Gynecologic Cancer Surgery Research Articles

First experience of enhanced recovery in a tertiary gynecologic oncology centre in the UK

Objective: Enhanced recovery is a novel approach to elective surgery that ensures that patients are in the optimal condition for the surgical treatment, thus minimizing complications, offering more effective rehabilitation and a shorter length of stay. The main aim of this project was to prospectively assess the effectiveness of this approach in patients undergoing major surgery for gynecologic cancers.

How risky is it to operate on patients with low albumin? Analysis of the patients undergoing surgery for gynecologic cancers

How risky is it to operate on patients with low albumin? Analysis of the patients undergoing surgery for gynecologic cancers

Trends in hospital volume and patterns of referral for women with gynecologic cancers

Objective: Hospital procedural volume is a strong predictor of outcome for several high-risk cancer surgeries. Over the last decade, there have been numerous initiatives to concentrate certain high-risk oncologic procedures to high-volume hospitals. As little is known on whether these efforts have altered the referral patterns for patients undergoing gynecologic cancer surgery, we examined trends in hospital volume and referral patterns for women with uterine cancer and women with ovarian cancer.

Two-Port Access Laparoscopic Surgery in Gynecologic Oncology

The purpose of this study was to evaluate the feasibility and safety of 2-port access (TPA) laparoscopy in gynecologic oncology. This was a retrospective review of 81 consecutive patients who underwent TPA laparoscopic surgery for various gynecologic cancers from March 2009 to September 2011. The TPA system consisted of a single multichannel port at the umbilicus and an ancillary 5-mm port in the suprapubic area. The surgical procedures included comprehensive ovarian cancer staging (33 patients), radical hysterectomy with pelvic lymph node dissection (19 patients), and endometrial cancer staging (29 patients). All surgical procedures were completed laparoscopically with no conversion to laparotomy. Two cases required 1 or 2 additional ports. The mean operating time, estimated blood loss, and number of lymph nodes were 253.8 minutes, 170.7 mL, and 34.9, respectively. Three patients (9.1%) with ovarian cancer and 4 patients (13.8%) with endometrial cancer were upstaged after surgery. The mean postoperative hospital stay was 6.6 days, and the mean postoperative pain scores (0-10 scale) were 3.4 at 6 hours, 3.0 at 24 hours, and 2.5 at 48 hours. Postoperative complications occurred at a low incidence (4.9%) and included one umbilical hernia, one vault dehiscence, and one lumbosacral nerve injury. Two-port access laparoscopic surgery using a single multichannel port system is a feasible and safe procedure in selected patients with gynecologic cancers. Prospective randomized trials will permit the evaluation of the potential benefits of this minimally invasive surgical technique.

Venous Thromboembolism (VTE) Rates Following the Implementation of Extended Duration Prophylaxis for Patients Undergoing Surgery for Gynecologic Malignancies

The most common preventable cause of hospital death in the United States is venous thromboembolism (VTE). The risk of VTE among women undergoing major surgery for gynecologic cancer can be substantially reduced by use of postoperative VTE prophylaxis consisting of subcutaneous unfractionated heparin or low-molecular-weight heparin (LMWH) and mechanical prophylaxis. Evidence-based guidelines from several national organizations recommend that patients undergoing abdominal or pelvic surgery for malignancy receive this VTE prophylaxis regimen for up to 28 days postoperatively. Despite these recommendations, VTE prophylaxis is widely underused in this patient population. Poor compliance with the VTE prevention guidelines at the MD Anderson Cancer Center in Houston resulted in a higher than expected postoperative VTE rate among gynecologic-oncology patients. In 2009, standardized extended VTE prophylaxis practice guidelines were initiated at this institution for all patients undergoing laparotomy for gynecologic cancer to improve guideline compliance and reduce postoperative VTE rates. The aim of this study was to compare the incidence of VTE before and after the implementation of the standardized prophylaxis guidelines in women undergoing laparotomy for gynecologic cancer. Patients were started on LMWH within 24 hours of surgery, and it was continued for a total of 28 days postoperatively. The incidence of VTE diagnosed within 30 and 90 days of surgery in a postimplementation guideline group (extended-duration LMWH, n = 334) was compared with a preguideline historical group (no extended-duration LMWH, n = 300). The incidence of VTE diagnosed within 30 days of surgery was reduced by 78% in the postguideline group compared with the preguideline group (2.7% vs 0.6%, respectively; P = 0.040). However, the effect was not sustained when the preguideline and postguideline implementation groups were compared for VTE diagnosed within 90 days of surgery (3.7% vs 3.0%, respectively; P = 0.619). The median time between surgery and VTE diagnosis was significantly longer following implementation of the guidelines (57 vs 12 days, respectively; P = 0.012). These data show significant reduction of VTE rates in a cohort of women undergoing laparotomy for gynecologic malignancy who received extended-duration LMWH compared with similar patients who did not receive extended-duration LMWH. This effect was not sustained, however, when the groups were compared for VTE diagnosis within 90 days of surgery.

