Radical vaginal hysterectomy with extraperitoneal pelvic lymphadenectomy in cervical cancer

OBJECTIVE: The aim of this work was to examine three types of radical vaginal hysterectomy with different degrees of radicality, performed in order to reduce surgical complications and sequelae in different indications, and to test the feasibility of a new simple and quick technique for extraperitoneal pelvic lymphadenectomy to be used in combination with radical vaginal hysterectomy for treatment of cervical cancer. In this way the advantages of vaginal surgery (e.g.: unnecessary general anaesthesia, reduced surgical trauma, applicability to obese and poor surgical risk patients, fast time-saving procedure) can be preserved. METHODS: We compared retrospectively the long-term results of radical vaginal and radical abdominal operations in a large series of stage IB-IIA cervical cancer patients treated at our institution in Florence from 1968 to 1983. Furthermore, we analysed the results of our experience from 1995 to 1998, when we performed extraperitoneal pelvic lymphadenectomy, followed by radical vaginal hysterectomy, on 48 patients affected by cervical cancer. Extraperitoneal pelvic lymphadenectomy was performed through two small abdominal incisions (6-7 cm). Twenty-two patients (45%) were obese (BMI>30 kg/m2) and 20 were poor surgical risks. FIGO stage was: IB1 in 18 cases, IB2 in eight, IIA in six, IIB in 12, IIIB in four. Neoadjuvant chemotherapy was given in 12 cases and preoperative irradiation was given in ten. General and regional anaesthesia were used in 30 (62.5%) and in 18 (37.5%) cases, respectively. RESULTS: As for past experience, in stage IB the five-year survival of 356 patients who underwent radical vaginal hysterectomy and that of 288 who had radical abdominal hysterectomy with pelvic lymphadenectomy were 81% and 75%, respectively (p<0.05). Surgical complications were fewer with no mortality in the first group. In stage IIA, survival rates were 68% for radical vaginal hysterectomy and 64% for radical abdominal hysterectomy, in 76 and 64 cases, respectively (p=n.s.). As for the more recent experience, median operative time for extraperitoneal pelvic lymphadenectomy was 20 minutes for each side (range 15-36). In each patient a median of 26 lymph nodes were removed (range 16-48). Positive nodes were found in 12 cases (25%). Median operative time for radical vaginal hysterectomy was 40 minutes (range 30-65). Extraperitoneal pelvic lymphadenectomy complications included: lymphocyst, five cases (10%) and retroperitoneal hematoma, one (2%); all occurred at the beginning of the experience. Radical vaginal hysterectomy complications included: ureteral stenosis, one (2%) and uretero-vaginal fistula, one (2%). All complications occurred in patients who received radiotherapy or chemotherapy preoperatively. Median hospital stay was ten days (range 6-20). CONCLUSIONS: The results of our work demonstrate that our technique for extraperitoneal pelvic lymphadenectomy shows a good applicability to cervical cancer patients submitted to radical vaginal hysterectomy, which has a high rate of cure for stage IB and IIA as shown by our past experience. The procedure of extraperitoneal pelvic lymphadenectomy was quick, easy, and safe, and its realization was not detrimental to the advantages of radical vaginal hysterectomy. Our experience supports the continued use of this combined extraperitoneal and vaginal approach in the treatment of cervical cancer. Moreover, the three classes of radical vaginal hysterectomy allow tailoring the type of the operation to the clinical and physical characteristics of the patients.     

