Laparoscopic En Bloc Pelvic Resection with Rectosigmoid Resection and Anastomosis for Stage IIB Ovarian Cancer: Hudson's Procedure Revisited

Study ObjectiveTo demonstrate a systematic approach to the laparoscopic en bloc pelvic resection with rectosigmoid resection and anastomosis as part of ovarian cancer treatment in a tertiary gynecologic surgery referral center.DesignThis video illustrates an en bloc pelvic resection performed par laparoscopy in 10 steps.SettingA 56-year-old patient with an advanced high-grade serous ovarian cancer extending into the rectum was amenable to primary debulking surgery in accordance with the French guidelines [1]. In diagnostic laparoscopy, a bilateral adnexectomy was performed, and the pelvic carcinomatosis was considered primarily resectable. Histopathology of the subsequent en bloc resection was consistent with stage IIB high-grade serous ovarian cancer with an indication for adjuvant chemotherapy.InterventionThe Hudson's procedure revisited consists of a radical monobloc excision by way of a completely extraperitoneal dissection and total mobilization of the rectum. In this case, owing to rectal invasion, we achieved a laparoscopic radical resection including rectosigmoidectomy and primary anastomosis without the need for a defunctioning stoma [2].ConclusionTraditionally, an en bloc pelvic resection with rectosigmoid resection and anastomosis was performed by laparotomy. The feasibility of performing laparoscopic optimal cytoreductive surgery in selected patients with advanced ovarian cancer was recently demonstrated without compromising survival in case of low residual disease. The prognosis depends rather on the resectability than on the operative access. However, the radicality and completeness of the cytoreduction, as well as the potential risk of tumor seeding, remain controversially discussed. Here, we demonstrate the minimally invasive approach following the same operative strategy as in open surgery. In this way, the radicality of the “en bloc resection” entailing avoidance of tumor rupture, less bleeding, and less urethral injury is combined with the benefits of a minimally invasive access. In expert hands, this procedure can be performed laparoscopically for other pelvic malignancies with peritoneal carcinomatosis.     

Laparoscopic Resection of an Epidermal Inclusion Cyst at the Vaginal Cuff

An epidermal inclusion cyst rarely occurs at the vaginal cuff, whereas it sometimes develops at the vulva and the site of episiotomy due to entrapment of the squamous epithelium. We present the case of a 58-year-old woman who developed an epidermal cyst at the vaginal cuff 6 years after laparoscopic hysterectomy. Although we could not make a precise diagnosis at imaging before the operation, the cyst was completely removed at laparoscopic surgery without any complications. To our knowledge, this is the first report of an epidermal inclusion cyst at the vaginal cuff that was successfully treated at laparoscopic surgery. Laparoscopic surgery was useful in magnifying the surgical field and in delicate manipulation of various devices to resect this pelvic floor tumor that required adhesiolysis of surrounding organs.     

Laparoscopic Debulking of Enlarged Pelvic Nodes during Surgical Para-aortic Staging in Locally Advanced Cervical Cancer: A Retrospective Comparative Cohort Study

Study ObjectiveTo evaluate laparoscopic pelvic lymph node debulking during extraperitoneal aortic lymphadenectomy in diagnosis, therapeutic planning, and prognosis of patients with locally advanced cervical cancer and enlarged lymph nodes on imaging before chemoradiotherapy.DesignRetrospective, multicenter, comparative cohort study.SettingThe study was carried out at 11 hospitals with specialized gynecologic oncology units in Spain.PatientsTotal of 381 women with locally advanced cervical cancer and International Federation of Gynecology and Obstetrics 2018 stage IIIC 1r (radiologic) and higher who received primary treatment with chemoradiotherapy.InterventionsPatients underwent pelvic lymph node debulking and para-aortic lymphadenectomy (group 1), only para-aortic lymphadenectomy (group 2), or no lymph node surgical staging (group 3). On the basis of pelvic node histology, group 1 was subdivided as negative (group 1A) or positive (group 1B).Measurements and Main ResultsFalse positives and negatives of imaging tests, disease-free survival, overall survival, and postoperative complications were evaluated.In group 1, pelvic lymph node involvement was 43.3% (71 of 164), and aortic involvement was 24.4% (40 of 164). In group 2, aortic nodes were positive in 29.7% (33 of 111). Disease-free survival and overall survival were similar in the 3 groups (p = .95) and in groups 1A and 1B (p = .25). No differences were found between groups 1 and 2 in intraoperative (3.7% vs 2.7%, p = .744), early postoperative (8.0% vs 6.3%, p = .776), or late postoperative complications (6.1% vs 2.7%, p = .252). Fewer early and late complications were attributed to radiotherapy in group 1A than in the others (p = .022).ConclusionLaparoscopic pelvic lymph node debulking during para-aortic staging surgery in patients with locally advanced cervical cancer with suspicious nodes allows for the confirmation of metastatic lymph nodes without affecting survival or increasing surgical complications. This information improves the selection of patients requiring boost irradiation, thus avoiding overtreatment of patients with negative nodes.     

