The use of thumbtacks to stop severe presacral bleeding

Massive presacral bleeding arising during gynaecological surgery can be sudden, rapid and life-threatening. Further, its control and management can be challenging, since standard measures are frequently ineffective. The use of thumbtacks to control severe presacral venous haemorrhage was first reported in 1985. Despite this, it does not appear to be widely known or used in gynaecological surgery. A case is presented in which the technique was used, and the literature on its use is reviewed.     

在体女性骶前静脉丛数字化三维模型构建方法及意义

目的探讨利用CT血管成像(CTA)原始数据集构建在体女性骶前静脉丛数字化三维模型的方法及意义。方法 2011年9月于南方医科大学南方医院获取1例宫颈癌患者的CTA原始数据集,利用Mimics10.01软件分别对骨盆、盆腔动脉血管网及静脉血管网进行三维重建并配准融合。结果构建出的盆腔静脉血管网数字化三维模型可清晰地显示下腔静脉、髂总静脉、髂内静脉、髂外静脉及其初级属支,骶前静脉丛亦清晰可见。与重建的骨盆、盆腔动脉血管网配准融合后,骶前静脉丛的解剖走形及引流区域变得更加清晰明了。尤为关键的是,骶前无血管区也可清晰显示。结论基于CTA的数字化三维重建技术是一种研究在体女性骶前静脉丛的好方法,可清晰显示骶前静脉丛及骶前的无血管区域,从而为阴道-骶骨固定术提供个体化的解剖学依据,并有效地降低手术并发症的发生率。     

Prevention of adhesion formation after radical hysterectomy using a sodium hyaluronate-carboxymethylcellulose (HA-CMC) barrier: a cost-effectiveness analysis

OBJECTIVE: To evaluate the cost-effectiveness of an adhesion prevention strategy compared to routine care, in which no adhesion prevention measures are taken, through a decision analysis model in the clinical setting of patients undergoing radical hysterectomy and pelvic lymphadenectomy for Stage IB cervical cancer. METHODS: A decision analysis model compared two strategies to manage the risk of adhesion-related morbidity following radical hysterectomy for Stage IB cervical cancer: (1) routine care with no adhesion prevention measures, and (2) the intervention strategy with a HA-CMC anti-adhesion barrier. The cost-effectiveness of each strategy was evaluated from the perspective of society and that of a third party payer. RESULTS: From the perspective of society, the HA-CMC strategy had an overall cost per patient of $1932 and effectiveness of 7.901 QALYs and dominated the routine care strategy, which had a cost per patient of $3043 and effectiveness of 7.805 QALYs. From the perspective of a third party payer, the HA-CMC strategy had an overall cost per patient of $1247 and effectiveness of 7.987 QALYs and dominated the routine care strategy, which had a cost per patient of $1629 and effectiveness of 7.970 QALYs. A series of one-way sensitivity analyses confirmed the robustness of the model. CONCLUSIONS: Under a conservative set of clinical and economic assumptions, an adhesion prevention strategy utilizing a HA-CMC barrier in patients undergoing radical hysterectomy for Stage IB cervical cancer is cost-effective from both the perspective of society as a whole and that of a third party payer.     

Robot-assisted versus total laparoscopic radical hysterectomy in early cervical cancer, a review

Objective

The aim of this study was to review current literature on total laparoscopic (TLRH) and robot-assisted radical hysterectomy (RRH) with pelvic lymphadenectomy in the treatment of early stage cervical cancer by analyzing data published in individual case series in order to compare surgical and oncological outcomes.

Methods

Up to January 2010, 27 studies were identified that met the inclusion criteria, together with our own unpublished data of patients, accounted for 342 RRH patients and 914 TLRH patients.

Results

There was no statistical difference between the methods in terms of age, BMI or prior abdominal surgery. Estimated mean operative time, blood loss and number of lymph nodes retrieved did not statistically differ between the RRH and TLRH method. Less blood transfusions were needed in patients treated by RRH (5.4%) versus TLRH (9.7%, p < 0.05). Both methods were similar in respect to adjuvant chemo- or (chemo)radiation and recurrence rate. When complications were prioritized to severity, major post-operative complications where more frequent in RRH patients (9.6%) than in TLRH patients (5.5%, p < 0.05). The length of hospital stay was significantly shorter in RRH compared to TLRH treatment (3.3 versus 6.2 days respectively; p:0.04).

