Management of early-stage cervical carcinoma by modified (Type II) radical hysterectomy

OBJECTIVE:. Surgical management of cervical carcinoma by radical hysterectomy has been proven a highly effective method in treating early-stage disease. The purpose of this study was to evaluate the efficacy and safety of modified (Type II) radical hysterectomy for the treatment of early-stage (I-IIA) cervical carcinoma. METHODS: A retrospective analysis of data on 435 patients with cervical carcinoma who were managed by modified radical hysterectomy was performed. In 145 cases a multimodal approach was used due to the presence of one or more risk factors such as lymph node metastasis, CLS involvement, bulky tumor, and exocervical extension of disease. Preoperative irradiation was offered to 62 patients, whereas adjuvant irradiation was offered to 101 patients. RESULTS: The mean age of the patients was 42.5 years. The majority of the patients had squamous cell cancer (81.6%). The patients were clinically staged as IA (3.2%), IB (86.7%), and IIA (10.1%). Positive pelvic lymph nodes were noted in 65 patients (14.9%). Operative morbidity was minimal, whereas adjuvant radiation treatment had no impact on the disease but caused genitourinary morbidity in terms of ureteral stricture and postoperative bladder dysfunction (P < 0.001). The overall 5-year survival was 88.7%. The most significant predictors related to 5-year survival were nodal metastasis (P < 0.001), adenomatous histology (P < 0.001), lesion size (P < 0.001), and CLS involvement (P = 0.004). Adjuvant radiation resulted in better local pelvic control of the disease. CONCLUSION: The results of our study support the concept that less radical procedures could be effectively applied to early-stage cervical carcinoma 4 cm or smaller with optimal surgical margins.     

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.     

Sexual dysfunction in Thai women with early-stage cervical cancer after radical hysterectomy

We determined the prevalence of sexual dysfunction in women with early-stage cervical cancer who had undergone radical hysterectomy in three institutions of Thailand. An interview was conducted according to the structured questionnaire composing of seven domains of sexual function: frequency, desire, arousal, lubrication, orgasm, satisfaction, and dyspareunia. From 105 women included in the study, mean age was 45.3 +/- 7.8 years. Seventy-five (71.4%) were in premenopausal period. Eight out of 105 women (7.6%) never resumed their sexual intercourse after radical hysterectomy, 97 women resumed their sexual intercourse during 1-36 months postoperation (median, 4 months). Dyspareunia was increased in approximately 37% of women, while the other six domains of sexual function were decreased, ranging from approximately 40-60%. Of interest, only 10.5% of these cervical cancer women had some information of sexual function from medical or paramedical personnel, 17.1% obtained it from other laymen or public media, and 61.9% had never had it from any resources. Our conclusion is-sexual dysfunction is a common problem after cervical cancer treatment, but it has not been well aware of. These findings may necessitate health care providers to be more considerate on this problem.     

Nerve-sparing class III radical hysterectomy: a modified technique to spare the pelvic autonomic nerves without compromising radicality

The objectives were to describe our nerve-sparing class III radical hysterectomy technique and assess the feasibility and safety of the procedure as well as its impact on voiding function. From January to August 2005, 21 consecutive patients with FIGO stage IB-IIA cervical cancer and 1 patient with clinical stage II endometrial cancer underwent nerve-sparing radical hysterectomy with systematic pelvic lymphadenectomy. The transurethral catheter was removed on the seventh postoperative day. Then intermittent self-catheterization was performed and post-void residual urine volume (PVR) was recorded. The nerve-sparing procedure was completed successfully and safely in all of the patients. Eight (36%) and 6 (27%) patients had the PVR of < 100 ml and < 50 ml respectively at the initial removal of the catheter. On the fourteenth day, 82% and 77% of the patients had the PVR of < 100 ml and < 50 ml, respectively. The mean duration before the PVR became < 50 ml was 11.27 (5-26) days. In conclusion, the technique described in this preliminary study appears safe, adequate, and feasible in our population with satisfactory recovery of voiding function. A larger comparative study is needed on long-term urinary, bowel, and sexual function as well as recurrence and survival.     