Cervical Cancer with Paraaortic Metastases: Significance of Residual Paraaortic Disease after Surgical Staging

Cervical carcinoma frequently metastasizes to the paraaortic region, necessitating extended field radiotherapy to effect a cure. As imaging modalities are unreliable in identifying all cases of paraaortic nodal metastases (PAN), surgical staging is often utilized prior to radiotherapy. This study was aimed at identifying factors predictive of survival in women with cervical carcinoma and paraaortic metastases. In particular, survival based on extent of paraaortic disease was examined. The study group consisted of 43 women (stages IB–IVB) identified between 1982 and 1993 who were treated with extended field radiation for cervical carcinoma with histologically confirmed paraaortic metastases. The estimated 5-year survival for the study population was 24% with a median survival of 18 months. Pelvic tumor size had a significant impact on survival with the median survival being 34 months if the primary lesion was <6 cm compared to 14 months if ≥6 cm (P= 0.01). Eight of the 26 (31%) women without residual PAN disease after surgical staging remain alive and disease free (mean follow-up, 74 months). In contrast, only 1 of the 17 (6%) women with gross residual PAN is alive 71 months after treatment (P= 0.05). However, a comparison of Kaplan–Meier survival curves did not show a statistically significant advantage to the surgical excision of grossly involved PAN (P= 0.98). Although long-term survival among women with grossly involved, unresected paraaortic metastases is uncommon, further study is necessary to elucidate the role of surgical excision of bulky aortic disease in women with cervical cancer.     

腹腔镜与开腹手术在早期卵巢癌全面分期手术中的疗效和并发症比较

目的：重新评价腹腔镜（laparoscopy,LPS）与开腹（laparotomy,LPT）应用于早期卵巢癌全面分期手术的疗效。方法：检索PubMed、Embase、Cochrane Library、中国生物医学文献数据库（CBM）、万方、知网（CNKI）、维普等数据库,查找建库至2015年9月2日期间关于LPS与LPT应用于早期卵巢癌全面分期手术疗效比较的相关文献。采用RevMan 5.3软件对相关数据进行统计学分析。结果：最终纳入26篇临床病例对照研究（CCT）共1 456例患者,其中LPS组661例,LPT组795例。2组研究对象在年龄、体质量指数（BMI）或体质量、肿瘤分型或分期等方面差异均无统计学意义。Meta分析结果显示：与LPT组相比,LPS组术中失血量少、输血率低、淋巴结切除总数少、术后肛门排气及下床活动时间早、疼痛轻、术后住院时间短、术后并发症发生率低、切口愈合不良发生率低、随访时间短、术后复发率及病死率低,差异均有统计学意义;与LPT组相比,LPS组手术时间长、腹主动脉旁淋巴结切除数多,差异有统计学意义;而盆腔淋巴结切除数、术中并发症、术中脏器损伤、肿瘤破裂发生率、术后辅助化疗率2组相比差异无统计学意义。结论：与LPT相比,LPS下早期卵巢癌全面分期手术具有创伤小、视野清晰、出血少、疼痛轻、恢复快等优点;未发现在盆腔淋巴结切除数、术中并发症、术中脏器损伤、肿瘤破裂发生率、术后辅助化疗率方面的优势;复发率及病死率则需要进一步研究证实;符合目前肿瘤根治性治疗兼顾微创的趋势,值得临床推广。     

Epithelial Ovarian Cancer Surgical Staging by Ontario Gynaecologic Surgeons: Is There a Gap Between Current Practice and the Canadian Clinical Practice Guidelines?

