腹腔镜下腹股沟淋巴清扫术在外阴癌中的应用技巧及可行性

目的探讨外阴癌患者行腹腔镜下腹股沟淋巴清扫术的手术技巧和可行性。方法 2008年8月至2010年5月,对重庆市第三军医大学第一附属医院收治的14例外阴浸润癌患者行腹腔镜下双侧腹股沟淋巴清扫术,观察治疗效果。结果 14例患者均顺利完成腹腔镜下双侧腹股沟淋巴清扫术,手术时间平均105m in(75~120m in),术中出血平均85mL(20~130mL),每侧腹股沟切除淋巴结数平均为5.8个(3~13个),术后住院平均10.4d。所有患者均未发生腹股沟区皮肤坏死。有3例患者4侧腹股沟区发生淋巴囊肿,持续2~4个月自行消失。2例患者3例腹股沟区术后出现腹股沟区皮下感染,经保守治疗痊愈。结论外阴癌患者施行腹腔镜下腹股沟淋巴清扫术安全可行,可有效降低术后并发症,是微创治疗外阴癌的一个有效方法,但其远期疗效有待进一步研究。     

负压引流联合皮内缝合在外阴癌腹股沟淋巴结切除术中的应用

外阴恶性肿瘤占妇科恶性肿瘤中3%～5%,为少见的妇科肿瘤[1],其治疗以手术为主,手术范围根据外阴癌的部位、组织学分类、分级和浸润深度等因素制定个体化的治疗方案,范围逐渐适度减小,争取在创伤和效果之间寻求新的平衡。山东大学附属省立医院采用放置皮下负压引流管结合皮内缝闭切口、不缝合皮下组织的方法,效果良好。     

外阴癌腹股沟前哨淋巴结切除术的研究进展

外阴癌的主要转移方式是淋巴结转移,存在淋巴结转移的患者5年生存率仅有25％～41％,严重影响患者的预后.传统的方式是外阴局部根治性切除术+腹股沟淋巴结清扫术,但是腹股沟淋巴结清扫由于手术范围大、创伤大,同时也带来了较高术后并发症如淋巴水肿、淋巴囊肿和切口延迟愈合等,尤其长期的下肢淋巴水肿,是最严重的长期并发症,影响患者...     

外阴癌腹股沟淋巴结清扫术的研究进展

外阴癌是一种罕见的妇科肿瘤,占女性生殖道原发性恶性肿瘤的5%。外阴癌的治疗强调以手术为主的个体化综合治疗,预后与腹股沟淋巴结转移密切相关。因此,对于有局部转移风险的外阴癌患者,根治性外阴切除术和腹股沟淋巴结清扫术(IFL)是治疗的标准方式。传统开放性腹股沟淋巴结清扫术的术后并发症发生率高,严重影响患者的生活质量。为了减少术后并发症,近几年不断有学者提出腹股沟淋巴结清扫术的改良式,前哨淋巴结活检(SLNB)技术及内镜下腹股沟淋巴结清扫术(VEIL),其中改良式的效果不确定,SLNB和VEIL可降低术后并发症的发生率,但其安全性有待大规模的随机对照试验来证实。     

外阴癌腹股沟淋巴结切除术中两种缝合引流方法的比较研究

目的:探讨外阴癌腹股沟淋巴结切除术中采用可吸收线皮内缝合并丝线间断皮外缝合加固、引流管持续负压引流法处理腹股沟切口的愈合效果.方法:对我院2000年至2010年间收治的26例外阴癌患者行手术治疗,均行腹股沟淋巴结切除.分析比较可吸收线皮内缝合并丝线间断皮外缝合加固、引流管持续负压引流法(A组,16例)和丝线间断皮外缝合、引流条引流法(B组,10例)的腹股沟切口愈合情况.结果:A组伤口愈合不良率18.75％,B组伤口愈合不良率为40.00％,两组比较差异有统计学意义(P＜0.05).A组平均术后住院天数15天,B组25天,两组比较差异有统计学意义(P＜0.01).结论:可吸收线皮内缝合并丝线间断皮外缝合加固、引流管持续负压引流有利于提高腹股沟切口愈合率,减少住院时间.     