The Use of Laparostomy in Patients With Gynecologic Cancer: First Report From a UK Cancer Center

To report on the use of laparostomy after major gynecologic cancer surgery. Operative records and surgical databases of patients who underwent major open abdominal surgery over a 6.5-year period at a tertiary referral center were searched. Patients who had diagnostic procedures, operative laparoscopy, and surgery for vulval cancer were excluded. All patients who had laparostomy were identified; and the diagnosis, indication for laparostomy, method of temporary cover, and complications were recorded. A total of 1592 laparotomies, including 37 emergencies, were performed. Of these, 14 patients (0.88%) had a laparostomy. Seven patients had primary cancer and 7 had recurrent cancer. As more patients had surgery for primary disease, laparostomy was more common in patients who underwent surgery for recurrent cancer. Seven patients had ovarian/fallopian tube/primary peritoneal cancer, 4 patients had uterine cancer, 2 patients had cervical cancer, and one patient had vaginal cancer. Ten laparostomies (71.4%) were performed after an emergency procedure; thus, laparostomy was approximately 100 times more common after emergency than elective major surgery. Massive bowel distension and bowel wall edema were the major indications for laparostomy. The method of temporary closure was variable, and a sterile saline bag was the most commonly used. The laparostomy was closed in all but 2 patients, most often on postoperative day 2 or 3. Two patients (14.3%) died within 30 days of the laparostomy, and 2 others died at postoperative days 40 and 62. Three of these 4 patients had recurrent cancer, and 2 patients had emergency procedures. The overall incidence of laparostomy associated with laparotomy for gynecological cancer surgery was less than 1:100 cases, was more common after surgery for recurrent cancer, and in particular, was approximately 100 times more common after emergency procedures. The 30-day operative mortality rate was 14.3%.

Prediction of major surgical complications by comprehensive geriatric assessment in elderly patients with gynecologic cancers: A prospective cohort study.

e20530 Background: To evaluate the ability of a preoperative comprehensive geriatric assessment (CGA) to predict the risk of postoperative complications in elderly patients who underwent primary surgery for gynecologic cancers. Methods: Sixty consecutive patients (26 ovarian, 16 cervical, 7 endometrial, 5 uterine sarcoma, 4 vulvar, and 2 metastatic cancers) older than 70 years scheduled to take surgery electively for gynecologic cancer were preoperatively assessed by CGA. Every category of CGA was evaluated for in-hospital postoperative complications and mortality within 30 days of surgery. Major complication included any complication of 2 or higher grade according to Memorial Sloan-Kettering Surgical Complication Criteria 12/99. Results: Mean age was 73.6±3.5 years (range 70-85). Overall postoperative complication rate was 30.0% (18/60) including 9 (15.0%) major and 8 (13.3%) multiple complications. Mean hospital stay was 18.4±13.3 days (range 3-81), during which in-hospital mortality was 2 (3.3%). Univariate analysis revealed that dependent instrumental activity of daily living (IADL) was associated with any postoperative complication (p=0.023), especially for multiple complications (p=0.019). However, poor performance status (PS) was associated only with major and multiple complications (p=0.021 and p=0.014, respectively). Multiple regression analysis revealed that dependent IADL was the independent risk factor for any postoperative complication (relative risk [RR] 8.0, 95% confidence interval [CI] 1.1-59.8, p = 0.042). Notably, poor PS was significantly associated with postoperative mortality (p = 0.006), however, dependent IADL with a marginal significance (p = 0.059). Conclusions: IADL and PS were useful to predict postoperative complications and related mortality in elderly patients with gynecologic cancers. Postoperative complications and related mortality can be prevented by identifying the elderly patients with gynecologic cancers who showed dependent IADL and poor PS in CGA.