ObjectivesBy determining, through self-report, Ontario gynaecologic surgeons’ practices regarding surgical staging for epithelial ovarian cancer, this study aimed to quantify the gap between current practice and the ideal practice of surgical staging for ovarian cancer, as defined by the corresponding Canadian clinical practice guidelines.MethodsAll 711 active Ontario gynaecologic surgeons identified from the website of the College of Physicians and Surgeons of Ontario were confidentially surveyed by mail, using a structured questionnaire to explore individuals’ surgical management of an adnexal mass suspicious for epithelial ovarian cancer, using a clinical case simulation. Specifically, gynaecologic surgeons’ adherence to the CPGs was determined by self-report, and various physician characteristics were explored for potential associations with adherence to the CPGs in the clinical case simulation using the Fisher exact test.ResultsThe survey response rate was 69.8%. Only 44.3% of Ontario gynaecologic surgeons adhered to the CPGs in their responses to the clinical case simulation. Gynaecologic oncologists were more likely than non-oncologists to self-report surgical staging according to the CPGs during the clinical case simulation (P = 0.0004). Adherence was also significantly associated with practice at a university centre (P = 0.013) and practice at a centre with a gynaecologic oncologist (P = 0.001) but was not associated with surgical volume.ConclusionThis study has confirmed that a significant gap exists between current practice and the ideal practice of surgical staging for epithelial ovarian cancer in Ontario, as defined by the corresponding Canadian CPGs. Further investigation will explore potential barriers to optimal practice to facilitate the development of a knowledge translation strategy to improve surgical staging for ovarian cancer in Ontario.     

Feasibility of Oophorectomy at the Time of Vaginal Hysterectomy in Patients with Pelvic Organ Prolapse

Study ObjectiveTo determine the feasibility of oophorectomy at the time of vaginal hysterectomy in patients with pelvic organ prolapse and to define prognostic factors and perioperative morbidity associated with the procedure.DesignA retrospective cohort study (Canadian Task Force classification II-2).SettingAn academic medical center.PatientsAll women who underwent total vaginal hysterectomy for the treatment of pelvic organ prolapse over 5 years were considered for inclusion in the study.InterventionsTotal vaginal hysterectomy and concomitant pelvic organ prolapse repair with or without oophorectomy.Measurements and Main ResultsA total of 289 women underwent total vaginal hysterectomy with pelvic organ prolapse repair. Vaginal oophorectomy was attempted in 179 patients (61.9%). The procedure was successful in 150 patients (83.8%; 95% confidence interval [CI], 77.6%–88.9%). High ovarian location was the most commonly cited reason for the inability to perform a planned unilateral/bilateral oophorectomy (n = 24, 82.7%). Attempting oophorectomy vaginally was associated with an increased duration of surgery by 7.3 minutes (p = .03), an increased change in hemoglobin by 0.2 g/dL (p = .02), and a higher rate of readmission (7.3% vs 1.8%, p = .04). Multiple logistic regression showed that increasing age (odds ratio = 1.12; 95% CI, 1.05–1.20; p <.001) and body mass index (odds ratio = 1.17; 95% CI, 1.07–1.27; p<.001) were associated with an increased risk of vaginal oophorectomy failure. On univariate analysis, race (p = .64), parity (p = .39), uterine weight (p = .91), need for uterine morcellation (p=.21), presence of endometriosis (p=.66), prior cesarean section (p=.63), prior laparoscopy (p=.37), and prior open abdominal/pelvic surgery (p = .28) did not impact the likelihood of successfully performing oophorectomy.ConclusionIn patients with pelvic organ prolapse, a planned oophorectomy at the time of vaginal hysterectomy can be successfully performed in the majority of cases. Greater age and body mass index are associated with an increased likelihood of failure.     