Conclusions

Robot-assisted and total laparoscopic radical hysterectomy appears to be equally adequate and feasible. RRH studies had small patient populations and further experience beyond the learning curve phase may improve operative time and complication rate. Both minimal invasive techniques should be investigated in a randomized manner.     

Comparative effectiveness of minimally invasive and abdominal radical hysterectomy for cervical cancer

Objective

We analyzed the uptake, morbidity, and cost of laparoscopic and robotic radical hysterectomies for cervical cancer.

Methods

We identified women recorded in the Perspective database with cervical cancer who underwent radical hysterectomy (abdominal, laparoscopic, robotic) from 2006 to 2010. The associations between patient, surgeon, and hospital characteristic and use of minimally invasive hysterectomy as well as complications and cost were estimated using multivariable logistic regression models.

Results

We identified 1894 patients including 1610 (85.0%) who underwent abdominal, 217 (11.5%) who underwent laparoscopic, and 67 (3.5%) who underwent robotic radical hysterectomy were analyzed. In 2006, 98% of the procedures were abdominal and 2% laparoscopic; by 2010 abdominal radical hysterectomy decreased to 67%, while laparoscopic increased to 23% and robotic radical hysterectomy was performed in 10% of women (p < 0.0001). Patients treated at large hospitals were more likely to undergo a minimally invasive procedure (OR = 4.80; 95% CI, 1.28-18.01) while those with more medical comorbidities (OR = 0.60; 95% CI, 0.41-0.87) were less likely to undergo a minimally invasive surgery. Perioperative complications were noted in 15.8% of patients who underwent abdominal surgery, 9.2% who underwent laparoscopy, and 13.4% who had a robotic procedure (p = 0.04). Both laparoscopic and robotic radical hysterectomies were associated with lower transfusion requirements and shorter hospital stays than abdominal hysterectomy (p < 0.05). Median costs were $9618 for abdominal, $11,774 for laparoscopic, and $10,176 for robotic radical hysterectomy (p < 0.0001).

Conclusion

Uptake of minimally invasive radical hysterectomy for cervical cancer has been slow. Both laparoscopic and robotic radical hysterectomies are associated with favorable morbidity profiles.     

Outcome of radical hysterectomies performed by general gynecologists in Jamaica

Objective

To review the modified (type II) radical hysterectomy procedures performed by 4 general gynecologists at the University Hospital of the West Indies, and to compare the outcomes with those of other published studies.

Methods

The case notes of the 58 women who underwent radical hysterectomies between January 1997 and December 2006 were reviewed. Accuracy of staging, duration of the operation, operative blood loss, types and rates of complications, recurrence rates, and 5-year survival rates were assessed.

Results

Accuracy of clinical staging, duration of the procedure, blood loss, and operative and postoperative complications were comparable to previously published data. The 5-year survival rate of 77.6% was also comparable to results seen in some other publications.

Conclusion

General gynecologists with significant experience in general gynecologic surgery who underwent adequate, but abbreviated, training became competent in performing a radical hysterectomy, with outcomes comparable to those seen in high-resource countries.     

Laparoscopic radical hysterectomy for invasive cervical cancer: 8-year experience of a pilot study

OBJECTIVE: The aim of this study was to retrospectively evaluate, in a series of 50 consecutive patients, the feasibility, morbidity, and survival outcome of the laparoscopic radical hysterectomy for carcinoma of the uterine cervix. METHODS: Fifty patients with invasive cervical cancer were operated on by laparoscopic radical hysterectomy between 1993 and 2001 at two cancer centers. Patients in a good general condition with a cervical carcinoma less than 4 cm and a body mass index up to 29 were eligible. Thirty-one patients had prior brachytherapy. RESULTS: The median overall operative time was 258 min. The mean number of harvested pelvic external iliac nodes was 13.22 per patient. The median postoperative hospital stay was 7.5 days. Two patients had major urinary complications; one had a bladder fistula and one a ureteral stenosis. The median follow-up was 44 months. The overall 5-year survival rate of FIGO stage Ia2 and Ib1 patients was 96%. CONCLUSION: Our results demonstrate that radical hysterectomy can be performed by laparoscopy in stage IB1 or less advanced node negative cervical cancer patients without compromising survival. Prior brachytherapy did not affect the feasibility of this radical procedure.     