外阴癌淋巴结切除适应证和争议

外阴局部广泛切除术+腹股沟淋巴结切除术是目前外阴癌的基本手术方式。FIGO和NCCN指南均推荐FIGOⅠA期可不行腹股沟淋巴结切除术,所有ⅠB期或Ⅱ期患者,应该行腹股沟淋巴结切除术。晚期外阴癌在确定总体治疗方案前,应先明确腹股沟淋巴结状态,再确定后续处理方案。如果术前未发现可疑转移淋巴结,行双侧腹股沟、股淋巴结切除术;术前已明确淋巴结阳性者,建议仅切除肿大的淋巴结,术后给予腹股沟和盆腔放疗,最好避免系统性淋巴结切除术。在有关淋巴结切除的争议中,切除腹股沟、股淋巴结及采用三切口腹股沟横切口技术、保留大隐静脉等被大多数学者认可;但对于靠近中线但不侵犯中线的病灶是否可不切除双侧腹股沟淋巴结及外阴黑色素瘤、前庭大腺癌等少见病理类型的淋巴结切除指征尚有争议。     

外阴恶性肿瘤腹股沟淋巴结转移与预后的关系

目的 探讨腹股沟及盆腔淋巴结转移情况及其对预后的影响。方法 对36％例行腹股沟淋巴结清除术的外阴恶性肿瘤患者进行回顾性分析。结果 腹股沟淋巴结阳性者13例,阳性率36.1％(13/36),5年生存率为15.4％(2/13);腹股沟淋巴结阴性者5年生存率为91.7％(11/12),并且随局部病灶的增大,腹股沟淋巴结转移率明显升高。结论 局部病灶大小及肿瘤病理类型与腹股沟淋巴结转移密切相关,成为影响外阴恶性肿瘤预后的主要因素。     

外阴癌淋巴结转移的有关因素分析

１９６４年至１９９２年收治外阴癌３２７例，其中行外阴扩广泛切除加双腹股沟及双盆腔淋巴结清扫９５例，９５例中４６例（４８．４２％）出现淋巴结转移，对淋巴结转移的有关临床因素和转移部位进行了分析，提示外阴癌淋巴结转移是多因素作用的结果，与原发肿瘤的大小，临床分期，病变部位及病理类型有关，原发肿瘤越大，临床分期越晚，淋巴结转移率越高，本组总的淋巴结转移率为４８．４２％，Ⅱ，Ⅲ，Ⅳ期的淋巴结转移率分别为２     

腹腔镜下淋巴结切除术在妇科恶性肿瘤中的应用

腹膜后淋巴结转移是妇科恶性肿瘤常见的转移途径，治疗前了解有否腹膜后淋巴结转移，有助于准确的分期和治疗方案的制定，同时也是预测预后的一个重要指标。20世纪90年代以来，随着腹腔镜技术和设备的发展、完善，以腹腔镜为代表的微创手术在腹膜后淋巴结切除术中的应用得到了进一步的开展。现将近年来腹腔镜在妇科恶性肿瘤腹膜后淋巴结切除术中的应用情况综述如下。     

Comparison of Perioperative Outcomes and Cost Between Robotic-Assisted and Conventional Laparoscopy for Transperitoneal Infrarenal Para-aortic Lymphadenectomy (TIPAL)

Study ObjectiveTo compare perioperative outcomes and cost of robotic-assisted and laparoscopic transperitoneal infrarenal para-aortic lymphadenectomy (TIPAL) for treatment of gynecologic malignant conditions.DesignProspective non-randomized study (Canadian Task Force classification II-2).SettingTertiary center for women's health.PatientsSixty-two patients with gynecologic cancer operated on by the same surgical team.InterventionsThirty-two patients underwent TIPAL via robotic-assisted laparoscopy, and 30 via conventional laparoscopy. Comparison analyses of perioperative outcomes and estimated costs were performed.Measurements and Main ResultsThere were no differences between robotic-assisted and laparoscopy insofar as age, body mass index, presurgical morbidity, operating time (92.5 minutes for robotics vs 96.6 minutes for laparoscopy), number of aortic nodes (12 vs 12), hospitalization stay (2 vs 2 days), or rate of complications (12.5% vs 13.3%). Blood loss tended to be lower in the robotic group (75.0 vs 92.5 mL; p = .08). Surgical cost was higher in the robotic group ($3.42 vs $2.55; p < .001), although hospitalization cost was similar.ConclusionRobotic-assisted and laparoscopy provide similar perioperative outcomes. However, the robotic-assisted approach is associated with higher surgical cost.     