The Physical Consequences of Gynecologic Cancer Surgery and Their Impact on Sexual, Emotional, and Quality of Life Issues

Surgical management of gynecologic cancer can cause short- and long-term effects on sexuality, reproductive function, and overall quality of life (QOL) (e.g., sexual dysfunction, infertility, lymphedema). However, innovative approaches developed over the past several decades have improved oncologic outcomes and reduced treatment sequelae. To provide an overview of the standards of care and major advancements in gynecologic cancer surgery, with a focus on their direct physical impact, as well as emotional, sexual, and QOL issues. This overview will aid researchers and clinicians in the conceptualization of future clinical care strategies and interventions to improve sexual/vaginal/reproductive health and QOL in gynecologic cancer patients. Comprehensive overview of the literature on gynecologic oncology surgery. Conceptual framework for this overview follows the current standards of care and recent surgical approaches to treat gynecologic cancer, with a brief overview describing primary management objectives and the physical, sexual, and emotional impact on patients. Extensive literature support is provided. The type and radicality of surgical treatment for gynecologic cancer can influence sexual function and play a significant role in QOL. Psychological, sexual, and QOL outcomes improve as surgical procedures continue to evolve. Procedures for fertility preservation, laparoscopy, sentinel lymph node mapping, and robotic and risk-reducing surgery have advanced the field while reducing treatment sequelae. Nevertheless, interventions that address sexual and vaginal health issues are limited. It is imperative to consider QOL and sexuality during the treatment decision-making process. New advances in detection and treatment exist; however, psycho-educational interventions and greater patient-physician communication to address sexual and vaginal health concerns are warranted. Large, prospective clinical trials including patient-reported outcomes are needed in gynecologic oncology populations to identify subgroups at risk. Future study designs need clearly defined samples to gain insight about sexual morbidity and foster the development of targeted interventions.

Perioperative care in gynecologic oncology

To review perioperative care in gynecologic oncology with special emphasis on areas of controversy. Major gynecologic surgery still represents the cornerstone of management among women diagnosed with gynecologic malignancies. The implementation of clinical guidelines can significantly impact perioperative morbidity and mortality. Preoperative evaluation and preparation allows the surgeon to identify patient risks and develop risk factor modification strategies decreasing delays in preparation and cost and improving patient safety. Preoperative areas of controversy include preoperative testing and evaluation, use of mechanical bowel preparation, prophylactic antibiotics, and use of anticoagulants, and the timing of postoperative feeding. In healthy women undergoing gynecologic cancer surgery preoperative evaluation requirements will be minimal. For women with extensive comorbid conditions a more detailed evaluation will be required to decrease perioperative morbidity and mortality. Mechanical bowel preparations should not be required preoperatively. Preoperative administration of antibiotics and anticoagulants should be provided to all patients undergoing major gynecologic cancer surgery.

The Role of Palliative Surgery in Gynecologic Cancer Cases

The decision to undergo major palliative surgery in end-stage gynecologic cancer is made when severe disease symptoms significantly hinder quality of life. Malignant bowel obstruction, unremitting pelvic pain, fistula formation, tumor necrosis, pelvic sepsis, and chronic hemorrhage are among the reasons patients undergo palliative surgeries. This review discusses and summarizes the literature on surgical management of malignant bowel obstruction and palliative pelvic exenteration in gynecologic oncology.