腹腔镜下和经腹广泛子宫切除及盆腔淋巴结清扫术治疗早期子宫恶性肿瘤的近期疗效分析

目的:探讨腹腔镜下广泛子宫切除加盆腔淋巴结清扫术治疗子宫恶性肿瘤的近期疗效及应用价值.方法:对协和医院妇产科2008年3月至2009年4月间的70例早期子宫恶性肿瘤患者行腹腔镜下广泛子宫切除加盆腔淋巴结清扫术(TLRH+LPL组),并与同期48例经腹广泛子宫切除术和淋巴结清扫术(ARH+APL组)的病例作为对照,比较两种术式的术中、术后情况及并发症等.结果:行腹腔镜手术的70例患者,有2例中转开腹,中转率为2.9%.TLRH+LPL组在手术时间、术中出血量、淋巴结切除数目和术后体温恢复正常平均时间上与ARH+APL组相比,具有明显优势,差异均有高度统计学意义(P<0.01);但膀胱功能恢复时间及术后并发症的发生率,两组比较差异无统计学意义(P>0.05).结论:腹腔镜下广泛子宫切除加盆腔淋巴结清扫术具有同常规的经腹手术同样的安全性和有效性,同时缩短了手术时间,减少了手术创伤,为微创手术治疗妇科恶性肿瘤提供了良好的应用前景.     

Systematic comparison of radical vaginal trachelectomy and radical hysterectomy in the treatment of early-stage cervical cancer

Objective

To review the effects of radical vaginal trachelectomy (RVT) and radical hysterectomy (RH) on overall progression-free survival rate, and intraoperative and postoperative complications in patients with cervical cancer (FIGO stage IA-IB1).

Methods

Electronic searches for studies of RVT and RH in the treatment of cervical cancer between 1994 and January 2010 were made on MEDLINE, the Cochrane Library, the China National Knowledge Infrastructure, and the Wan Fang dissertation database.

Results

No significant differences were found between RVT and RH in 5-year overall survival rate (relative risk [RR] 0.97; 95% confidence interval [CI], 0.93-1.02); 5-year progression-free survival rate (RR 0.99; 95% CI, 0.95-1.02); intraoperative complications (RR 1.99; 95% CI, 0.61-6.52)]; and postoperative complications (RR 0.36; 95% CI, 0.10-1.27). There were fewer blood transfusions (RR 0.33; 95% CI, 0.12-0.90), less blood loss, and shorter hospital stays in patients undergoing RVT.

Conclusion

Radical vaginal trachelectomy should be considered as a viable treatment option for young patients with early cervical cancer (FIGO stage IA-IB1) who wish to preserve their fertility.     

A model for prediction of parametrial involvement and feasibility of less radical resection of parametrium in patients with FIGO stage IB1 cervical cancer

Objective

The objective of this study was to evaluate the potential risk factors associated with parametrial invasion and to identify preoperatively a subgroup of patients at low risk for parametrial involvement who could be appropriate candidates for less radical surgery in FIGO stage IB1 cervical cancer.

Methods

We retrospectively reviewed the medical records of 317 FIGO stage IB1 cervical cancer patients undergoing class III radical hysterectomy and bilateral pelvic lymphadenectomy. Clinocopathologic factors associated with parametrial invasion were analyzed and the risk criteria predicting parametrial involvement were calculated using a logistic regression model.

Results

Of 317 patients, 17 patients (5.4%) had parametrial involvement. Tumor size > 3 cm (OR, 3.80; [95% CI, 1.19-12.06]; p = 0.02) and pelvic lymph node metastasis (OR, 3.02; [95% CI, 1.04-8.79]; p = 0.04) were independent pathologic factors for parametrial invasion on multivariate analysis. Significant preoperative factors associated with parametrial involvement were tumor size > 3 cm (OR, 4.29; [95% CI, 1.43-12.89]; p < 0.01) and serum SCC Ag level > 1.40 ng/mL (OR, 3.27; [95% CI, 1.11-9.69]; p = 0.03). We identified 185 low-risk (tumor size ≤ 3 cm and SCC ≤ 1.4 ng/mL) and 132 high-risk (tumor size > 3 cm and/or SCC > 1.4 ng/mL) patients. The rates of parametrial involvement in low- and high-risk patients were 1.1% and 11.4%, respectively (p < 0.01).

Conclusions

In this dataset, a model using tumor size and SCC Ag level is highly predictive of parametrial involvement in patients with stage IB1 cervical cancer and may identify candidates for less radical parametrial resection.     