Laparoscopic Management of an Ovarian Dermoid Cyst Containing a Mandibular Structure with Teeth: A Novel Surgical Approach

BackgroundThe presence of ectodermal-derived tissue, including teeth, in an ovarian dermoid cyst is a common occurrence. The presence of a fully formed mandibular structure with teeth, however, is rare, and there are few case reports in the literature that discuss its surgical management.CaseWe report a case of an adolescent girl found to have a mandibular structure with teeth in her dermoid cyst at the time of her laparoscopic ovarian cystectomy and a novel surgical approach in the extraction of the cyst contents from the abdominal cavity.Summary and ConclusionThe use of an arthroscopic surgical blade to morcellate the mandibular-like bone allowed for completion of the procedure laparoscopically, without laparotomy for specimen extraction, allowing the patient to benefit from the advantages of minimally invasive surgery.     

A Way to Reduce the Occurrence of Intraoperative Capsule Rupture in Presumed Clinically Early-stage Ovarian Cancer with Adhesions to the Abdominal Wall

Study ObjectiveTo present a procedure to reduce the occurrence of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall.DesignStepwise presentation of the procedure with narrated video footage.SettingThe occurrence of intraoperative capsule rupture exerts a negative effect on the prognosis of early-stage ovarian cancer [1,2]. Thus, it is important to reduce intraoperative capsule rupture to improve the oncologic outcome of such patients. In this video we describe a laparoscopic procedure to minimize the risk of intraoperative capsule rupture in presumed clinically early-stage ovarian cancer with adhesions to the abdominal wall. A 52-year-old woman was referred from a local clinic for a 6 × 6 × 4-cm left ovarian mass and a 7 × 6 × 6-cm right ovarian mass. Her serum cancer antigen 125 level was 214.4U/mL. Pelvic magnetic resonance imaging and positron emission tomographic/computed tomographic imaging showed no evidence of metastatic diseases or lymph node involvement. A diagnosis of ovarian malignancy was suspected.InterventionsLaparoscopic evaluation suggested that the right adnexa was adhered to the right abdominal wall and there was no evidence of tumor seeding in the peritoneal cavity. We collected the peritoneal lavage fluid. Since pelvic adhesiolysis between the right adnexa and the abdominal wall may increase the occurrence of intraoperative capsule rupture of the ovarian tumor, leading to a worse clinical outcome, we decided to remove both the right adnexa as well as the adhered peritoneum. The key steps of the procedure are summarized as follows. First, the utero-ovarian ligament and tubal isthmus were coagulated and excised. Second, the pelvic peritoneum was excised, and the infundibulo-pelvic ligament and ureter were identified and mobilized. Third, the infundibulo-pelvic ligament was coagulated and excised. Fourth, the pelvic peritoneum which was adhered to the right adnexa was dissected off the ureter and excised. Then, the resected right adnexa as well as the adhered peritoneum were collected in a disposable pocket and removed to avoid further contamination. Adenocarcinoma was diagnosed by frozen section evaluation. So, surgical staging was performed laparoscopically, and consisted of hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymph node dissection, omentectomy, and random peritoneal biopsies from the pelvis, paracolic gutters, and undersurfaces of the diaphragm. Final pathologic reports showed ovarian clear cell carcinoma with involvement of both ovaries and the adhered peritoneum.ConclusionOur method is effective for intact removal of the involved adnexa without rupture and the adhered pelvic peritoneum with potential for tumor seeding.     

Laparoscopic Resection of Endometriosis in a Patient with a Ventriculoperitoneal Shunt Using the LapDisc

The surgical approach in a patient with a ventriculoperitoneal shunt in need of abdominal surgery remains controversial. The risk of increased intracranial pressure with pneumoperitoneum in laparoscopy is still unresolved. We used the LapDisc (Ethicon, Inc., Somerville, New Jersey) to access the shunt and temporarily seal it, which enabled us to perform laparoscopic resection of endometriosis without subjecting the shunt to high intraabdominal pressure. The benefits of this approach are the ability to perform laparoscopy, less skin-to-shunt contact minimizing infection, and elimination of possible increased intracranial pressure secondary to pneumoperitoneum.With the progress made in the management of hydrocephalus, patients with ventriculoperitoneal (VP) shunts enjoy a longer lifespan. Therefore, the gynecologic laparoscopic surgeon can expect to treat a patient with a VP shunt in place.     