ASGO 2nd International Workshop on Gynecologic Oncology

ASGO 2nd International Workshop on Gynecologic Oncology

Therapeutic and prognostic value of lymphadenectomy in gynecological oncology

Lymphadenectomy is an integral part of gynecological cancer surgery however there is still lack of standardization in the terminology used. In the current literature several types of surgical procedures for pelvic lymph nodes dissection are recognized. Complete pelvic lymphadenectomy is defined as the removal of all fatty lymphatic tissue from the predicted areas of high incidence of lymph nodes with possible metastatic involvement. Para-aortic lymphadenectomy is defined as the removal of all lymphatic tissue from the aortic region. The latter is divided into two levels: the lower--up to the inferior mesenteric artery and the upper--up to the left renal vein. Another classification divided pelvic and aortic lymphadenectomy into three classes. Class I is defined as the removal of the chosen lymph nodes, class II as the removal of lymph nodes located ventrally and laterally to the large retroperitoneal pelvic vessels, obturator nerves and laterally to the aorta and the inferior vena cava, whereas class III as the complete removal of lymphatic tissue surrounding the iliac vessels, obturator pits, dorsally to the obturator nerve and the presacral lymph tissue around the aorta and the inferior vena cava. In each gynecological cancer depending on the severity of the disease different procedures are applied concerning lymphadenectomy. In patients with advanced ovarian cancer systematic lymphadenectomy prolongs the survival rate. Omission of systematic lymphadenectomy can be considered only for patients with mucinous carcinoma G1 level. In the case of vulvar cancer removal of pelvic, iliac and obturator lymph nodes is inappropriate as it has not been proven to result in an increased survival rate. Inguinal lymphadenectomy in this cancer depends on the stage and location of the primary tumor--at an early stage vulvar cancer located laterally a superficial, unilateral inguinal lymphadenectomy can be performed, if the primary lesion is located centrally an inguinal lymphadenectomy should be performed on both sides. Deep inguinal lymphadenectomy should be performed only in cases where: primary tumor is located centrally in case of cancer in the early stages, in advanced stage and in patients with metastases in the superficial nodes. Sentinel lymph node biopsy is an alternative method that can be offered to patients with early-stage vulvar cancer located laterally. Lymphadenectomy in endometrial cancer is beneficial in stages I G3, II and III. In stages I G1 and G2 an increase in the survival time has not been shown. The cervical cancer stage IB-IIA removal of para-aortic lymph nodes (to the mesenteric artery) is indicated in patients with large tumors and suspected or known disease in the pelvic nodes. In patients in whom diagnostic imaging studies have not shown metastasis in para-aortic and pelvic lymph nodes or distant metastasis, para-aortic lymphadenectomy can be omitted. Further randomized studies are needed to elucidate the necessity and extent of lymphadenectomy in given gynecological cancers.

The Role of Intraoperative Fluid Optimization Using the Esophageal Doppler in Advanced Gynecological Cancer: Early Postoperative Recovery and Fitness for Discharge