Rethinking the use of radiation and chemotherapy after radical hysterectomy: a clinical-pathologic analysis of a Gynecologic Oncology Group/Southwest Oncology Group/Radiation Therapy Oncology Group trial

OBJECTIVE: To retrospectively analyze data from a previously reported randomized trial of either pelvic radiation (RT) or RT + chemotherapy (CT) in patients undergoing radical hysterectomy and pelvic lymphadenectomy with positive pelvic lymph nodes, parametrial involvement, or surgical margins; to explore associations between RT + CT; and to investigate histopathologic and clinical factors which might be predictive of recurrence. METHODS: Histopathologic sections from biopsies and hysterectomies and clinical data were reviewed from patients with stage IA2, IB, or IIA cervical cancer treated with RT or RT + CT (cisplatin 70 mg/m2 plus fluorouracil 1000 mg/m2 every 3 weeks for four cycles). A univariate analysis was performed because the relatively small sample size limited the interpretation of a multivariate analysis. RESULTS: Of the 268 enrolled women, 243 (RT = 116; RT + CT = 127) were evaluable. The beneficial effect of adjuvant CT was not strongly associated with patient age, histological type, or tumor grade. The prognostic significance of histological type, tumor size, number of positive nodes, and parametrial extension in the RT group was less apparent when CT was added. The absolute improvement in 5-year survival for adjuvant CT in patients with tumors < or =2 cm was only 5% (77% versus 82%), while for those with tumors >2 cm it was 19% (58% versus 77%). Similarly, the absolute 5-year survival benefit was less evident among patients with one nodal metastasis (79% versus 83%) than when at least two nodes were positive (55% versus 75%). CONCLUSIONS: In this exploratory, hypothesis-generating analysis, adding CT to RT after radical hysterectomy, appears to provide a smaller absolute benefit when only one node is positive or when the tumor size is < 2 cm. Further study of the role of CT after radical hysterectomy in patients with a low risk of recurrence may be warranted.     

A comparative study of laparoscopic radical hysterectomy with radical abdominal hysterectomy for early-stage cervical cancer: a long-term follow-up study

Objective

To determine whether laparoscopic radical hysterectomy (LRH) is a feasible alternative to radical abdominal hysterectomy (RAH) for early-stage cervical cancer.

Study design

A retrospective, matched case-control study of 24 consecutive cases with International Federation of Gynecology and Obstetrics stage I-II cervical cancer who underwent LRH by a single surgeon between January 1994 and December 2001. Cases were matched with controls (ratio 1:2) who underwent RAH by surgeon, age, stage and histology. Patient characteristics, clinical course, intra-operative complications and disease-free survival were compared between the two groups. Median counts were analyzed using the Mann-Whitney U-test. Differences between means were compared using Student's t-test. Dichotomous groupings were analyzed using Chi-squared test and Fisher's exact test as appropriate. Survival data were estimated using Kaplan-Meier estimates and compared with the log-rank test.

Results

The mean estimated blood loss in the RAH group was significantly greater than that in the LRH group (836.0 ml and 414.3 ml, respectively; p < 0.001). Five patients (20.8%) from the LRH group and 23 patients (47.9%) from the RAH group received blood transfusion (p < 0.03). The mean length of hospital stay was significantly shorter in the LRH group compared with the RAH group (10.7 days and 18.8 days, respectively; p < 0.01). No statistically significant difference existed between the two groups with respect to operative time, pelvic lymph node count, frequency of lymph node involvement, extent of parametrial or vaginal resection margins, adjuvant treatment and intra-operative complications. Median follow-up was 78 months for the LRH group and 75 months for the RAH group. There was no significant difference in the 5-year disease-free survival rate between the groups (90.5% and 93.3% for LRH and RAH, respectively; p = 0.918).

Conclusions

LRH is a useful alternative to RAH for the management of early-stage cervical cancer. The benefits of LRH include reduced blood loss, fewer transfusions and shorter hospital stay, with comparable oncologic outcome.     

Feasibility and safety of type C2 total extraperitoneal abdominal radical hysterectomy (TEARH) for locally advanced cervical cancer

Introduction

Radical hysterectomy represents the gold standard treatment in patients with early-stage cervical cancer and a valid choice of treatment, after neoadjuvant chemotherapy (NACT), in locally advanced tumors. Laparotomy is still considered the standard approach for radical hysterectomy; however, the extraperitoneal route has been described as a valid alternative for pelvic lymphadenectomy, with shorter operative time, shorter ileus and reduced postoperative pain and hospitalization. We designed the first prospective study to evaluate the technique of total extraperitoneal radical hysterectomy for surgical treatment of locally advanced cervical cancer after platinum-based NACT, in terms of feasibility and safety.

