Laparoscopic modified radical hysterectomy and lymphadenectomy simulating open operation for stage 1A2 cervical carcinoma

A 31 year old patient with Stage 1A2 cervical carcinoma underwent a laparoscopically modified radical hysterectomy and pelvic lymphadenectomy simulating the open operation. The operative technique is described. The operative time was 7 hours and 40 minutes. The patient was discharged on the third post-operative day. The procedure warrants further evaluation.     

Radical hysterectomy with pelvic lymphadenectomy in patients with carcinoma of the uterine cervix--3 years' experience

INTRODUCTION: Almost all patients with invasive cervical carcinoma can be treated with either primary irradiation therapy or primary surgery. Some patients are appropriately treated with the combination of irradiation and surgery. Chemotherapy is not effective as primary treatment of invasive cervical cancer but may be used as additional therapy and when the disease is recurrent or persistent. There are some important advantages of primary extensive surgery over irradiation. The findings at operation and that from the careful pathologic examination of surgical specimens can be very helpful in selection of patients for supplementary postoperation irradiation therapy or chemotherapy, or both [1-6]. AIM OF THE STUDY: The aim of the study was to compare pretreatment clinical evaluations with surgical and postsurgical pathohistological findings. METHODS: Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. The patients were treated at the Department of Obstetrics and Gynaecology of the Clinical Centre of Serbia in Belgrade, between 1993 and 1995. Cervical cancer was detected by clinical examination, colposcopic and cytologic (Pap smear) findings, colposcopically directed biopsy or conisation and pathological findings, sonography, chest radiography, blood and urine analyses. In some cases we had to make other examinations (cystography, cystoscopy, intravenous pyelography, sygmoidoscopy, rectoscopy, CT scanning and magnetic resonance). The surgical treatment of invasive carcinoma of the cervix was limited to those patients in whom the disease was confined to the cervix or vaginal fornix (stage Ia, stage Ib or stage IIa), and who were in high surgical risk. RESULTS: Over a three year period (1993-1995) there were 251 patients with invasive cervical cancer, treated by primary surgery (radical hysterectomy and bilateral pelvic lymphadenectomy sec. Werthein-Meigs), average age 42 years. Most of the patients demonstrated invasive cervical cancer, clinically classified in Ib st. (81.67%). Some characteristics of pathologic findings, such as parametric width, number of removed lymph nodes, percentage of lymph nodes metastases and correlation with clinical stage of invasive cervical cancer, histologic grade of cervical cancer with lymph node metastasis, pathologic findings after surgical treatment, correlation between clinical and surgical staging, were already presented in tables. DISCUSSION: In the last decades the incidence of invasive cervical cancer and death rate have been decreased. Progress in reducing mortality is primarily attributed to the introduction of cervical cancer screening as part of regular gynaecologic examinations. Regular testing with Papanicolaou (Pap) smear and colposcopy have an important role in this problem [1]. Extensive hysterectomy and bilateral pelvic lymphadenectomy were used in the treatment of 251 patients with early invasive cervical cancer. We found that the clinical diagnosis of disease extent was correct in 67.7% of patients who underwent extensive surgery for early invasive cervical cancer. Sensitivity of clinical findings was 75.8% and positive predictive value was 86.2%. Lymph node metastasis was detected in 17% patients. Brodman at al. [14] found that clinical examinations, including CT scanning and magnetic resonance, were correct in only 62.5% of cases. It is very difficult to detect parametric involvement and lymph node metastasis by clinical examinations. Irradiation therapy was used in the postoperative period as additional treatment of extensive hysterectomy and bilateral pelvic lymphadenectomy in 89.7% of patients. CONCLUSION: The findings at operation and that from the careful pathologic examination of surgical specimens are absolutely irreplaceable and important in grading invasive cervical cancer and selection of patients for supplementary postoperate irradiation therapy.     

Is total abdominal hysterectomy with bilateral salpingo-oophorectomy adequate for new FIGO stage I endometrial carcinoma?