Evaluation of the Pfannenstiel incision for radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy

Abstract. Mendez LE, Cantuaria G, Angioli R, Mirhashemi R, Gabriel C, Estape R, Penalver M. Evaluation of the Pfannenstiel incision for radical abdominal hysterectomy with pelvic and para-aortic lymphandenectomy.
Radical abdominal hysterectomy with pelvic and para-aortic lymphadenectomy (RAH/P + PAL) has classically been described through a low midline vertical incision. Transverse incisions have been used with good results for various pelvic surgical procedures. Hesitancy has been encountered when utilizing these transverse incisions in gynecologic oncology patients. In most studies, muscle-splitting transverse incisions seem to be of equal efficacy as midline vertical incisions in regards to surgical exposure and clinicopathologic data obtained and are known to be superior in cosmesis and postoperative morbidity. A retrospective chart review was performed to identify 25 patients who underwent RAH/P + PAL for stage I carcinoma of the cervix from 1990 to 1998 through a nonmuscle splitting (Pfannenstiel) abdominal incision. All patients were seen and had follow-up in the Division of Gynecologic Oncology, University of Miami School of Medicine/Jackson Memorial Medical Center (Miami, FL). Data were collected on various clinical and surgical parameters including height/weight, operative time, blood loss, number of lymph nodes obtained, length of hospital stay, and postoperative complications. Analysis of the data revealed that operative time and average blood loss were within acceptable parameters. The yield at lymphadenectomy for pelvic and para-aortic lymph nodes was also respectable. Postoperative complications were minimal and there were no wound complications reported. Therefore, the Pfannenstiel incision can be safely utilized in a select group of patients undergoing RAH/P + PAL.     

阴式广泛全子宫切除加腹腔镜下淋巴结切除术与开腹手术治疗早期宫颈癌疗效比较

目的探讨阴式广泛全子宫切除加腹腔镜下淋巴结切除术治疗早期宫颈癌的临床价值。方法 2004年11月至2011年4月于佛山市妇幼保健院,回顾性分析行阴式广泛全子宫切除加腹腔镜下淋巴结切除术的90例早期宫颈癌患者(阴式组)的病例资料,抽取同期行开腹广泛全子宫切除加盆腔淋巴结切除术42例(开腹组)作为对照。结果两组手术时间差异无统计学意义(P>0.05)。阴式组术中出血量[(348±114)mL]、肠道功能恢复时间[(36.76±4.9)h]、住院天数[(10.56±2.10)d]均少于开腹组的[(398±127)mL]、[(40.09±6.5)h]、[(11.79±2.45)d],差异有统计学意义(P<0.05)。阴式组切除阴道长度[(3.12±0.17)cm]大于开腹组的[(3.05±0.21)cm](P<0.05)。阴式组尿潴留发生率(30.0%)较开腹组(11.9%)高(P<0.05)。阴式组术后5年内复发率(14.6%)低于开腹组(31.5%)(P<0.05)。结论阴式广泛全子宫切除加腹腔镜下淋巴结切除术式创伤小,术后恢复快,手术彻底,有临床应用价值。     

Ureteric obstruction after radical hysterectomy

Two patients with invasive carcinoma of the cervix treated with radical hysterectomy developed total unilateral ureteric obstruction postoperatively. A temporary percutaneous nephrostomy was inserted. Because both patients needed adjuvant radiotherapy, intended reimplantation of the ureter was postponed. During this period spontaneous passage through the ureter was observed after 5 and 14 weeks, respectively. It is emphasized that a 'wait and see' policy may be justifiable in the case of ureteric obstruction of unclear etiology after radical hysterectomy for at least 3 months, as long as renal function is preserved by percutaneous nephrostomy drainage of the affected kidney side.     

Unilateral or bilateral nerve-sparing radical hysterectomy: a surgical technique to preserve the pelvic autonomic nerves while increasing radicality

We performed unilateral or bilateral nerve-sparing (UNS or BNS) radical hysterectomies combined with a parametrial excision in patients with locally advanced cervical cancer. The parametrial excision technique is characterized by a meticulous sharp dissection of the avascular plane outside the visceral fascia of the uterus and vagina under direct vision, providing an en bloc parametria and ensuring that all regional spread of the disease is contained within negative surgical margins. The aim of this study was to describe this surgical technique and to retrospectively evaluate the feasibility and the impact on early bladder function. From February 2005 to November 2006, 32 patients with FIGO stage IB-IIB cervical cancer, who had the tumor of more than 20 mm in diameter, underwent the UNS surgery or BNS surgery. A parametrial excision was performed in all the patients. The surgical procedure was safely completed in all the patients. Though 14 patients had tumor invasion to the parametria, none of the patients had a positive surgical margin in the parametrium. The bladder function of patients in the UNS group immediately after surgery was more damaged than that in the BNS group. However, all the patients in both groups recovered spontaneous voiding with no need of self-catheterization during the perioperative periods. This preliminary study showed that the surgical technique is feasible and safe. For confirmation of the efficacy of this technique, further large prospective studies are needed.     