Methods

Consecutive patients affected by locally advanced cervical carcinoma were considered for eligibility in this observational study. After a primary complete evaluation, all patients were submitted to platinum-based NACT. Inclusion criteria were: stage IB2-IIIB cervical carcinoma already submitted to neoadjuvant chemotherapy with a complete or partial response after three cycles of chemotherapy, WHO performance status ≤ 1, adequate renal, hepatic and cardiac function, BMI < 40, age ≤ 75 years, no concurrent or previous malignant disease, no previous radiation therapy, and signed informed consent. Patients included in the study were submitted to type C2 extraperitoneal radical hysterectomy.

Results

From January 2006 to October 2008, 46 patients were enrolled and compared with a control group selected from the historical database. The mean operative time in the extraperitoneal radical hysterectomy group was 195 min (range: 120-240) versus 235 min (range: 215-310) in the intraperitoneal radical hysterectomy group (P < 0.05). Median postoperative ileus was 32 h (range: 24-36) versus 67 h (range: 42-78) (P < 0.05). VAS (Visual Analogue Scale) score at 24 and 48 h was 8 (range: 6-8) versus 8 (range: 6-9) (P = NS) and 3.5 (range: 2-7) versus six (range: 5-9) (P < 0.05) respectively. No differences in terms of intraoperative and postoperative complications were recorded.

Conclusions

Total extraperitoneal radical hysterectomy in locally advanced cervical cancer is feasible and safe. If compared with intraperitoneal abdominal radical hysterectomy, no significant differences in terms of surgical data or complications were found. Extraperitoneal radical hysterectomy seems to compare favorably to the intraperitoneal approach in terms of operative time, postoperative ileus, and VAS score at 48 h.     

Treatment of dysfunctional uterine bleeding: patient preferences for endometrial ablation, a levonorgestrel-releasing intrauterine device, or hysterectomy

OBJECTIVE: To investigate patient preferences for endometrial ablation and a levonorgestrel-releasing intrauterine device (IUD) as alternatives to hysterectomy in the treatment of dysfunctional uterine bleeding. DESIGN: Comparative study based on structured interviews. SETTING: A large teaching hospital with 500 beds in the Netherlands. PATIENT(S): Ninety-six patients who were scheduled for endometrial ablation, 25 patients who were scheduled for hysterectomy, and 23 patients who were scheduled for a levonorgestrel-releasing IUD were interviewed. All of the women had dysfunctional uterine bleeding. INTERVENTION(S): Patients were asked to state their most significant complaints and their reasons for choosing a particular treatment. Subsequently, the preference for endometrial ablation and a levonorgestrel-releasing IUD as alternatives to hysterectomy was assessed during a structured interview. Women were informed about the advantages and disadvantages of all three treatment options. Patients rated their preferences according to different hypothetical success rates. The success rates after endometrial ablation and levonorgestrel-releasing IUD were varied until patients found an acceptable treatment outcome. MAIN OUTCOME MEASURE(S): Patient preference of endometrial ablation and the levonorgestrel-releasing IUD over hysterectomy. RESULT(S): The main reason for the treatment of choice differed between the three groups. Most of the patients in the hysterectomy group wanted a definite solution to their problems, whereas patients in the levonorgestrel-releasing IUD group and in the ablation group put greater emphasis on a minimally invasive intervention with or without a short hospital stay. In women undergoing ablation, 70% of the patients preferred this treatment and the levonorgestrel-releasing IUD to hysterectomy in cases in which the success rate of noninvasive treatment was presumed to be 50%. In women having a levonorgestrel-releasing IUD inserted, 95% of the patients preferred this approach over hysterectomy in cases in which the success rate of this device was presumed to be 50%, whereas 35% of patients preferred ablation over hysterectomy in cases in which the success rate of ablation was presumed to be 50%. In women undergoing hysterectomy, 30% would have opted for ablation and 45% would have opted for a levonorgestrel-releasing IUD in cases in which success rates were 50%. Of patients who opted for hysterectomy, however, 60% stated that they would have preferred a noninvasive treatment if the success rate of this type of treatment were >80%. CONCLUSION(S): A majority of the patients who had dysfunctional uterine bleeding and who were scheduled for an endometrial ablation or a levonorgestrel-releasing IUD were inclined to take a risk of 50% likelihood of treatment failure to avoid a hysterectomy. As a consequence, research of treatment for dysfunctional uterine bleeding should focus on this 50% success level.