Vulvar intraepithelial neoplasia (VIN 2/3): Comparing clinical outcomes and evaluating risk factors for recurrence

Objective

To evaluate demographic and clinical characteristics associated with the development of vulvar intraepithelial neoplasia (VIN 2/3), and factors associated with recurrence.

Methods

A retrospective chart review of 303 patients with VIN 2/3 evaluated at a single institution between 1993 and 2011 was performed. Medical records were reviewed for demographic information, risk factors, treatment type, pathologic diagnosis, and recurrence/outcome information.

Results

Median age at diagnosis was 47 years (range 14-87). 40% of patients reported current tobacco use and 26% reported previous use. Primary treatment included excision (n = 176, 59%), laser ablation (n = 40, 13%), imiquimod (n = 22, 7.4%), excision with laser (n = 24, 8.1%), excision with imiquimod (n = 10, 3.4%), and laser with imiquimod (n = 3, 1.0%). 92 patients (62.6%) were noted to have positive margins, which was associated with larger tumor size (p = 0.004). 87 patients (28.7%) developed recurrent disease, which was associated with smoking (p < 0.001), larger lesion size (p = 0.016), and positive margins (p = 0.005). On univariate analysis, higher rates of recurrence were associated with laser ablation (45.0%) compared with excision (26%) or imiquimod (13.6%) (p = 0.018). However, on multivariate analysis of recurrence-free survival (RFS) these therapies were equivalent when used individually, but the use of excision plus laser had an adverse impact on RFS (p < 0.001). 7 patients (2.3%) recurred with invasive disease a median of 109 months (range 12-327) from initial VIN 2/3 diagnosis.

Conclusions

This large cohort of women with VIN 2/3 further delineates the demographic and clinical factors associated with VIN 2/3. High rates of recurrence were noted and found to be associated with smoking, larger lesion size, and positive margins. While higher rates of recurrence were found among those treated with laser ablation, it was not inferior with respect to RFS when used alone, but the use of laser with excision was associated with decreased RFS. Our findings provide hypothesis-generating material for further research in the management of VIN2/3.     

Sentinel Lymph Node Biopsy in Vulvar Cancer: A Health Technology Assessment for the Canadian Health Care Context

ObjectiveInguinofemoral lymphadenectomy for vulvar cancer is associated with a high incidence of groin wound complications and lymphedema. Sentinel lymph node biopsy (SLNB) is a morbidity-reducing alternative to lymphadenectomy. The objective of this health technology assessment was to determine the clinical effectiveness, costeffectiveness, and organizational feasibility of SLNB in the Canadian health care system.MethodsA review of the English-language literature published from January 1992 to October 2011 was performed across five databases and six grey-literature sources. Predetermined eligibility criteria were used to select studies, and results in the clinical, economic, and organizational domains were summarized. Included studies were evaluated for methodologic quality using the Newcastle-Ottawa Scale.ResultsOf 825 reports identified, 88 observational studies met the eligibility criteria. Overall study quality was poor, with a median Newcastle-Ottawa Scale score of 2 out of 9 stars. Across all studies, the detection rate of the sentinel lymph node was 82.2% per groin and the false-negative rate was 6.3%. The groin recurrence rate after negative SLNB was 3.6% compared with 4.3% after negative lymphadenectomy, and complications were reduced after SLNB. No economic evaluations were identified comparing SLNB to lymphadenectomy. Safe implementation of SLNB requires appropriate patient selection, detection technique, and attention to the learning curve.ConclusionAlthough study quality is poor, the available data suggest implementation of SLNB may be safe and feasible in Canadian centres with adequate procedural volumes, assuming that implementation includes careful patient selection, careful technique, and ongoing quality assessment. Cost-effectiveness has yet to be determined.     