OBJECTIVE: The new FIGO staging for endometrial cancer cases complies with other forms of surgical staging and correlates better with clinical outcomes because it includes prognostic factors. This study was done to investigate whether total abdominal hysterectomy with bilateral salpingo-oophorectomy (TAH+BSO) is adequate for new FIGO Stage I endometrial carcinoma. SUBJECTS: Sixty-five cases of endometrial carcinoma defined according to the new FIGO Stage Ia (n = 26), Ib (n = 24) and Ic (n = 15) were analysed. They all received TAH+BSO only and were followed up for at least two years. METHODS: The histologic type, grade, depth of myometrial invasion, lympho-vascular tumour emboli and tumour size were analysed by t-test to correlate the risk factors for treatment failure. RESULTS: There were no recurrences after TAH+BSO in Ia and Ib cases. However, recurrences occurred in five cases (33%) of Stage Ic with deep myometrial invasion, high histologic grade, large tumour size and tumour emboli. CONCLUSIONS: TAH+BSO is inadequate in some Ic cases with a high histologic grade, deep myometrial invasion and tumour emboli. Thus, thorough pre-operative and intra-operative staging, adequate operation method and prompt post-operative adjuvant therapy are indispensable for successful treatment.     

Laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB nonseminomatous testicular carcinoma

PURPOSE: We investigated laparoscopic retroperitoneal lymphadenectomy after chemotherapy for stage IIB testicular carcinoma in terms of operative feasibility, overall morbidity and tumor control. MATERIALS AND METHODS: Between February 1995 and April 1998, 24 patients underwent laparoscopic retroperitoneal lymphadenectomy following initial chemotherapy for stage IIB (2 to 5 cm.) solitary or unilateral lymph node metastases. Mean tumor diameter was 2.4 cm. before and 1.1 cm. after chemotherapy. Laparoscopic retroperitoneal lymphadenectomy was performed in all patients, including those with complete remission. RESULTS: Laparoscopic retroperitoneal lymphadenectomy could be completed as planned in all patients and there was no need for conversion to open surgery. Operative time was 150 to 300 minutes (mean 240). Blood loss was minimal and no blood transfusions were required. The only postoperative complications were chylous ascites (5 patients) which resolved with conservative management (low fat diet) and a small asymptomatic lymphocele. Histological examination revealed necrosis in 71%, mature teratoma in 25% and active tumor in 4% of patients. Antegrade ejaculation was preserved in all patients. Mean postoperative hospital stay was 4 days, return to normal activities between 1 and 3 weeks, and time to complete recovery between 5 and 10 weeks. All patients were well without evidence of disease at a mean followup of 24.4 months. CONCLUSIONS: Laparoscopic retroperitoneal lymphadenectomy after chemotherapy proved feasible in select patients presenting with solitary or unilateral lymph node metastases and was associated with a low morbidity. Tumor control was not compromised by the laparoscopic approach.     

Initial experiences and outcome of gasless laparoscopic pelvic lymph node excision combined with Schauta vaginal radical hysterectomy in stage IB cervix carcinoma

In 11 patients with a cervical cancer stage IB a gasless laparoscopic pelvic lymph node dissection in combination with a vaginal radical Schauta-Amreich-hysterectomy was performed. The technique of the gasless lymph node dissection with the Laparolift (ORIGIN Medsystems, Menlo Park) is described. Because of the advantages of this technique (ability to use conventional and endoscopic instruments, perform irrigation and suction, dot with sponge sticks, change instruments quickly, prepare and remove lymph nodes without influence on visibility) it was possible to obtain a radicality (45 lymph nodes-median value) according to oncological standards for an abdominal radical Wertheim hysterectomy. If the radicality is equivalent to a Wertheim hysterectomy the combination of the radical vaginal Schauta-Amreich-hysterectomy and the gasless laparoscopic pelvic lymph node dissection offers a real alternative to the abdominal Wertheim hysterectomy because of low postoperative morbidity and quick mobilisation.     