非脱垂子宫阴式子宫全切除术的适应证和禁忌证探讨

目的探讨非脱垂子宫阴式子宫全切除术(TVH)的适应证和禁忌证。方法回顾性分析我院1992年6月至2003年6月间2086例非脱垂子宫TVH的临床资料,按子宫体积、既往有无盆腹腔手术史、有无阴道分娩史、是否同时处理附件等分别进行统计,比较手术并发症的发生情况。结果(1)不同体积子宫比较:子宫体积>16孕周患者的非脱垂子宫TVH手术时间、术中出血量及术后盆腔感染率分别为(73±25)min、(237±86)ml、1.69%(7/413);子宫体积≤16孕周患者的非脱垂子宫TVH手术时间、术中出血量及术后盆腔感染率分别为(42±16)min、(101±58)ml、0.78%(13/1673),不同体积子宫上述各项指标比较,差异有统计学意义(P<0.01)。(2)既往有无盆腹腔手术史比较:既往有无盆腹腔手术史患者的非脱垂子宫TVH手术时间和术中出血量比较,差异无统计学意义(P>0.05),但有盆腹腔手术史患者非脱垂子宫TVH的术中并发症发生率升高;(3)有无阴道分娩史患者非脱垂子宫TVH的手术时间和术中出血量比较,差异也无统计学意义(P>0.05);119例合并卵巢囊肿患者均成功行非脱垂子宫TVH。结论子宫体积≤16孕周患者的非脱垂子宫TVH是安全、可行的,子宫体积>16孕周患者的非脱垂子宫TVH手术难度较大,是否行TVH,需根据术者的经验及患者的情况进行选择;既往有盆腹腔手术史,可增加非脱垂子宫TVH并发症的发生率;对于子宫体积≤16孕周的患者,有无阴道分娩史均不影响TVH的成功率;TVH同时处理直径≤6cm的卵巢单纯性囊肿是可行的。     

Analysis of survival after laparoscopic-assisted vaginal hysterectomy compared with the conventional abdominal approach for early-stage endometrial carcinoma: a review of the literature

STUDY OBJECTIVE: To assess potential differences in perioperative features and survival between laparoscopic-assisted vaginal hysterectomy and conventional transabdominal hysterectomy in stage I endometrial cancer. DESIGN: Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). SETTING: Acute-care, teaching hospital. PATIENTS: A total of 370 patients undergoing hysterectomy and bilateral salpingo-oophorectomy with surgical staging for primary treatment for clinical stage I endometrial cancer from January 1995 through June 2001. INTERVENTION: Clinical outcomes and survival in patients treated with laparoscopic-assisted vaginal hysterectomy (n = 55) and hysterectomy using the conventional abdominal approach (n = 315) were compared. MEASUREMENTS AND MAIN RESULTS: Baseline characteristics and histopathologic variables were similar in both groups. A total of 91.4% of patients underwent pelvic lymphadenectomy and 49.7% paraaortic lymphadenectomy. The median follow-up was 38.1 months. Blood loss, blood transfusions required, and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The mean number of pelvic and aortic nodes recovered was higher in the laparoscopic group (p < .001). Differences in overall and recurrence-free survival rates were not observed. CONCLUSION: Surgical staging of early-stage endometrial cancer by laparoscopic-assisted vaginal hysterectomy is feasible, with lower perioperative morbidity and shorter hospital stay compared with transabdominal hysterectomy. Prognosis and survival were not affected by the laparoscopic vaginal approach to hysterectomy.     

Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer

OBJECTIVE: To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer. METHODS: We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006. RESULTS: Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function. CONCLUSION: Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.     

Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly

OBJECTIVE: The purpose of this study was to analyze the outcome of vaginal and abdominal hysterectomy for treatment of endometrial cancer in elderly patients. METHODS: In a retrospective series of 171 patients with age > or =70 years and at stages I-III, we evaluated operative and hospitalization data, as well as morbidity, mortality, and long-term survival associated with vaginal and abdominal hysterectomy. A total of 128 patients were operated on with vaginal hysterectomy and 43 cases underwent abdominal hysterectomy. RESULTS: Medically compromised patients were significantly more frequent in the vaginal surgery group (P = 0.01). Overall, the 10-year disease-specific survival rates after vaginal and abdominal hysterectomy were 80% and 78%, respectively (P = n.s.). Limiting the analysis to stage I (130 patients), 10-year disease-specific survival was 83% in 95 women operated on by the vaginal route and 84% in 35 patients operated by the abdominal approach (P = n.s.). Patients in the vaginal surgery group had a significantly shorter operative time (P = 0.01), less blood loss (P < 0.05), and were discharged earlier (P < 0.05). Severe complications occurred in 5.4% of the vaginal and in 7.0% of the abdominal procedures. Perioperative mortality was zero after vaginal hysterectomy and 2.3% after abdominal hysterectomy, respectively. CONCLUSIONS: Vaginal hysterectomy showed a high cure rate, shorter operative time, less blood loss, reduced morbidity, and no mortality and therefore may be considered the elective approach for treatment of elderly patients with endometrial cancer.     