Avascular Necrosis Following Extensive Chemotherapy and Dexamethasone Treatment in a Patient with Advanced Ovarian Cancer: Case Report and Review of the Literature

Avascular necrosis has long been recognized as a complication of glucorticoid therapy. With the recent recognition of paclitaxel's activity in advanced ovarian cancer, increasing attention has been focused on the concomitant use of corticosteroid premedication and its associated morbidities. This report describes avascular necrosis occurring in a patient receiving chemotherapy with corticosteroid medication for advanced recurrent ovarian cancer.     

Long-Term Follow-Up after Laparoscopic Uterovestibular Anastomosis in Patients with Cervical Atresia and Complete Absence of the Vagina

BackgroundThe surgical treatment of girls with cervical atresia and complete absence of the vagina remains a problem because of the rarity of cases and the controversial study results.ObjectiveTo describe the surgical technique and long-term results of laparoscopically assisted uterovestibular anastomosis in patients with cervical atresia and complete absence of the vaginaStudy DesignSixteen consecutive patients with cervical atresia and complete absence of the vagina were conservatively treated with laparoscopically assisted uterovestibular anastomosis in 2 tertiary care referral centers. The follow-up assessments included clinical examination, determination of the presence and quality of sexual intercourse, and vaginoscopy.ResultsAll patients underwent laparoscopically assisted uterovestibular anastomosis. No perioperative complications occurred. The mean follow-up period was 8 ± 3.2 years. In all patients, the length of the neovagina was greater than 4 cm at 1 year after the surgery and approximately 6 cm after 2 years. After the start of sexual intercourse, the neovagina exceeded 7 cm in length in 2 of the 11 sexually active patients. At 12 months after the surgery, iodine-positive epithelium was present in all patients and was maintained over time. The continuity of the neovagina, neocervix, and uterine body was maintained without further interventions in 15 of the 16 patients. During the follow-up, 11 patients were sexually active, 5 were married, 4 were seeking conception, and 2 had spontaneous pregnancy.ConclusionsLaparoscopically assisted uterovestibular anastomosis seems to be a safe and effective treatment for patients with cervical atresia and complete absence of the vagina, at least in terms of the recovery of menstrual function and sexual activity.     

Sexual Function and Quality of Life in Women with Urinary Incontinence Treated by a Complete Pelvic Floor Rehabilitation Program (Biofeedback,Functional Electrical Stimulation,Pelvic Floor Muscles Exercises,and Vaginal Cones)

IntroductionUrinary incontinence (UI) is a debilitating condition that can cause discomfort, embarrassment, loss of confidence; it can lead to withdrawal from social life, and adversely affects physical and mental health, sexual function and quality of life (QoL) in women.AimThe aim is to determine the impact of combined pelvic floor rehabilitation (PFR) on UI, female sexual dysfunction, and QoL.Main Outcome MeasuresFemale Sexual Function Index questionnaire (FSFI) and King's Health Questionnaire (KHQ).MethodsSixteen patients with UI were selected and underwent a complete PFR program (biofeedback, functional electrical stimulation, pelvic floor muscles exercises, and vaginal cones). Patient filled out the FSFI questionnaire and the KHQ at the baseline and at follow-up.ResultsAfter PFR none of the patients reported urine leakage during sexual activity. Resolution of incontinence was achieved in 13 (81.25%) women. Only three (18.75%) patients had positive 1-hour pad test after the treatment. There was significant difference between pad test leakage before and after the PFR (P < 0.001).The mean Stamey incontinence score was 1.37 ± 0.5 at the baseline vs. 0.25 ± 0.57 at the follow up (P < 0.001). Before PFR, FSFI total score ranged from 25.8 to 2 (mean 14.65 ± 6.88), after treatment the FSFI total score ranged from 36 to 2 (mean 22.65 ± 9.5) (P < 0.001). The improvement of the scores in the six FSFI domains, 5 months after the conclusion of PFR, was statistically significant (desire, arousal, lubrication, orgasm, satisfaction, and pain). All the nine domains in the KHQ presented a low average score after treatment and the improvements were statistically significant.ConclusionsPFR led to a significant difference in the daily use of pads, 1-hour pad test, and Stamey incontinence scores. The treatment caused an improvement in patient's QoL index and sexual function. Rivalta M, Sighinolfi MC, Micali S, De Stefani S, and Bianchi G. Sexual function and quality of life in women with urinary incontinence treated by a complete pelvic floor rehabilitation program (biofeedback, functional electrical stimulation, pelvic floor muscles exercises, and vaginal cones).     