To determine the effect of fluid optimization using esophageal Doppler monitoring (EDM) when compared to standard fluid management in women who undergo major gynecological cancer surgery and whether its use is associated with reduced postoperative morbidity. From January 2009 to December 2010, women undergoing laparotomy for pelvic masses or uterine cancer had either fluid optimization using intraoperative EDM or standard fluid replacement without using EDM. Cases were selected from 2 surgeons to control for variability in surgical practice. Demographic and surgical details were collected prospectively. Univariate and multivariate analyses were performed to quantify the association between the use of EDM with "early postoperative recovery" and "early fitness for discharge." A total of 198 women were operated by the 2 prespecified surgeons; 79 women had fluid optimization with EDM, whereas 119 women had standard anesthetic care. The use of ODM was associated with earlier postoperative recovery (adjusted odds ratio, 2.83; 95% confidence interval, 1.20-6.68; P = 0.02) and earlier fitness for discharge (adjusted odds ratio, 2.81; 95% confidence interval, 1.01-7.78; P = 0.05). Women with advanced-stage disease in the "EDM" group resumed oral diet earlier than women in the "no EDM" group (median, 1 day vs 2 days; P = 0.02). These benefits with EDM did not extend to women with early-stage disease/benign/borderline tumors. No significant difference in postoperative complications was noted. Intraoperative fluid optimization with EDM in women with advanced gynecological cancer may be associated with improved postoperative recovery and early fitness for discharge. Studies with adequate power are needed to investigate its role in reducing postoperative complications.

A novel therapeutic strategy for chylous ascites after gynecological cancer surgery: a continuous low-pressure drainage system

Postoperative chylous ascites is an unusual complication following retroperitoneal surgery. A search of the English literature showed only 44 cases of chylous ascites following gynecological cancer surgery. The treatment is primarily conservative, but surgical treatment is considered in resistant cases. We developed a novel non-surgical therapeutic strategy for postoperative chylous ascites. We report a case of severe chylous ascites following pelvic lymph node dissection for gynecological cancer. Total abdominal hysterectomy, bilateral salpingo-oophorectomy, peritoneal washing, and systematic pelvic lymph node dissection were performed for a stage II G1 endometrioid adenocarcinoma (FIGO 2009). Forty-one days after surgery, the patient was readmitted due to massive ascites. Repeated paracentesis and a low-fat diet were only partially effective. Fifty-one days after surgery, we started paracentesis with a continuous low-pressure drainage system. Nine days later, there was no further fluid drainage. The patient was asymptomatic and without recurrent disease at follow-up 3 months later. Pelvic lymph node dissection may cause postoperative chylous ascites. Paracentesis with a continuous low-pressure drainage system can be an effective conservative treatment for postoperative chylous ascites.

O113 PORT SITE METASTASIS AFTER ROBOTIC SURGERY FOR GYNECOLOGIC CANCER

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S300-S300 Free communication (oral) presentations O113 PORT SITE METASTASIS AFTER ROBOTIC SURGERY FOR GYNECOLOGIC CANCER T. Bossmar, Search for more papers by this authorJ. Persson, Search for more papers by this author T. Bossmar, Search for more papers by this authorJ. Persson, Search for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)60543-8AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S300-S300 RelatedInformation

Would complex decongestive therapy reveal long term effect and lymphoscintigraphy predict the outcome of lower-limb lymphedema related to gynecologic cancer treatment?

ObjectiveThe aims of this study were to investigate the long-term effect of complex decongestive therapy (CDT) on lymphedema volume reduction, especially considering the proximal and distal parts of the leg, and to evaluate the utility of pre-therapy lymphoscintigraphy in predicting the response to CDT in patients with lower-limb lymphedema after surgery for gynecologic cancer. MethodsMedical records of 158 patients with secondary lymphedema of unilateral leg after surgery for gynecological cancer were reviewed retrospectively. They were treated with two weeks of CDT along with self-administered home therapy and were followed up for 24months. Whole, proximal and distal leg volume was serially measured by using an optoelectric volumeter prior to and immediately after therapy, and follow-up visits at months 3, 6, 12 and 24. Lymphoscintigraphy was performed prior to therapy. ResultsThe percent volume reduction was 22.1% in the whole leg, 30.9% in the distal leg and 18.4% in the proximal leg immediately after CDT. The volume reduction was maintained for 24months, but the distal leg was significantly well maintained better than the proximal leg. Extremity radioisotope uptake ratio (EUR) among lymphoscintigraphic findings could predict the improvement of lymphedema volume in the distal, proximal and whole leg. ConclusionsThis study suggests that the long-term edema reducing effects of CDT are better maintained in the distal leg than in the proximal part, and initial lymphoscintigraphic quantitative finding may usefully predict the short and long-term response to CDT.