Laparoscopic pelvic lymph node dissection for prostate cancer: comparison of the extended and modified techniques

PURPOSE: We compared the results of extended (obturator, hypogastric, common and external iliac nodes) to modified (obturator and hypogastric nodes only) laparoscopic pelvic lymph node dissection in patients with clinically localized prostate cancer. MATERIALS AND METHODS: A total of 189 patients with stage T1 to T3 prostate cancer underwent modified (150) or extended (39) laparoscopic pelvic lymph node dissection for pelvic nodal assessment before definitive treatment. RESULTS: Twice as many lymph nodes were removed via extended than modified laparoscopic pelvic lymph node dissection (mean 17:8 versus 9.3). The overall positivity rate was 23 of 189 lymph nodes (12.2%), including 14 of 150 (7.3%) for modified and 9 of 39 (23.1%) for extended dissection (p = 0.02). Two patients (22%) who underwent extended dissection had positive lymph nodes in the external iliac area. Patients who presented with the high risk features of prostate specific antigen (PSA) greater than 20 ng./ml., Gleason score 7 or greater, or stage T2b disease or greater had a 26.5% (p = 0.0002), 22% (p = 0.0006) or 16.4% (p = 0.003) likelihood of positive lymph nodes, respectively. For extended versus modified laparoscopic pelvic lymph node dissection node positivity in high risk patients was 27% versus 18.8% (p = 0.4), 30 versus 26.4% (p = 0.8) and 25.4 versus 14.6% (p = 0.17) for Gleason score 7 or greater, PSA greater than 20 ng./ml. and disease stage T2b to T3a, respectively. Patients who underwent the extended procedure had a higher complication rate (35.9 versus 2%, p < 0.0001). No laparotomy was required. CONCLUSIONS: Despite yielding a 2-fold higher node count and higher node positivity rate, extended laparoscopic pelvic lymph node dissection offers no advantage over modified laparoscopic pelvic lymph node dissection for diagnosing positive lymph nodes when results are analyzed by prognostic factors. The extended procedure is associated with a much higher complication rate. In patients with the high risk features of PSA greater than 20 ng./ml., Gleason score 7 or greater and stage T2b to T3a disease modified laparoscopic pelvic lymph node dissection can be performed safely and effectively to help identify those who may benefit most from curative therapy.     

Laparoscopic retroperitoneal lymphadenectomy for cancer of the testis

Laparoscopic retroperitoneal lymph node dissection (RPLND) is a technically advanced procedure that has been undertaken for the management of low-stage nonseminomatous germ cell testis tumor. Although it has been shown to be an effective staging technique, its role as a therapeutic operation is currently unknown. Laparoscopic RPLND requires longer operative times but offers the patient all the advantages of minimally invasive surgery, such as less postoperative pain and shorter hospitalization and convalescence. The role of laparoscopic RPLND for the evaluation of residual abdominal masses following chemotherapy is currently being examined.     

Complications of absorbable pelvic mesh slings following surgery for rectal carcinoma

PURPOSE: To evaluate the intraoperative, postoperative, and long-term complications of an absorbable pelvic mesh sling after surgery for rectal carcinoma. METHODS: A retrospective review of medical records from April 8, 1991, through April 8, 1996. RESULTS: Twenty patients with a mean age of 57 (range, 37-79) years underwent pelvic mesh sling placement. The tumor stages were as follows: Stage I, 5; Stage II, 2; Stage III, 11; and Stage IV, 1. A recurrent perianal basal cell carcinoma was not included in the staging group. Surgery consisted of 18 abdominoperineal resections, 1 total proctocolectomy, and one Hartmann's procedure. Mean follow-up was 18 (range, 2-49) months. There were no intraoperative complications related to mesh placement. Twenty-nine complications occurred in 14 patients during the immediate postoperative period. Five were possibly mesh-related and included a pelvic abscess, perineal seroma, toxic perineal wound, pulmonary embolus, and lower extremity deep venous thrombosis, respectively. A mild postoperative ileus developed in 17 patients (85 percent), and a diet was initiated at a mean of seven (range, 4-24) days. Fourteen patients received postoperative radiotherapy with a mean dose of 5,339 (range, 2,500-7,020) cGy delivered in 180-cGy fractions. There were 14 immediate complications caused by radiotherapy in 11 patients, but only two patients required delays in treatment. Two patients had diarrhea alone, six developed perineal dermatitis alone, and three patients had both diarrhea and perineal dermatitis. All patients with diarrhea had received chemoradiation. One patient developed a partial small-bowel obstruction following radiation. CONCLUSIONS: Absorbable pelvic mesh sling placement can be performed with minimum morbidity and is recommended following surgery for rectal cancer when radiation is anticipated as part of multimodality therapy.     