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。     

Prognostic factors in endometrial cancer

The 5 year survival rates of 228 patients with endometrial cancer treated in the period 1978-1982 according to the prognostic factors (stage, grade, depth of myometrial invasion, lymph node metastasis) is presented. All patients were treated with primary surgery consisting of classical Wertheim operation with lymphadenectomy (98 cases-43%), total abdominal hysterectomy with bilateral salpingo-oophorectomy with lymphadenectomy (52 cases-48%) and without lymphadenectomy (55 cases-52%) and vaginal hysterectomy with bilateral salpingo-oophorectomy (23 cases-10%). All patients except 6.6% were postoperatively irradiated. The 5 year survival for all stages was 74.6%. In SI cases it was 83.8%, in SII 57.9% and only 37.5% in SIII group. The survival was 90.1% in patients with superficial myometrial invasion and 56.4% in cases of deeper invasion. The survival of patients with node metastasis (8.6%) was only 39.5%, irrespective of the type of surgery and postoperative external irradiation. Vaginal recurrences were observed in 3.9%, and all the patients died. To improve the results it is necessary to individualize the treatment according to the pathologic and clinical prognostic factors.     

Place of Schauta's radical vaginal hysterectomy

Women affected by early stage invasive cancer of the cervix are usually treated by surgery. Radical abdominal hysterectomy with pelvic lymphadenectomy is the most widely used technique. Because the morbidity of the abdominal approach can be important, the radical vaginal hysterectomy has gained acceptance in gynaecologic oncology. New instrumentation in laparoscopy also opens the possibility of treating cervical cancer by laparoscopically assisted vaginal radical hysterectomy and also total laparoscopic radical hysterectomy. Before these techniques become widely accepted, it has to be shown that safety and efficacy are comparable with the 'standard' abdominal approach. In this chapter, we review the technique of radical vaginal hysterectomy with pelvic lymphadenectomy and evaluate results of published studies, comparing the abdominal, vaginal and laparoscopic approaches.     

Potential benefit of lymphadenectomy for the treatment of node-negative locally advanced uterine cancers

OBJECTIVE: The aim of this study was to examine the outcomes in patients with high-risk Stage I endometrial cancers surgically staged by complete pelvic and para-aortic lymphadenectomy, with negative nodes, and treated with postoperative brachytherapy. METHODS: From the database of patients treated for Stage I endometrial cancer, 23 patients were identified with either >50% myometrial invasion or grade 3 histology treated with total abdominal hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy. All patients had no pathologic evidence of disease in the lymph nodes. These patients were then treated with brachytherapy and followed for treatment and cost outcomes. A comparison was made of the cost of treatment between brachytherapy and external beam radiation. RESULTS: All 23 patients with either grade 3 tumor or greater than 50% myometrial invasion were treated with total abdominal hysterectomy with lymphadenectomy followed by brachytherapy for lesions that did not extend outside the uterine specimen. For all patients in this series, there were no recurrences in the follow-up period (median 25 months). This regimen is more cost efficient and spares the patient from possible complications related to whole pelvic radiation, at an average cost savings of $4100. CONCLUSION: Women undergoing hysterectomy for endometrial adenocarcinoma with high-risk node-negative disease confined to the uterus can be safely treated with brachytherapy, at a substantial cost savings, without compromising survival.     