保留盆腔神经的广泛性子宫切除术治疗宫颈癌疗效及安全性荟萃分析

目的 评价保留盆腔自主神经的广泛性子宫切除术(nerve-sparing radical hysterectomy,NSRH)治疗宫颈癌的临床疗效和安全性。方法 检索大型数据库中近11年发表的关于NSRH与传统广泛性子宫切除术(radical hysterectomy,RH)临床疗效比较的前瞻性同期对照试验。并按Cochrane系统评价方法提取有效数据进行Meta分析。结果 NSRH与RH相比,其术后留置尿管时间[加权均数差（weighted mean difference,WMD）=－6.73,95%可信区间（CI）－7.39~－6.06]、残余尿量<50 mL时间(WMD=－7.80,95%CI－11.93~－3.67)、首次排气时间(WMD =－12.05,95%CI －15.87~－8.24)、首次排便时间(WMD =－24.99,95%CI －26.87 ~－23.11)、住院天数(WMD =－4.00,95%CI －4.60 ~－3.40)均明显减少,宫旁切除长度明显减小(WMD =－0.10,95%CI －0.15 ~－0.06),手术总时间延长(WMD =30.74,95%CI 16.66~44.82);而在淋巴结活检数、术中出血量、术后总体复发率等方面比较差异无统计学意义。结论 NSRH治疗早期宫颈癌具备安全性和可行性,在缩短膀胱功能恢复时间、肠道功能恢复时间及住院时间等方面有一定优势。     

The impact of intraoperative autologous blood transfusion during type III radical hysterectomy for early-stage cervical cancer

Objective: The aim of this study was to determine the effects on transfusion rates, perioperative complications, and survival of using intraoperative autologous blood transfusions for patients undergoing type III radical hysterectomy and lymphadenectomy. Study Design: A retrospective analysis was conducted on 156 patients treated with type III radical hysterectomy and lymphadenectomy at the University of Miami School of Medicine from 1990 to 1997. One group of patients (n = 50) had intraoperative autologous blood transfusions and the other (n = 106) did not. Results: The group that received intraoperative autologous blood transfusion had a significant reduction in homologous blood transfusions (12% vs 30%; P = .02). Patient demographic data, histologic parameters, and operative factors were similar between the 2 groups. There was a higher percentage of patients with positive pelvic lymph nodes in the group that did not receive intraoperative autologous blood transfusion (10% vs 30%; P = .02). Seven patients in the intraoperative autologous blood transfusion group (14%) died with disease present and all the recurrences in this group were local. Conclusion: The use of intraoperative autologous blood transfusions during type III radical hysterectomy and lymphadenectomy appears to be safe and effective without compromising rates and patterns of recurrence. (Am J Obstet Gynecol 1999;181:1310-6.)     

Do the pelvic lymph nodes predict the parametrial status in cervical cancer stages IB–IIA?

The aim of this study was to determine whether the pelvic lymph nodes would predict the parametrial status in patients with cervical cancer stages IB1-IIA submitted to radical surgery and pelvic lymphadenectomy. To this end, we evaluated the relationship between positive and negative pelvic lymph nodes and their parametria. Our final purpose was to use this information to recommend the tailoring of the parametrial resection according to the status of pelvic lymph nodes to decrease the morbidity related with radical paratrectomy. From January 1996 to December 2001, 107 consecutive patients with cervical cancer stages IB1 and IIA were primarily treated by radical hysterectomy type III with systematic pelvic lymphadenectomy in a prospective study. Parametria were studied in two sections: the first included the tissue adjacent to the cervix, and the second the distal 2/3. Lymph nodes were routinary processed. Twenty-two patients (20.6%) had positive pelvic nodes and 16 patients (14.9%) had parametrial involvement, mostly by direct extension. Eight patients with positive pelvic nodes (36.4%) had parametrial involvement, whereas among 85 patients with negative pelvic nodes only eight patients (9.4%) had parametrial involvement (P < 0.001), most in internal parametria (62.5%). The sensitivity of pelvic lymph nodes for parametrial involvement was 50% and the positive predictive value was 36.4%, whereas the specificity was 84.6%; and the negative predictive value 90.6%. In the group of negative pelvic lymph nodes, only two patients (2.3%) had parametrial involvement beyond internal parametria. The univariated and multivariated analysis of prognostic factors was always significant but without a significant independent factor for positive parametria. Pelvic lymph nodes appear as good predictors of parametrial status, especially in node-negative patients, and could be used to decrease the paratrectomy in radical surgery.     

