Perioperative outcomes of total laparoendoscopic single-site hysterectomy versus total robotic hysterectomy in endometrial cancer patients: a multicentre study

Objective

To compare the peri-operative outcomes between total laparo-endoscopic single-site (LESS) and robotic approaches for the staging and treatment of early stage endometrial cancer patients.

Methods

A multicentre retrospective study involving three Italian gynaecological groups and one American centre. The peri-operative outcomes of LESS and robotic approach were compared in similar groups of patients, with regard to surgical outcomes and intra- and post-operative parameters and complications.

Results

During the study period, 75 patients submitted to a total LESS hysterectomy and 75 patients received a total robotic hysterectomy. The median operative time - 122 versus 175 min (p = 0.0001) - and the estimated blood loss - 50 versus 80 mL (p = 0.03) - were slightly more favourable in the LESS group. The intra-operative complications were equally distributed (p = 0.99); in the robotic group there were 4 (5.3%) post-operative grade IIIb complications versus 1 (1.3%) in the LESS group (p = 0.172).

Conclusions

The LESS and robotic approaches both appear reasonable and each may have benefits and limitations depending upon the patient population. Further studies are needed to validate these preliminary conclusions.     

Small volume stage 1B1 cervical cancer: Is radical surgery still necessary?

Objective

Current surgical treatment of FIGO stage 1B1 cervical cancer is radical surgery. However, several reports have shown that for small tumours a more conservative approach can be as effective in terms of survival, whilst at the same time reducing the morbidity associated with removing the parametrium. The objective of our study was to report survival and obstetric outcomes following conservative management of small-volume stage 1B1 disease.

Methods

All patients with FIGO stage 1B1 cancer and estimated tumour volume of less than 500 mm³ in a loop biopsy specimen were included in the study, irrespective of other histological characteristics. A second loop biopsy was performed to rule out residual disease in 79% of patients.

Results

Sixty two women were identified with a median age of 35 years (range 27-67). Median tumour length was 9.75 mm (7.2-20) and median depth of invasion was 1.55 mm (0.3-5). Thirty five women (56.4%) were treated with loop biopsy, whilst 27 (45.6%) had simple hysterectomy. Fifty seven women (92%) had pelvic lymphadenectomy and one positive node was recorded. After a median follow up of 56 months (16-132) no recurrence was noted. Seven full term pregnancies have been achieved. There were no preterm deliveries or mid-term miscarriages.

Conclusion

Cervical loop biopsy or simple hysterectomy combined with negative pelvic lymphadenectomy for small-volume stage 1B1 cervical cancer offers excellent prognosis in terms of survival. Postoperative morbidity is reduced and obstetric outcomes may be improved. Should these results be verified by further prospective studies, radical surgery for these women may be avoided.     

Impact of histological subtype on survival of patients with surgically-treated stage IA2-IIB cervical cancer: Adenocarcinoma versus squamous cell carcinoma

Objectives

To evaluate the significance of adenocarcinoma (AC) compared with squamous cell carcinoma (SCC) with regard to the survival of surgically-treated early stage cervical cancer patients.

Methods

We retrospectively reviewed the medical records of 520 patients with FIGO stage IA2-IIB cervical cancer who were treated with radical hysterectomy with or without adjuvant radiotherapy between January 1998 and December 2008. The patients were classified according to (i) pathological risk factors (low-, intermediate-, or high-risk group) and (ii) adjuvant radiotherapy (concurrent chemoradiotherapy [CCRT group] or radiotherapy alone [RT group]). Survival outcomes were examined by Kaplan-Meier method and compared with Log-rank test. Multivariate analysis for disease-specific survival (DSS) was performed using Cox proportional hazards regression model to investigate the prognostic significance of histological subtype.

Results

AC histology was associated with significantly decreased DSS compared with SCC histology in the intermediate- and high-risk groups (hazard ratio: 3.06 and 2.88, respectively, both P < 0.05) while there was no survival difference in the low-risk group (P = 0.1). Among patients who received any types of adjuvant radiotherapy, DSS of AC histology patients were significantly poorer than SCC histology. Multivariate analysis demonstrated AC histology to be an independent predictor of decreased DSS in both CCRT and RT groups. Moreover, pelvic nodal metastasis significantly predicted the poor survival of patients with AC histology who received CCRT in multivariate analysis

Conclusions

Adenocarcinoma is an independent prognostic indicator of poor survival in early stage cervical cancer patients with intermediate- and high-risk factors, regardless of the type of adjuvant radiotherapy after radical hysterectomy.     