Changes in soluble fibrin levels during the perioperative period of gynecologic cancer surgery

The purpose of this study was to evaluate the changes in plasma soluble fibrin (SF) levels over time in gynecologic cancer patients following surgery. Furthermore, we examined the duration of the coagulation stage and determined a suitable duration for which thromboprophylaxis with anticoagulant agents should be administered. We retrospectively studied 311 patients with invasive gynecologic cancer who underwent surgery at Okayama University Hospital, Japan. The plasma SF levels were measured serially prior to the operation and on postoperative days 0, 1, 3, 5, 7, 10, 14, 21 and 28. The plasma SF levels increased rapidly, peaked on postoperative day 1 and then decreased. The SF levels of patients with venous thromboembolism (VTE) were significantly different from those of VTE-negative patients on postoperative days 0-10. The SF levels on each day did not significantly differ between patients treated with chemical anticoagulants and those treated mechanically. The plasma SF levels were elevated (≥7.0 μg/ml) in 159 of the 311 patients (51.1%) on one of the days when these levels were measured. Among the patients with elevated plasma SF levels, 110 patients (69.2%) peaked on days 0-3 and only 9 patients (5.7%) peaked on days 21-28. Although only 1 of the 14 patients (7.1%) who showed peak levels on day 14 had undergone chemotherapy following surgery, 8 of the 9 patients (88.9%) whose levels peaked on days 21-28 had undergone chemotherapy following surgery (P= 0.0002). In conclusion, the plasma SF levels increased rapidly, peaked on postoperative day 1 and then decreased. These levels peaked within 14 days of surgery in most cases. Therefore, chemical thromboprophylaxis may be administered for at least up to 14 days following surgery.

Quality of life following panniculectomy for gynecologic cancer surgery

Quality of life following panniculectomy for gynecologic cancer surgery

Port-site recurrence in a patient undergoing robot-assisted gynecologic cancer surgery for endometrial cancer — A case report

► First case of port-site metastasis after robotic staging surgery for uterine cancer. ► Changes to robotic surgical technique to reduce risk of port-site recurrence. ► Further areas of investigation worth examining in this aspect of robotic surgery.

A prospective study of the feasibility and acceptability of a Web-based, electronic patient-reported outcome system in assessing patient recovery after major gynecologic cancer surgery

PurposeThe purposes of this study are to evaluate the feasibility of capturing patient-reported outcomes (PROs) electronically and to identify the most common distressing symptoms in women recovering from major gynecologic cancer surgery. MethodsThis was a prospective, single-arm pilot study. Eligible participants included those scheduled for a laparotomy for presumed or known gynecologic malignancy. Patients completed a Web-based “STAR” (Symptom Tracking and Reporting for Patients) questionnaire once preoperatively and weekly during the 6-week postoperative period. The questionnaire consisted of the patient adaptation of the NCI CTCAE 3.0 and EORTC QLQ-C30 3.0. When a patient submitted a response that was concerning, an automated email alert was sent to the clinician. The patient's assessment of STAR's usefulness was measured via an exit survey. ResultsForty-nine patients completed the study. The procedures included the following: hysterectomy±staging (67%), resection of tumor (22%), salpingo-oophorectomy (6%), and other (4%). Most patients (82%) completed at least 4 sessions in STAR. The CTC generated 43 alerts. These alerts resulted in 25 telephone contacts with patients, 2 ER referrals, one new appointment, and one pharmaceutical prescription. The 3 most common patient-reported symptoms generating an alert were as follows: poor performance status (19%), nausea (18%), and fatigue (17%). Most patients found STAR useful (80%) and would recommend it to others (85%). ConclusionApplication of a Web-based, electronic STAR system is feasible in the postoperative period, highly accepted by patients, and warrants further study. Poor performance status, nausea, and fatigue were the most common distressing patient-reported symptoms.