受侵肠段切除与联合化疗治疗卵巢癌肠转移62例分析

１９８３年３月至１９９６年２月间，在施行肿瘤细胞减灭术中，为６２在转移瘤侵犯深肌层或侵透肠腔的卵巢部做了胺侵肠段切除术。包括上皮性癌５５例，恶性生殖细胞瘤４例，性索间质瘤３例。其中Ⅱ期１例，Ⅲ期３９例，Ⅳ期２例，复发癌２０例。术式主要为小肠部分切除，结肠部分切险及乙状结肠直肠部分切除术。     

Is the Decision for Colorectal Resection Justified by Histopathologic Findings: A Prospective Study of 100 Patients with Advanced Ovarian Cancer

Objective. We compare the indication for colorectal resection in patients with advanced ovarian cancer with histopathologic findings. We describe the effect on pelvic control and morbidity associated with surgery.Methods. Between February 1995 and March 2001, 100 patients with FIGO stage IIIc ovarian cancer underwent pelvic en bloc resection with excision of the rectosigmoid colon as part of primary or secondary cytoreductive surgery. Decision for resection was made by the surgeon when tumor involvement of the cul-de-sac was suspected. Rectosigmoid infiltration was histopathologically defined as infiltration of the serosa or deeper.Results. In 73 of 100 patients (73%) tumor involvement of the rectum was confirmed histopathologically: infiltration of the serosa in 28 (28%) patients, infiltration of the muscularis in 31 (31%) patients, and infiltration of the mucosa in 14 (14%) patients; in 27 (27%) patients no infiltration was found. Histopathologically confirmed pelvic R0 resection was achieved in 85 (85%) patients. In 11 (11%) patients the pelvic resection margins were tumor-involved and in four (4%) patients visible parametric tumor remained in situ. Pelvic recurrence occurred in 4 (4.7%) of 85 optimally debulked patients compared with 9 (60%) of 15 patients with suboptimal pelvic resection status (P < 0.05). End colostomy could be prevented in 94 (94%) of 100 patients.Conclusion. Pelvic en bloc surgery with rectosigmoid resection was justified by histopathologic outcome since deperitonealization with preservation of the rectosigmoid would have left tumor in situ in 73% of patients with suspected cul-de-sac involvement.     

Outcomes after Fertility-sparing Surgery for Women with Ovarian Cancer: A Systematic Review of the Literature

ObjectiveTo compare reproductive and oncologic outcomes of patients diagnosed with early-stage epithelial ovarian carcinoma, borderline ovarian tumors, or nonepithelial ovarian carcinoma according to receipt of fertility-sparing surgery or conventional surgery.Data SourcesPubMed was searched from January 1, 1995, to May 29, 2020.Methods of Study SelectionStudies were included if they (1) enrolled women of childbearing age diagnosed with ovarian cancer between the ages of 18 years and 50 years, (2) reported on oncologic and/or reproductive outcomes after fertility-sparing surgery for ovarian cancer, and (3) included at least 20 patients.Tabulation, Integration, and ResultsThe initial search identified 995 studies. After duplicates were removed, we abstracted 980 unique citations. Of those screened, 167 publications were identified as potentially relevant, and evaluated for inclusion and exclusion criteria. The final review included 44 studies in epithelial ovarian cancer, 42 in borderline ovarian tumors, and 31 in nonepithelial ovarian carcinoma. The narrative synthesis demonstrated that overall survival does not seem to be compromised in patients undergoing fertility-sparing surgery compared with those undergoing conventional surgery, although long-term data are limited. Areas of controversy include safety of fertility-sparing surgery in the setting of high-risk factors (stage IC, grade 3, and clear cell histology), as well as type of surgery (salpingo-oophorectomy vs cystectomy). It seems that although there may be some fertility compromise after surgery, pregnancy and live-birth rates are encouraging.ConclusionFertility-sparing surgery is safe and feasible in women with early-stage low-risk ovarian cancer. Pregnancy outcomes for these patients also seem to be similar to those of the general population.