Robotic radical parametrectomy in cervical cancer

Radical parametrectomy is indicated in cases of undiagnosed early-stage invasive cervical carcinoma discovered after simple hysterectomy performed for a presumed benign disease process. This radical surgical procedure is rarely performed for benign disease; however, there are some benign conditions such as endometriosis or ovarian remnant syndrome which may require wide excision, including parametria. Traditionally, radical parametrectomy has been performed via laparotomy; however, a minimally invasive approach via laparoscopy has been reported to be feasible and safe. Here we describe the robotic surgical approach to radical parametrectomy.     

Total laparoscopic radical parametrectomy, partial colpectomy, and pelvic lymphadenectomy in patients with occult cervical cancer

Objective

To assess total laparoscopic radical parametrectomy (TLRP) with pelvic lymphadenectomy and partial colpectomy as a safe and feasible treatment option for patients with occult cervical cancer.

Methods

Twelve patients with occult invasive cervical cancer underwent TLRP after prior extrafascial hysterectomy.

Results

No intraoperative complications occurred. Two patients experienced postoperative complications: an iliac lymphocyst with pyelectasis, and a vaginal evisceration that occurred during sexual intercourse. Nine patients required no further treatment. One patient with residual disease received brachytherapy as adjuvant treatment. Two patients with positive nodes not detected at preoperative work-up received adjuvant concomitant radiochemotherapy.

Conclusion

TLRP with pelvic lymphadenectomy is a safe and feasible treatment in patients with occult invasive cervical cancer discovered after extrafascial hysterectomy.     

Laparoscopic radical hysterectomy with pelvic lymphadenectomy in early invasive cervical cancer

Laparoscopic radical hysterectomy is one surgical procedure currently performed to treat gynecologic cancer. The objective of this review was to update the current knowledge of laparoscopic radical hysterectomy in early invasive cervical cancer. Articles indexed in the MEDLINE database using the key words "Laparoscopic radical hysterectomy" and "Cancer of the cervix" were reviewed. Studies of laparoscopic radical hysterectomy for treatment of early cervical cancer with a minimum study population of 10 patients were selected. The laparoscopic approach was associated with less surgical morbidity (surgical bleeding) and with shorter length of hospital stay, although the duration of the operation may be longer. Laparoscopic radical hysterectomy with endoscopic pelvic lymphadenectomy, and paraaortic lymphadenectomy if needed, is a safe surgical option for treatment and staging of early invasive cervical cancer considering surgical risk, intraoperative bleeding, intraoperative and postoperative complications, and patient recovery. It is important to respect the learning curve. Surgical advances including new laparoscopic instrumentation and, in particular, use of robotics will contribute to reducing the duration of the operation and to facilitating learning and teaching of the procedure.     

Robotic radical parametrectomy for unstaged invasive endometrial carcinoma

A 51-year-old woman underwent total laparoscopic hysterectomy for complex hyperplasia; however, final postoperative pathology revealed a deeply invasive high-grade adenocarcinoma. The patient was, therefore, unstaged. Forty-five days later, she underwent robot-assisted radical parametrectomy, upper vaginectomy, and bilateral salpingo-oophorectomy with pelvic and para-aortic lymph node dissection.     

Total laparoscopic radical hysterectomy (type II-III) with pelvic lymphadenectomy in early invasive cervical cancer