Modified type IV-V radical hysterectomy with systematic pelvic and aortic lymphadenectomy in the treatment of patients with stage III cervical carcinoma. Feasibility, technique, and clinical results

BACKGROUND: Due to the high prevalence of perioperative major morbidity and the difficulties in achieving surgical disease free margins, surgery has had no role in the treatment of patients with Stage III cervical carcinoma. METHODS: Forty-two women with International Federation of Gynecology and Obstetrics (FIGO) Stage III cervical carcinoma responding to platinum-based neoadjuvant chemotherapy underwent the maximum surgical effort, comprised of a modified type IV-V radical hysterectomy (37 patients) or anterior pelvectomy (5 patients) with systematic pelvic and aortic lymphadenectomy. Feasibility, modifications of surgical technique, and pathologic and clinical data were analyzed. RESULTS: Surgery was feasible in all 42 patients intraoperatively selected. Disease free margins were achieved in all but one patient. The median operating time was 390 minutes, and the median estimated blood loss was 800 mL. In the last series of patients, these figures declined to 320 minutes and 600 mL, respectively. Major morbidity consisted of severe intraoperative hemorrhage in two patients, pulmonary embolism in four, ureteral fistula in three, and laparocele in three. The number of lymph nodes removed ranged from 30 to 117 with a median of 56. The mean lengths of vagina and lateral parametrium resected were 55 and 48 mm, respectively. Despite perioperative chemotherapy, lymph node metastasis was present in 36% of patients, parametrial disease in 38%, and vaginal disease in 45%. After a median follow-up of 53 months, the 5-year overall and disease-free survival rates of radically operated patients were 70% and 58%, respectively. CONCLUSIONS: Thanks to improved surgical technique and perioperative care, extended radical surgery appears to be feasible with acceptable morbidity in chemosensitive women with Stage III cervical carcinoma and may constitute a valid alternative to radiotherapy in these patients.     

腹腔镜用于子宫内膜癌分期手术39例分析

Objective:The purpose of our study was to investigate the feasibility and short-term therapeutic effects of laparoscopic staging operation in women with endometrial carcinoma.Methods:We analyzed 86 patients with endometrial carcinoma in PLA general hospital between 2006 and 2009 retrospectively.Thirty-nine patients were performed laparoscopic modified radical hysterectomy plus systemic retroperitoneal lymphadenectomy.Forty-seven patients received traditional abdominal radical hysterectomy plus systemic retroperitoneal lymphadenectomy.We compared the operation time,blood loss,number of lymph nodes retrieved,time for restoration of gastrointestinal function,postoperative complications and morbidity,the incidence of wound infection,the length of hospital stay,and hospital charges.Results:There was no significant deviation between the two groups in age,clinical stage,and pathology.We found that there was no significant deviation between the two groups in the number of lymph nodes retrieved,postoperative complications,the rate of wound infection or hospital charge(P>0.05).The laparoscopic group had an advantage in blood loss,time for restoration of gastrointestinal function,time for postoperative hospital stay(P<0.05).Conclusion:Laparoscopic surgery,as a primary surgical intervention,seems to be a safe and feasible option especially in patients with early endometrial cancer.     

Laparoscopic diagnosis and excision of Meckel's diverticulum

Meckel's diverticulum is one of the primary concerns in the differential diagnosis of the pediatric patient with massive, acute gastrointestinal bleeding, intussusception, or abdominal pain of uncertain cause. The hospital course of two children with Meckel's diverticulum, successfully treated by laparoscopic excision, is presented, along with details of the operative procedure. Both patients recovered from the procedure without incident and were discharged at 24 and 48 hours after surgery. The authors believe a laparoscopic approach is safe and effective in the diagnosis and treatment of Meckel's diverticulum.     