Pelvic lymphadenectomy in high risk endometrial cancer

Two hundred and thirty-eight out of a total of 1012 patients with 'high risk' endometrial cancer underwent a complete pelvic lymphadenectomy. When the disease was confined to the corpus, the rate of node positivity was 7%, when the cervix was involved it was 22% and with adnexal involvement was 52%. The recurrence rate with negative nodes was 14% compared to 45% with positive nodes. Age, menopausal status, histology and depth of invasion were predictors of survival after stratification by node status. Node status had no significant influence on site of recurrence. Women who underwent total abdominal hysterectomy, bilateral salpingo-oophorectomy (TAH-BSO) and pelvic lymphadenectomy followed by vaginal vault brachytherapy had a similar cancer-free survival to those treated by TAH-BSO alone, followed by adjuvant megavoltage therapy and vaginal vault brachytherapy.     

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.     

Influence of a decisional tree on the route of hysterectomy for benign disease in Italy: personal experience

BACKGROUND: Mainly to report our experience in the route of hysterectomy after introducing specific guidelines according to the Society of Pelvic Reconstructive Surgeons and to record all hysterectomy-related complications after abdominal and vaginal hysterectomies. METHODS: The records of 22 patients who underwent abdominal hysterectomy and 59 who underwent vaginal hysterectomy for benign disease were reviewed. Complications related to hysterectomy were recorded during surgery, postoperative hospital stay and a period of six weeks. Statistical methods used were t-tests and chi square analysis. RESULTS: Operation time was shorter with the vaginal route. Patients operated on via the vaginal route had less blood loss and shorter hospital stay. CONCLUSIONS: The main standard to select the route for hysterectomy is the severity of the clinical status. Decreasing the ratio between the abdominal and vaginal route is possible, but it is crucial to make the indications clear, based on scientific evidence.     

Detection and patterns of treatment failure in 300 consecutive cases of "early" endometrial cancer after primary surgery.

From November 1977 to July 1987, 300 consecutive patients with endometrial carcinoma clinically confined to the uterine corpus underwent primary surgery consisting of at least abdominal hysterectomy and adnexectomy. Patients with aggressive disease characteristics received postoperative radiotherapy. Forty-seven patients (16%) demonstrated recurrent disease from 2 to 125 (median of 12.8) months after surgery. Forty-seven percent of the recurrences were detected within the first year following surgery and 70% by 2 years after hysterectomy. Of the 47 recurrences, 29 were at distant sites, 16 were within the pelvis, and 2 consisted of both local and distant recurrences. Patients treated with pelvic radiotherapy after hysterectomy were more likely to experience distant, rather than local recurrences. Only 7 of the 148 patients (5%) treated with postoperative radiotherapy recurred in the pelvis. Approximately half of the recurrences were detected in asymptomatic individuals; physical examination and chest X-ray were the most useful means to detect disease in patients without symptoms. The combination of history, physical examination, pap smear, and chest X ray detected all of the recurrences. Actuarial survivals at 12, 24, and 36 months after recurrence were 42, 24, and 17%, respectively. The site of recurrence, time interval of surgery to recurrence, and use of postoperative pelvic radiotherapy were statistically related to patient prognosis. The identification of patients at risk of recurrence and more effective adjuvant therapy need to be developed in order to decrease the frequency of recurrence. In order to substantially improve the survival of patients with recurrent disease, more sensitive methods of detection, as well as more effective salvage therapy, will be required.     