STUDY OBJECTIVE: To describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy in early cervical cancer. DESIGN: Retrospective, nonrandomized study (Canadian Task Force classification II-2). SETTING: Acute-care, teaching hospital. PATIENTS: Twenty-seven nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 (n = 4) or IB1 (n = 23) cancer of the cervix. INTERVENTION: Laparoscopic type II (n = 9) or type III (n = 18) hysterectomy with systematic bilateral pelvic lymphadenectomy. Monopolar coagulation, vascular clips, and harmonic scalpel were used. Resection of the cardinal and uterosacral ligaments was performed with Endo GIA stapling and the harmonic scalpel. MEASUREMENTS AND MAIN RESULTS: Histopathologically, there were 20 cases of squamous carcinoma, 6 adenocarcinomas, and 1 adenosquamous carcinoma. The operation was performed entirely by laparoscopy in 26 patients. One patient underwent laparotomy because of equipment failure. The patients' mean age was 45.1 years (95% CI 41.7-48.4), with a median body mass index of 26.0 kg/m2. The mean number of resected pelvic nodes was 19.1 (95% CI 17.02-21.2). Three patients had microscopic metastatic nodal disease. The surgical margins were free of disease in all cases. The median blood loss was 400 mL (range 250-700 mL). The median length of stay was 5 days. Major intraoperative complications did not occur. All patients are free of disease after a median follow-up of 32 months (range 4-52 months). CONCLUSION: Radical hysterectomy can be successfully completed by laparoscopy in patients with early cervical cancer. This procedure may reduce the morbidity associated with abdominal or transvaginal radical hysterectomy.     

Twelve-year experience with laparoscopic radical hysterectomy and pelvic lymphadenectomy in cervical cancer

Objectives

This study aims to evaluate the morbidity, oncological outcome, and prognostic factors of cervical cancer patients treated with laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH).

Methods

Patients with cervical cancer undergoing LRH at the First People's Hospital of Foshan between August 1998 and March 2010 were enrolled in this study. The medical records were reviewed.

Results

A total of 240 patients were identified. According to FIGO stage, the number of patients with stage Ia2, Ib1, Ib2, IIa, and IIb was 2, 163, 34, 35, and 6, respectively. The conversion rate was 1.25%. Intraoperative and postoperative complications occurred in 7.08% and 9.16% patients, respectively. Other medical problems included 74 cases (30%) of bladder dysfunction. Excluding the lost cases, the median follow-up of 221 cases was 35 months, and 5-year survival rate for Ia2, Ib1, Ib2, IIa was 100%, 82%, 66%, 60%, respectively. Univariate analysis showed factors impacting the survival rate were FIGO stage > Ib1, non-squamous histologic type, deep cervical stromal invasion, and lymph node metastasis (P = 0.027, 0.023, 0.007, 0.000). The Cox-proportional hazards regression analysis indicated that only lymph node metastasis (OR = 3.827, P = 0.000) was independent of poor prognostic factor. The 5-year survival rates in Ib1 were 88% with negative lymph nodes and 59% with positive lymph nodes (P = 0.000).

Conclusions

Our data demonstrate that LRH can be performed in stage Ia2-Ib1 or less advanced node negative cervical cancer patients without compromising survival. The feasibility of LRH for more advanced patients needs further investigations.     

子宫颈癌患者腹腔镜下广泛子宫切除术联合淋巴结切除术的临床效果评估

目的 评估腹腔镜下广泛子宫切除术联合盆腹腔淋巴结切除术用于治疗子宫颈癌的临床效果。方法 对57例Ⅰa～Ⅱb期的子宫颈癌患者,施行腹腔镜下广泛子宫切除术联合盆腔及腹主动脉周围淋巴结切除术。其中子宫颈鳞状细胞癌48例,腺癌7例,腺鳞癌2例。结果 除2例外,所有患者均在腹腔镜下完成手术,平均手术时间为186min(150～320min),术中平均出血168ml(120～700ml),切除盆腔和腹主动脉周围淋巴结数量平均为18．6个和8．2个;8例患者淋巴结为阳性。所有切除组织边缘大体检查均为阴性。术中2例膀胱损伤、1例静脉损伤,均于镜下修补成功;2例中转开腹。术后肛门排气时间平均为2．3d,恢复自主排尿时间平均为10．2d。手术后每3个月随访1次,发现轻度输尿管狭窄1例,尿潴留2例,阴道残端复发3例,病情未控1例。结论 腹腔镜下广泛子宫切除术联合盆腹腔淋巴结切除术j治疗子宫颈癌手术创伤小、并发症少、术后恢复快,是一种治疗子宫颈癌的理想方法。     

Pelvic node removal and disease-free survival in cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy

ObjectiveTo examine the relationship between the number of pelvic nodes removed and 5-year disease-free survival in early-stage cervical cancer patients who underwent radical hysterectomy and pelvic lymphadenectomy (RHPL).MethodsThe medical records of 826 cervical cancer patients who underwent RHPL and who had at least 11 pelvic nodes removed at Chiang Mai University Hospital between January 2002 and December 2008 were reviewed. The patients were divided into 4 groups according to the number of nodes removed: 11–20 nodes (n = 243); 21–30 nodes (n = 344); 31–40 nodes (n = 171); and ≥ 41 nodes (n = 68). The 5-year disease-free survival of patients in each group was compared. The clinicopathological factors were analyzed using Cox regression to identify independent prognostic factors.ResultFive-year disease-free survival was not significantly different among the 4 groups. When patients with and without nodal involvement were considered separately, the 5-year disease-free survival in all groups was not significantly different. At multivariate analysis, the number of pelvic nodes removed was not an independent prognostic factor.ConclusionThe number of pelvic nodes removed was not associated with 5-year disease-free survival or number of positive pelvic nodes.     

Fertility-sparing robotic-assisted radical trachelectomy and bilateral pelvic lymphadenectomy in early-stage cervical cancer

A combined pelvic lymphadenectomy with radical vaginal trachelectomy is an alternative to radical hysterectomy in the treatment of young women with cervical cancer desiring fertility preservation. This technique requires advanced vaginal surgery skills not commonly acquired. In an attempt to simplify the procedure we preformed what we believe to be the first case of robotic-assisted radical trachelectomy. A 30-year-old woman, gravida 1, para 1, desiring fertility preservation was given the diagnosis of invasive adenocarcinoma on cervical cone excision. The patient was treated with robotic-assisted pelvic lymphadenectomy and radical trachelectomy. We hope robotic-assisted radical trachelectomy will become an option for select women with early-stage cervical cancer who desire fertility preservation.     

Laparoscopic radical parametrectomy and pelvic and aortic lymphadenectomy for vaginal carcinoma: A case report

OBJECTIVE: The objective of this study was to examine the feasibility of laparoscopic radical parametrectomy after previous hysterectomy. METHODS: This was a prospective study of a patient with vaginal adenocarcinoma after previous simple hysterectomy. The technique of radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy as used for open cases for years was performed laparoscopically. RESULTS: The operating time was 270 min, the estimated blood loss was 200 mL, and the duration of hospitalization was 3 days. There were no intraoperative or postoperative complications. CONCLUSIONS: Radical parametrectomy with vaginectomy and pelvic and aortic lymphadenectomy can be successfully accomplished laparoscopically.     

Three classes of pelvic and aortic lymphadenectomy in patients with cervical cancer

Currently, the extent of pelvic and aortic lymphadenectomy is currently described by numerous and ambiguous terms. The aim of this study is to present a classification of pelvic and aortic lymphadenectomy in cervical cancer patients. On the base of the data from the literature, pelvic and aortic lymphadenectomies have been assigned to three different classes, depending on surgical technique, the extent of the lymphadenectomy and the specificity of the removed lymph node groups. Class I equals removal of selected lymph nodes; Class II: removal of lymph nodes situated ventrally and laterally to large extraperitoneal vessels and the obturator nerve and of lymph nodes situated ventrally and laterally to the aorta and vena cava; Class III: total removal of lymphatic tissue around the iliac vessels and from the obturator fossa dorsally to the obturator nerve and from the presacral region and lymphatic tissue around the aorta and vena cava. The presented classification allows for a unequivocal assessment of pelvic and aortic lymphadenectomy.     

Robotic single-site pelvic lymphadenectomy

Objective

: To examine the feasibility of performing pelvic lymphadenectomy with robotic single site approach. Recent papers described the feasibility of robotic-single site hysterectomy [,  and ] for benign and malign pathologies but only with the development of new single site 5 mm instruments as the bipolar forceps, robotic single site platform can be safely utilized also for lymphadenectomy.