Economic evaluation of hysteroscopic endometrial ablation versus vaginal hysterectomy for menorrhagia

PURPOSE: To assess the efficacy and safety of percutaneous catheter drainage combined with alcohol sclerosis in the treatment of postoperative lymphoceles. PATIENTS AND METHODS: Thirteen patients with 14 postoperative symptomatic lymphoceles were treated. Drainage catheters were inserted under ultrasound (n = 13) or computed tomographic (n = 1) guidance. Lymphocele sclerosis was performed by instilling 10-100 mL of absolute alcohol into the lymphocele cavity and aspirating the alcohol after 30 minutes. Sclerosis sessions were carried out one to three times per day, usually three times per week. Catheter sinograms were obtained and prophylactic antibiotics administered. Imaging was repeated if symptoms or signs of recurrence developed. RESULTS: Successful drainage and sclerosis were achieved in all 13 patients. One patient with a recurrence was successfully treated with repeated drainage and alcohol ablation. No adverse effects of alcohol instillation were seen. The mean duration of catheterization was 36 days (range, 17-65 days; median, 30 days). CONCLUSION: Percutaneous drainage combined with alcohol ablation is a safe and effective treatment of postoperative lymphoceles.     

Importance of extended lymphadenectomy with lateral node dissection for advanced lower rectal cancer

A total of 448 patients with advanced lower rectal cancer who underwent curative wide lymphadenectomy with autonomic nerve preservation were reviewed with respect to surgical techniques, operative burdens, node status, survival rate, and mode of recurrence. Operative time and blood loss in patients who underwent lateral dissection were much greater than those encountered with conventional resection. According to the direction of lymphatic spread in patients with Dukes C disease, the incidence of upward spread was 94% and lateral spread 27%. The overall incidence of lateral metastasis was 14%. The overall 5-year survival was 70%. According to the Dukes classification, the 5-year survival rates were 92% for Dukes A, 79% for Dukes B, and 55% for Dukes C, whereas it was 43% in patients with lateral node metastasis. An analysis of the survival rate was carried out with regard to the number of node metastases, direction of lymphatic spread, and autonomic nerve preservation. The overall incidence of local recurrence was 9.3% and amounted to 16.0% in patients with Dukes C disease. The case of advanced lower rectal cancer was characterized by positive lymph nodes or circular lesions around the circumference (both diagnosed by endorectal ultrasonography). We recommend extended lymphadenectomy with lateral node dissection, as it preserves the autonomic nerve.     

Systematic pelvic and paraaortic lymphadenectomy for advanced ovarian cancer: prognostic significance of node metastases

A retrospective study of 488 patients with untreated advanced ovarian cancer is presented. Systematic pelvic and paraaortic lymphadenectomy was performed in 248 cases (50.8%). Selective sampling and node biopsy was performed in 33 (6.7%) and 47 (9.6%) patients, respectively. Node metastases were found in 194 of 328 patients (59.1%). The incidence of metastatic nodes significantly increased with more advanced stages, with serous histology, and with a greater amount of residual tumor. Node status appeared to be related to pathology findings at second-look. A complete pathologic response was documented in 26 of 31 (83.8%) patients with negative nodes and in 38 of 59 (64.6%) with positive nodes at first surgery. Patients with negative nodes survived significantly longer (5-year survival, 46%; median, 60 months) than those who had node metastases (5-year survival, 25%; median, 36 months). Using multivariate analysis, lymph node status, together with the stage of disease and residual tumor, still had a significant impact on 5-year survival. Moreover, among patients with optimal cytoreduction, 5-year survival was 46% (median, 56 months) and 30% (median, 41 months) for patients who did and did not undergo lymphadenectomy, respectively (P = 0.05). Likewise, when suboptimal cytoreduction was considered, a median 5-year survival of 24 months was obtained in patients who underwent lymphadenectomy compared with 14 months in patients who did not (P < 0.005).     