Evaluation of different surgical approaches in the treatment of endometrial cancer at FIGO stage I

From January 1, 1970 to December 31, 1979, 425 cases of endometrial carcinoma, FIGO stage I, were treated at the First Department of Obstetrics and Gynecology, University of Milan. Three different surgical approaches were used: total abdominal hysterectomy with bilateral salpingo-oophorectomy and selective pelvic lymphadenectomy was performed in 245 women, total abdominal hysterectomy and bilateral salpingo-oophorectomy without pelvic lymphadenectomy in 100, and vaginal hysterectomy with bilateral salpingo-oophorectomy in 80. Five-year survival was evaluated as a function of risk factors (histological grade, depth of myometrial invasion, metastatic nodes) in the three groups of patients, and we conclude that lymphadenectomy is useful for prognostic purposes but does not confer a therapeutic benefit.     

Double laparotomy wound recurrence of endometrial carcinoma

INTRODUCTION: Abdominal scar recurrence of endometrial carcinoma after abdominal total hysterectomy is very rare. We report a case of a 65-year-old woman who had two recurrences in the abdominal incisional scar after total hysterectomy. Case report: A 65-year-old woman underwent total hysterectomy with bilateral salpingo-oophorectomy and pelvic lymphadenectomy because of well-differentiated endometrial adenocarcinoma (Stage IIB). Thus, the patient was treated by external beam radiotherapy. She developed two recurrences in the abdominal incisional scar two and three years after total hysterectomy, respectively. Surgery plus chemotherapy and surgery plus hormonal therapy were used for treatment of the first and second scar recurrence, respectively. CONCLUSIONS: It is a very intriguing and controversial biologic question how neoplastic cells can implant and grow in an abdominal scar without other concomitant metastases. We report a review of the literature and the possible mechanism of recurrences in laparotomy wounds.     

Laparoscopic-assisted vaginal hysterectomy with laparoscopic pelvic and paraaortic staging for early endometrial cancer

While abdominal hysterectomy with bilateral salpingo-oophorectomy and pelvic and paraaortic lymphadenectomy is still considered the gold standard for the surgical treatment of endometrial cancer, the laparoscopic-assisted vaginal hysterectomy (LAVH) plus laparoscopic lymphadenectomy has been performed in FIGO stage I endometrial cancer in selected centers for about a decade. Clinical studies have shown that the frequency of intra- and postoperative complications, the pelvic and paraaortic lymph node yield, and—more importantly—the overall survival, are similar both with the laparoscopic-assisted vaginal approach and the abdominal approach in stage I disease. Blood loss and duration of hospital stay may even be reduced with the LAVH. In summary, provided there is compliance with established oncologic guidelines, LAVH with pelvic and paraaortic lymphadenectomy can probably be performed in patients with endometrial cancer FIGO stage I without safety loss.     

Vaginal hysterectomy: is previous pelvic operation a contraindication?

A retrospective comparison was undertaken between the responses to vaginal hysterectomy of women who had previous pelvic surgery and those who had not. Of 1563 vaginal hysterectomies performed over a 10-year period, 39% had previously undergone pelvic procedures. 6.9% of the patients who had previous pelvic surgery had major complications and 31.2% had minor complications. 6.1% of the 942 patients not previously operated had major complications and 31.8% had minor complications. The range of complications was similar in both groups. The authors conclude that previous pelvic surgery is not a contraindication for vaginal hysterectomy.     

Survival of women with surgical stage II endometrial cancer.