宫颈癌根治术中腹膜代阴道临床分析

目的　探讨宫颈癌根治术中腹膜代阴道的临床价值。方法　前瞻性分析 15例Ⅰb～Ⅱa期病例 ,行广泛性子宫全切术同时行腹膜代阴道。取同期对照组 2 0例 ,未行腹膜代阴道。结果　此手术形成的阴道具有宽敞、光滑、湿润、弹性好等与正常阴道类似的生理功能 ,性生活满意。结论　年轻患者宫颈癌根治术中腹膜代阴道能有效地提高生活质量 ,值得临床推广。     

耻骨上膀胱造瘘术在宫颈癌根治术中的应用

目的探讨耻骨上膀胱造瘘术在宫颈癌根治术中的应用价值。方法采用回顾性对比分析耻骨上膀胱造瘘术和经尿道口留置尿管两种方法对宫颈癌患者术后膀胱功能恢复、尿道感染率和平均住院时间的影响,评价耻骨上膀胱造瘘术在宫颈癌根治术中的应用价值。结果 99例宫颈癌根治术患者,56例采用耻骨上膀胱造瘘术,与43例留置尿管组比较,其膀胱功能恢复时间无明显差异(16.7d和18.4d,P0.05),但尿道感染率明显降低(16.7%和31.8%,P0.01),住院时间明显缩短(18.1d和25.2d,P0.05),可减轻患者的经济负担。结论在宫颈癌根治术中应用耻骨上膀胱造瘘术安全可行,具有良好的临床应用前景。     

Class III vs class II radical hysterectomy in stage IB cervical carcinoma: a comparison of morbidity and survival

The classical Piver III and a modified class II radical hysterectomy were applied in stage IB patients with cervical cancer and were compared as to morbidity and disease-free survival (DFS). Class III was performed in a group of 68 cases and class II in 50. The mean observation period was 31 and 69 months respectively. Most of the prognostic factors (age, histology, grade, bulky tumors, lymph node (LN) metastases) were comparable in the two groups. Postoperative irradiation was given to 31% and 64% of the type III and II hysterectomy group respecitvely ( P <0.05). Perioperative morbidity (mean operative time, blood units transfused, febrile cases and hospital stay) was quite similar. Major complications (mainly voiding problems) were significantly more frequent in class III operation. However, DFS was higher (86.5% vs 76.5%, P <0.05) after class III hysterectomy. These data indicate that class III operation is a more morbid procedure but appears to be advantageous regarding survival. In order to reduce morbidity without compromising therapeutic results (tailoring the radicality), a better insight in the prognostic factors is necessary.     

Outcomes of abandoned radical hysterectomy in patients with stages IB–IIA cervical cancer found to have positive nodes during the operation

The objective of this study was to evaluate the outcomes of stages IB-IIA cervical cancer patients whose radical hysterectomy (RH) was abandoned for positive pelvic nodes detected during the operation compared with those found to have positive nodes after the operation. Among 242 patients with planned RH and pelvic lymphadenectomy (RHPL) for stages IB-IIA cervical cancer, 23 (9.5%) had grossly positive nodes. RH was abandoned, and complete pelvic lymphadenectomy was performed. Of these 23 patients, 22 received adjuvant chemoradiation, and the remaining 1 received adjuvant radiation. Four patients with positive para-aortic nodes were additionally treated with extended-field irradiation. When compared with 35 patients whose positive nodes were detected after the operation, there were significant differences regarding number of positive nodes and number of patients receiving extended-field irradiation. Complications in both groups were not significantly different, but the 2-year disease-free survival was significantly lower in the abandoned RH group compared with that of the RHPL group (58.5% versus 93.5%, P= 0.01). In conclusion, the survival of stages IB-IIA cervical cancer patients whose RH was abandoned for grossly positive pelvic nodes was significantly worse than that of patients whose node metastasis was identified after the operation. This is because the abandoned RH group had worse prognostic factors.