Does a uterine manipulator affect cervical cancer pathology or identification of lymphovascular space involvement?

Objective

Uterine manipulators are a useful adjunct for robotic-assisted radical hysterectomy (RARH), but some surgeons avoid their use for fear of altering pathology or interpretation of lymphovascular space involvement (LVSI). We retrospectively compared clinico-pathological data and tumor pathology from patients with cervical cancer operated by laparotomy vs. RARH.

Methods

Charts from cervical cancer patients who underwent radical hysterectomy from January-1997 to June-2010 were reviewed for tumor histology, grade, FIGO stage, lymph node status, LVSI, depth of invasion, and tumor size. A ConMed V-Care® uterine manipulator was used in all robotic cases. H&E stained slides from 20 robotic and 24 open stage IB1 cases with LVSI reported in the original pathology were re-reviewed by a blinded pathologist for analysis of tissue artifacts and LVSI.

Results

Two-hundred-thirty-six cases (185 open, 51 robotic) with stages IA2, IB1 and IB2 cervical cancer were reviewed. No significant differences in histology (squamous cell carcinoma, 65% vs. 51%; p = 0.1), IB1 lesion size (≤ 2 cm, 62% vs. 61%, p > 0.1), LVSI (34% vs. 39%, p > 0.1), and depth of stromal invasion (p > 0.1) was found between open and robotic groups. Histologic examination of all IB1 cervical carcinomas revealed a higher degree of surface disruption [45% (9/20) vs. 12.6% (3/24), p = 0.038] and artifactual “parametrial carryover” [65% (13/20) vs. 29% (7/24), p = 0.037] in robotic vs. open groups, respectively, but no significant differences in the rate of LVSI.

Conclusion

RARH cases that utilized a uterine manipulator did not show any clinico-pathological differences in depth of invasion, LVSI, or parametrial involvement compared to open cases.     

Learning curve analysis of laparoscopic radical hysterectomy and lymph node dissection in early cervical cancer

Objective

Locally advanced bulky cervical cancer (LABCC) is characterized by poor local control. The objective of this study was to identify the clinicopathologic variables associated with one-year central-only recurrence, which will serve as criteria for adjuvant hysterectomy after radiation (AHR) in patients with LABCC.

Study design

Between January 2000 and August 2007, we retrospectively evaluated outcomes in 225 patients with LABCC who were initially treated with radiation or chemoradiation.

Results

Among the 225 patients with LABCC, there were 41 recurrences within one year after treatment (8 central-only and 33 pelvis and/or distant site recurrences). Age, stage, and treatment type were not associated with the one-year central-only recurrences, but tumor size ≥8 cm had a statistically significant association based on multivariate analysis (OR, 5.39; 95% CI, 1.15–25.31; p = 0.03). The combination of non-squamous cell (non-SCC) type and tumor size ≥8 cm had a significantly higher rate of recurrence within one year (OR, 43.0; 95% CI, 4.78–386.68; p < 0.01).

Conclusions

Of patients with LABCC, those with non-SCC tumors ≥8 cm in size were at high risk for early central-only recurrence after cisplatin-based chemoradiation, and represent the subset of patients for whom AHR is beneficial.     

The satisfaction survey that matters

Laparoendoscopic single-site surgery is a logical advance in the evolution of minimally invasive surgery and is being utilized to perform increasingly complex procedures. We report its use for completion of radical hysterectomy as treatment for cervical 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。     

Ectopic tubal pregnancy after hysterectomy and tubal ligation

Posthysterectomy ectopic pregnancy is an unusual condition that may present soon after hysterectomy or several years later. Similarly, although tubal ligation is a widespread method of contraception, tubal pregnancy after tubal ligation is not common either. If any of these conditions are rare, having an ectopic pregnancy after hysterectomy and tubal ligation is even more infrequent and only one of such cases was found in our review of the literature. We describe the case of a 35-year-old patient, with history of bilateral tubal ligation and vaginal hysterectomy that looked for medical attention due to abdominal pain. A pregnancy test was positive and a transvaginal ultrasound demonstrated the presence of a gestational sac at the vaginal cuff, adjacent to the ovary. An exploratory laparotomy showed a ruptured ectopic pregnancy located in the distal portion of the left fallopian tube. The occurrence of an ectopic pregnancy several years following tubal ligation and vaginal hysterectomy is a rare phenomenon that appears to be secondary to a fistulous connection into the peritoneal cavity.