OBJECTIVE: The aim of this study was to report survival and determine prognostic factors and results of therapy in women with surgical stage II endometrial cancer. METHODS: Forty-eight consecutive women with surgical stage II endometrial cancer treated at the University of Vermont between March 1984 and March 1998 were reviewed. Patients' characteristics, surgical procedure, postoperative treatment and its complications, and tumor recurrence and its treatment were recorded. In addition, a formal review of their pathological material for confirmation of the diagnosis was performed. RESULTS: The median duration of follow-up was 6.2 years. Three patients (6.3%) had tumor recurrence and two (4.2%) died of their disease. The estimated 5-year overall survival and disease-free survivals were 92.1% (SE = 5.5%, 95% confidence interval: 81.3, 100%) and 89.9% (SE = 5.8%, 95% confidence interval: 78.5%, 100%), respectively. None of the patients treated by total abdominal hysterectomy followed by both whole pelvic and vaginal cuff radiation therapy (the main line of treatment for patients in whom cervical involvement was diagnosed following hysterectomy, n = 20) or by radical hysterectomy (the main line of treatment for patients in whom cervical involvement was known before hysterectomy, n = 11) had tumor recurrence. Three of 17 (17.6%) patients treated with total abdominal hysterectomy followed by either whole pelvic (n = 13) or vaginal cuff (n = 4) radiation therapy had tumor recurrence. The difference between those two groups was statistically significant (0/31 versus 3/17, P = 0.02). There was no difference in survival among women with stage IIA and IIB or women who underwent radical abdominal hysterectomy and those who underwent total abdominal hysterectomy with postoperative pelvic and vaginal cuff radiation. Morbidity secondary to therapy was mild. Age, depth of myometrial invasion, tumor histology, and grade were not significantly related to recurrence. CONCLUSIONS: Survival of women with surgical stage II endometrial cancer is excellent especially among those treated with total abdominal hysterectomy followed by both pelvic and vaginal cuff radiotherapy or by radical abdominal hysterectomy.     

Electrosurgical bipolar vessel sealing for radical abdominal hysterectomy

OBJECTIVE: We analyzed the use of an electrosurgical bipolar vessel sealing system for radical abdominal hysterectomy. METHODS: We compared operating time, transfusion requirements and other surgical parameters in 52 patients undergoing radical abdominal hysterectomy with systematic pelvic +/- paraaortic lymphadenectomy for stage IB1-IIB cervical cancer between January 2001 and June 2004. At 21 operations between January 2001 and March 2002, the parametrium, paracolpos and vaginal cuff were resected with clamps and the pedicles suture ligated; 31 operations between November 2001 and June 2004 were done with a bipolar vessel sealing system (LigaSure Vessel Sealing System, Valleylab, Boulder, CO). Four surgeons did all operations. Data were compared with the t test. RESULTS: Patients operated with the LigaSure system received fewer packed RBC transfusions than those operated with clamps (mean, 0.61 +/- 1.1 vs. 2.14 +/- 2.6 units, respectively; P = 0.01), even when looking at patients who underwent only pelvic (without paraaortic) lymphadenectomy (mean, 0.52 +/- 1.1 vs. 1.29 +/- 1.2 units, respectively; P = 0.02). The transfusion rate in the two groups was 26% (8/31) and 67% (14/21), respectively (P < 0.05). Operating time did not differ significantly (199 +/- 33 vs. 213 +/- 45 min, respectively). There were no significant differences between the groups in number of pelvic nodes removed, febrile morbidity, postoperative stay, or days until residual urine <100 ml. One patient in the LigaSure group developed a ureterovaginal fistula that resolved with stenting. CONCLUSION: The LigaSure system appears useful to reduce blood loss at radical abdominal hysterectomy.     

The evolution of a treatment program for adenocarcinoma of the endometrium.

Previous studies at the University of Minnesota suggest that overall survival rates after treatment for adenocarcinoma of the endometrium are related to increased surgical applicability, that vaginal recurrence is frequently related to cervical involvement, and that virtually all women can safely undergo abdominal hysterectomy and radical irradiation therapy. In this program a simple abdominal hysterectomy was applied to as many women with this disease as possible. High-risk patients also received preoprative or postoperative irradiation. This program increased the survival rate for all stages from 58% to 69.7%. The survival rate among women with Stage I high-risk disease treated with supplementary irradiation was significantly lower when compared to that among women with low-risk disease who were treated by surgery alone. No vaginal recurrences were observed in either group and 98.4% were operated upon. The survival rate of women with Stage II disease treated with irradiation and surgery improved significantly. The rate of vaginal recurrence was 2.2%.