Methods

: A 65 year-old, multiparous patient with a body mass index of 22.5 and diagnosed with well differentiated adenocarcinoma of the endometrium underwent a robotic single-site peritoneal washing, total hysterectomy, bilateral adnexectomy and pelvic lymphadenectomy. The procedure was performed using the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA) through a single 2,5 cm umbilical incision, with a multi-channel system and two single site robotic 5 mm instruments. A 3-dimensional, HD 8.5 mm endoscope and a 5 mm accessory instrument were also utilized.

Results

: Type I lymphonodes dissection for external iliac and obturator regions was performed [4]. Total operative time was 210 min; incision, trocar placement and docking time occurring in 12 min. Total console time was 183 min, estimated blood loss was 50 ml, no intra-operative or post-operative complications occurred. Hospital discharge occurred on post operative day 2 and total number of lymphnodes removed was 33. Difficulties in term of instrument's clashing and awkward motions have been encountered.

Conclusion

: Robotic single-site pelvic lymphadenectomy using bipolar forceps and monopolar hook is feasible. New developments are needed to improve surgical ergonomics and additional studies should be performed to explore possible benefits of this procedure.     

Prognostic factors in node-positive patients with stage IB-IIB cervical cancer treated by radical hysterectomy and pelvic lymphadenectomy.

OBJECTIVE: The purpose of the present study was to identify prognostic factors in surgically treated patients with stage IB-IIB cervical cancers, who also presented with positive pelvic nodes. METHOD: The patient population consisted of 68 individuals presenting with stage IB-IIB cervical cancers and with histologically proven pelvic lymph nodes. RESULT: We found no association between the type of adjuvant therapy and patient outcome. Multivariate analysis revealed that non-squamous histology was an independent prognostic factor for disease-free and overall survival rates. In squamous cell carcinomas, the bilateral nature of the positive nodes was found to be a significant factor for disease-free survival rates. In non-squamous cell carcinomas, positive nodes of more than 2 cm in size were found to be a significant factor for disease-free survival rates. CONCLUSION: Non-squamous histology was an independent prognostic factor and chemoradiotherapy did not improve the survival outcomes of the patients in this study population.     

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.     

Laparoscopic radical trachelectomy or parametrectomy and pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma: report of six cases

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.     

Management of symptomatic pelvic lymphocyst after radical pelvic or pelvic and paraaortic lymphadenectomy for cervical and endometrial cancer

Pelvic and paraaortic lymph node dissection, as part of the staging surgery for cervical and endometrial carcinoma, interrupts the afferent lymphatics. The high acceptance by the community of gyn-oncologists was after finding that laparoscopic lymphadenectomy can be performed in the majority of patients and is associated with low complication rate. Incidence of lymphocele formation and incidence of severe complications associated with lymphocele, such as infection, deep venous thrombosis, or urinary tract occlusion, were retrospectively evaluated in the past years (01.2001–01.2007) after surgery. From January 2001 to January 2007, 226 women underwent surgery including pelvic or pelvic and paraaortic lymphadenectomy for primary gynecological pelvic malignancies, of which 68 (30%) patients had cervical cancer and 158 (60%) patients had endometrial cancer; all of them were retrospectively analyzed. Patients with symptoms such as pain in the pelvic area, lymphedema, or suspicious cyst in the pelvis were sent to our clinic for further evaluation. The identification was made by physical examination and confirmed by US or CT. Twenty three out of 226 (10.2%) patients were diagnosed to have symptomatic pelvic lymphocyst. Additionally, two of the 23 patients had lymphedema, another two patients had lymphocyst infection, one patient had deep venous thrombosis, and one patient had ureteral stenosis. A partial (ventral) resection of the lymphocyst was performed. Median duration of hospital stay was 12.5 days and median duration of drainage was 10 days. Laparoscopic lymphocyst resection and drainage was successful in 22 patients. In one patient, a re-laparoscopy was necessary because of a recurrent lymphocyst formation 6 months after the operation. The laparoscopic lymphocyst resection is a safe and effective procedure and was applied in all 23 patients successfully.