometrial cancer having moderate to high risk for lymph node metastasis. The aim of this study was to investigate the risk factors for the occurrence of early and late postoperative complications in patients managed primarily by surgery in our institution. STUDY DESIGN: Two-hundred and fifty-nine consecutive cases of endometrial cancer were enrolled in the study. Past history, body mass index, type of surgery, intraoperative findings, and follow-up information were collected from patient charts. Of these, 200, 127, and 30 patients underwent systematic pelvic lymphadenectomy, systematic paraaortic lymphadenectomy, and radical hysterectomy, respectively. The median numbers of dissected pelvic and paraaortic lymph nodes were 32 and 14, respectively. RESULTS: None of the complications resulted in death. Of the study population, 36 early complications and 34 late complications occurred. Overall 65 patients (25.1%) had at least one complication. Multivariate analysis revealed that a longer operative time and paraaortic lymphadenectomy were independent predictors for the occurrence of early and late postoperative complications, respectively. CONCLUSIONS: Since the therapeutic value of lymphadenectomy is still under evaluation, the indications for systematic pelvic and paraaortic lymphadenectomy should be carefully considered.     

Clinical evaluation of laparoscopic-assisted radical vaginal hysterectomy with pelvic and/or paraaortic lymphadenectomy

STUDY OBJECTIVE: To report our experience with radical laparoscopic-assisted vaginal hysterectomy (LAVH) with bilateral pelvic and/or paraaortic lymphadenectomy. DESIGN: Retrospective review (Canadian Task Force classification III). SETTING: University-affiliated hospital. PATIENTS: Fifty-two women with invasive carcinoma of the cervix, stage Ib1, smaller than 3 cm. INTERVENTION: Radical LAVH with pelvic and/or paraaortic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS: Total operating time ranged from 230 to 650 minutes (mean 380 min). Major surgical complications were two cases of ureter injury, two cases of ureteral stricture, and one case of hematoma at the cannula site. Two cases were converted to laparotomy due to incomplete hemostasis of the uterine artery and obturator vein. The mean hemoglobin decrement was 1.7 g/dl the day after operation. Thirty patients received blood transfusion (mean 1.8 pints). Average numbers of pelvic and paraaortic lymph nodes removed were 27.7 (range 9-63) and 22.1 (range 6-52), respectively. After surgery, patients passed gas in 2.2 days and self-voided in 18.4 days on average. One woman had pelvic recurrence at 26 months after surgery. One died from brain metastasis 10 months after surgery. CONCLUSION: This technique is feasible for treatment of early cervical carcinoma. An experienced surgeon could shorten operating time and reduce complications.     

Primary double invasive cervical carcinoma, squamous cell carcinoma and adenocarcinoma--case report

A case of 56-year old women with double primary invasive cervical carcinoma, squamous cell carcinoma and endometrioid adenocarcinoma is presented. The patient was subjected to radical abdominal hysterectomy with pelvic and paraaortic lymphadenectomy. Surgery was followed by radiotherapy. Since the treatment the patient has been doing well and is free of any signs of relapse of the disease.     

Laparoscopic total radical hysterectomy by the Pune technique: our experience of 248 cases

STUDY OBJECTIVE: To describe our experience and technique of total laparoscopic radical hysterectomy with pelvic lymphadenectomy, which is the largest single- institution study. DESIGN: Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: Private hospital. PATIENTS: Two hundred forty-eight patients with International Federation of Gynecology and Obstetrics stage IA2 (n = 32) and IB1 (n = 216) of cancer of the cervix. INTERVENTION: Total laparoscopic type III radical hysterectomy with bilateral pelvic lymphadenectomy was done. Simple repetitive steps were used to perform this surgery and develop an easily replicable technique. Harmonic Shears, bipolar coagulation, and vascular clips were used. Resection of the cardinal and uterosacral ligaments was performed with LigaSure (LigaSure Vessel Sealing System; Valleylab, Tyco Healthcare, Boulder, CO) or the Harmonic Shears (Ethicon Endo-Surgery, Inc., Cincinnati, OH). Pelvic lymph node dissection was done. MEASUREMENTS AND MAIN RESULTS: Histopathologically, there were 183 (73%) cases of squamous carcinoma, 52 (20%) adenocarcinomas, and 13 (5%) adenosquamous carcinomas. Four patients needing anterior exenteration because of bladder involvement were excluded from data analyses. The operation was performed entirely by laparoscopy in all patients and by the same surgical team. The patients' median age was 61 years. The median operative time was 92 minutes (range 65-120 minutes). The median number of resected pelvic nodes was 18. The median blood loss was 165 mL. The median length of stay was 3 days. All 15 intraoperative complications were tackled laparoscopically. No patients were converted to the open technique. There were no deaths in our series. Seventeen patients had complications within 2 months of surgery. Seven patients had recurrences after a median follow-up of 36 months. CONCLUSION: Our technique of total laparoscopic radical hysterectomy, developed over 248 cases, can be performed safely. It is an easily replicable technique. This procedure reduces the morbidity associated with abdominal radical hysterectomy. All of the complications can also be tackled laparoscopically, which does not further add to the morbidity.     

Laparoscopic radical hysterectomy using pulsed bipolar system: comparison with conventional bipolar electrosurgery

OBJECTIVE: To compare the efficacy, results and complications of using the pulsed bipolar system (PlasmaKinetic; Gyrus Medical, Maple Grove, MN) and conventional bipolar electrosurgery (Kleppinger bipolar forceps; Richard Wolf Instruments, Vernon Hills, IL) in laparoscopic radical hysterectomy and pelvic lymphadenectomy in the management of early invasive cervical carcinoma. METHODS: This was a retrospective case-control study. We recruited consecutively 38 patients with cervical cancer for laparoscopic radical hysterectomy with pulsed bipolar system. For comparison, we recruited consecutively the latest 38 patients with cervical cancer for laparoscopic radical hysterectomy with conventional bipolar electrosurgery in the same period. From Jan. 2001 to Dec. 2005, total 76 patients with cervical cancer for laparoscopic radical hysterectomy were recruited for statistical analysis. RESULTS: No significant difference was found between the two groups in terms of age, body weight, staging, and hospital stay. There were statistically significant difference in blood loss and operative time. The blood loss was more in conventional bipolar electrosurgery group (mean 564 ml, median 500 ml, range 50-2400 ml) compared with pulsed bipolar system group (mean 397 ml, median 350 ml, range 100-1200 ml) (p<0.03). But there was no statistically significant difference in blood transfusion between the two groups (p=0.454). The operation time for the conventional bipolar electrosurgery group (mean 229 min, median 232 min, range 121-352 min) was longer than that for the pulsed bipolar system group (mean 172 min, median 177 min, range 65-267 min) (p<0.001). None of the laparoscopic procedure was required to be converted to laparotomy. There was no significant difference in the intra-operative complication, but there was statistically less postoperative complication in the pulsed bipolar system group (p<0.01). There was no significant difference in recurrence rate in both groups. CONCLUSIONS: Our findings indicate that pulsed bipolar system is more effective in laparoscopic radical hysterectomy when compared with conventional bipolar electrosurgery. Pulsed bipolar system has advantage over conventional bipolar electrosurgery in less blood loss, shorter operative time, less postoperative complication and may offer an alternative option for patients undergoing laparoscopic radical hysterectomy.