Comparison of laparoscopic and minilaparotomy pelvic lymphadenectomy for prostate cancer staging in a community practice

OBJECTIVES: To compare the cost-effectiveness and morbidity of minilaparotomy (MINILAP) and laparoscopic pelvic lymphadenectomy (LAP) in a community practice setting. METHODS: We reviewed our experience with 44 consecutive patients with prostate cancer who had staging pelvic lymphadenectomy from January 1992 through April 1995 in a general health maintenance organization urology practice. Of this group, 22 men had LAP and 22 men had MINILAP. RESULTS: MINILAP and LAP groups were similar in age (mean 67 years). Gleason score (mean 7.2 and 6.8), prostate-specific antigen level (mean 46 and 49 ng/mL), and clinical stage (T1 to T3). Operative time was statistically significantly shorter for MINILAP (mean 1.2 hours) than for LAP (mean 2.9 hours). Complication rate was 9.1% for MINILAP and 31.8% for LAP. Lymph node metastasis was found in 45% of MINILAP patients and in 27% of LAP patients. Mean initial hospital stay was 1.0 day for MINILAP and 1.6 days for LAP. Total hospital stay including hospital readmission for complications was 1.5 days for MINILAP and 2.6 days for LAP. Cost of MINILAP was at least $1900 less than that of LAP because of shorter total hospital stay, shorter operation time, and lower equipment cost. CONCLUSIONS: Compared with LAP, MINILAP was more cost-effective and produced less morbidity. Patient satisfaction with the procedures was similar. MINILAP is an excellent alternative to LAP for prostate cancer staging in general urology practice.     

Laparoscopic ovarian transposition for pelvic malignancies: indications and functional outcomes

OBJECTIVE: To assess the indications and effectiveness of laparoscopic ovarian transposition before pelvic irradiation for a gynecologic cancer. DESIGN: Prospective study. SETTING: A gynecologic oncology department in a French anti-cancer center. PATIENT(S): Twenty-four patients treated for pelvic cancer. INTERVENTION(S): Laparoscopic ovarian transposition to paracolic gutters. Uterine conservation in 18 patients. MAIN OUTCOME MEASURE(S): Clinical and laboratory follow-up tests of ovarian function. RESULT(S): Bilateral laparoscopic ovarian transposition was achieved in 22 patients (94%). Twelve patients were treated for clear cell adenocarcinoma of the cervix and/or upper vagina, 6 patients for invasive squamous cervical carcinoma, 3 patients for pelvic sarcoma, 1 patient for recurrent cervical cancer to the upper vagina, 1 patient for ependymoma of the cauda equina, and 1 patient for ovarian dysgerminoma. Ovarian preservation was achieved in 79%. Three pregnancies were obtained. CONCLUSION(S): Laparoscopic ovarian transposition is a safe and effective procedure for preserving ovarian function. Bilateral ovarian transposition should be performed. The main indications for laparoscopic ovarian transposition are a patient with a small invasive cervical carcinoma (<2 cm) in a patient <40 years of age who is treated by initial laparoscopically assisted vaginal radical hysterectomy and a patient with a clear cell adenocarcinoma of the cervix and upper vagina.     

Vaginal intraepithelial neoplasia (VAIN) following hysterectomy in patients treated for carcinoma in situ of the cervix

BACKGROUND: Cell adhesion in the limbal region is of outstanding importance for the regeneration of the corneal epithelium and for repair mechanisms after antiglaucomatous fistulating surgery. In the basement membranes cell adhesion is largely modified by the extracellular matrix protein laminin. The aim of our study was to establish the immunohistochemical pattern of the different laminin-isoforms and subunits in the basal membrane of the limbal conjunctiva and episcleral vessels. MATERIAL AND METHOD: For immunohistochemistry five normal human donor eyes were included; we used antibodies against the laminin heterotrimers 1 and 2, against the laminin subunits alpha 2, beta 1, beta 2, gamma 1, gamma 2 and against the laminin-associated protein nidogen. RESULTS: The basement membrane of the limbal conjunctiva reveals immunoreactivity against all used antibodies. The subconjunctival and episcleral vessels showed no staining for the laminin subunit gamma 2, but for all other used antibodies. CONCLUSION: The basement membrane of the limbal and conjunctival epithelium as well as the basement membrane of subconjunctival and episcleral vessels express a broad spectrum of laminin variants. This diversity emphasizes functional specialization of the limbal region, although the exact importance of the laminin variants is still unknown.