Robotic,Laparoscopic, or Open Hysterectomy: Surgical Outcomes by Approach in Endometrial Cancer

Study Objectives

To compare patient outcomes by surgical approach in the management of endometrial cancer (EC) in Washington State from 2008 to 2013.

Para-aortic and Right Obturator Lymphadenectomy for Surgical Staging of Advanced Cervical Cancer through the TU-LESS Extraperitoneal Approach

ObjectiveTo present an innovative transumbilical laparoendoscopic single-site (TU-LESS) extraperitoneal approach for lymphadenectomy in a patient with advanced cervical carcinoma.DesignDemonstration of the novel technique through video.SettingIn advanced cervical cancer, determining the status of the para-aortic lymph nodes is essential because extended-field radiologic therapy is recommended for a patient with positive para-aortic lymph nodes [1]. Nonetheless, the sensitivity and specificity of currently available imaging workup for positive lymph nodes are limited. Surgical staging enables precise evaluation. However, laparotomy has potential wound complications and leads to treatment delay. Multiport laparoscopic transperitoneal and extraperitoneal approaches limit surgeons’ ability to reach the para-aortic area or obturator fossa in the same operation [2]. Thus, we take full use of these approaches’ advantages and avoid their disadvantages to design a promising minimally invasive surgery approach [3].InterventionsPara-aortic and obturator lymphadenectomy through the TU-LESS extraperitoneal approach was successfully performed without complications. The patient recovered quickly and received subsequent concurrent chemoradiation on schedule.ConclusionTU-LESS extraperitoneal para-aortic lymphadenectomy provides satisfactory exposure and easy access to both the para-aortic area and obturator fossa. In addition, the bowels are uplifted by an extraperitoneal air cushion to achieve excellent exposure and reduce the risk of bowel injury. With quick recovery, the patient could start accurate radiation treatment promptly.     

Radical Hysterectomy and Age: Outcomes Comparison Based on a Minimally Invasive vs an Open Approach

Study Objective

To compare outcomes of radical hysterectomy (RH) across age groups based on surgical approach: minimally invasive surgery (MIS) vs laparotomy (LP).

New Retroperitoneal Transvaginal Natural Orifice Transluminal Endoscopic Surgery Approach to Sentinel Node for Endometrial Cancer: A Demonstration Video

Study ObjectiveTo assess whether sentinel node resection for endometrial cancer is feasible via retroperitoneal transvaginal natural orifice transluminal endoscopic surgery (vNOTES) and gives better exposure than transperitoneal vNOTES.DesignThis is a first small IDEAL (Idea Development Exploration Assessment Long-term follow up) stage 1 study to assess the feasibility of a new approach; the technique is explained step-by-step using videos (Video 1) and pictures.SettingThe gynecologic oncology department of a nonuniversity teaching hospital in Belgium.PatientsSince 2015, 15 patients were operated on via vNOTES for endometrial cancer [1].InterventionsOur initial experience showed that a transperitoneal approach via vNOTES [2] provided good access to the cranial pelvic retroperitoneum but not to the caudal pelvic retroperitoneum. Therefore, a new retroperitoneal vNOTES approach via a paracervical incision in the lateral vaginal fornix was developed. Via this incision, the obturator fossa is accessed, and a vNOTES port is placed for endoscopic dissection of the retroperitoneal space. This video article shows this new access route to the pelvic retroperitoneal space.Measurements and Main ResultsOur initial experience with vNOTES for endometrial cancer showed that transperitoneal access to the retroperitoneal space did not give optimal exposure to the caudal parts of the obturator space. The new retroperitoneal vNOTES approach shown in this video article gives better exposure to the entire retroperitoneal space including the caudal part of the obturator space; the sacral plexus; the external, internal, and common iliac arteries; and even the lower para-aortic region.ConclusionIt has been previously shown that vNOTES hysterectomy offers patient benefits over total laparoscopic hysterectomy [3]. The retroperitoneal vNOTES approach now also offers good transvaginal access to the entire retroperitoneal space for sentinel node resection. This is a new approach that requires further validation before vNOTES hysterectomy with retroperitoneal sentinel node resection can be used outside study settings for the treatment of endometrial cancer.