Laparoscopic Radical Hysterectomy Research Articles

Feasibility and Outcomes of "No-Look No-Touch" Laparoscopic Radical Trachelectomy for Early-Stage Cervical Cancer.

Intraoperative tumor manipulation and dissemination may compromise the survival of women with early-stage cervical cancer who undergo laparoscopic surgery. This study aimed to examine survival and obstetrical outcomes related to laparoscopic radical trachelectomy (LRT) with a “no-look no-touch” technique in 40 women. This technique incorporates five measures to prevent tumor spillage and damage to the uterine artery perfusion. Five LRTs were aborted because of positive nodes or positive surgical margins. Compared with those of type III laparoscopic radical hysterectomy, the surgical outcomes of LRT in 35 patients were acceptable: operative time (380 min), estimated blood loss (140 mL), length of hospital stay (15 days), and lengths of excised parametrium and vagina. During follow-up (median, 41.3 months), the 5-year disease-free survival and overall survival were 95.0% (95% CI: 69.5–99.3%) and 100%, respectively. Of the nine patients (26%) who attempted pregnancy, seven conceived (nine pregnancies, 76%). Eight were delivered by term cesarean section, while one was miscarried in the first trimester. Our study suggests that the no-look no-touch technique may be effective in reducing the risk of recurrence and improving obstetrical outcomes during LRT for early-stage cervical cancer.

The Effect of Laparoscopic Radical Hysterectomy Surgical Volume on Oncology Outcomes in Early-Stage Cervical Cancer

Purpose: To examine the association between surgical volume and surgical and oncological outcomes of women with stage IB1 cervical cancer who underwent laparoscopic radical hysterectomy (LRH).Methods: We retrospectively analyzed the oncological outcomes of 1,137 patients with stage IB1 cervical cancer receiving LRH from 2004 to 2016. The surgical volume for each surgeon was defined as low [fewer than 50 surgeries, n = 392(34.5%)], mid [51-100 surgeries, n = 315(27.7%)], and high [100 surgeries or more, n = 430(37.8%)]. Surgical volume-specific survival was examined with Kaplan–Meier analysis, multivariable analysis, and propensity score matching.Results: The operative times of the high-volume group (227.35 ± 7.796 min) were significantly shorter than that of the low- (272.77 ± 4.887 min, p < 0.001) and mid-volume (255.86 ± 4.981 min, p < 0.001) groups. Blood loss in the high-volume group (169.42 ± 8.714 ml) was significantly less than that in the low-volume group (219.24 ± 11.299 ml, p = 0.003). The 5-year disease-free survival (DFS) and overall survival (OS) in the low-volume, mid-volume, and high-volume groups were similar (DFS: 91.9, 86.7, and 89.2%, p = 0.102; OS: 96.4, 93.5, and 94.2%, p = 0.192). Multivariable analysis revealed surgical volume was not an independent risk factor for OS or DFS. The rate of intraoperative and postoperative complications was similar among the three groups (p = 0.210).Conclusions: Surgical volume of LRH may not be a prognostic factor for patients with stage IB1 cervical cancer. Surgery at high-volume surgeon is associated with decreased operative time and blood loss.

Wertheim’s Operation. Problems and achievments

Aim. Analysis of modern modification of Wertheim’s operation and its results in Bukovina region for last 10 years.Methods. Analysis of literature in internet. Data about morbidity and mortality of cancer colli uteri in Chernivtsi Oncology Center.Results. An original description of the technique of radical hysterectomy for cervical cancer by Wertheim is presented. Modifications of the Wertheim operation with various classifications of interventions are considered. In first class of this classification are included extra fascial hysterectomies without resection of tissues, lymph nodules and fascia of pelvis which directly contradicts the principles of Wertheim's operation. The results of radical laparoscopic hysterectomy for cervical cancer are discussed. In 2019 trials, there was an almost three-fold excess of relapses after laparoscopic hysterectomies compared to open operations. The issues of the epidemiology of cervical cancer in Ukraine and Bukovina are considered. The incidence of cervical cancer in the Chernivtsi region was about 70 patients per year, or 8.4 per 100,000 population (data from 2016-2018). Cervical cancer mortality was from 40 to 43 people annually or 4.3-4.7 per 100,000 population. Wertheim’s operation is performed annually in 26-34 women and is practically not accompanied by complications and mortality.Conclusion. Wertheim’s operation is safe and unique method for treatment of cervical cancer.

Comparison between laparoscopic and abdominal radical hysterectomy for low-risk cervical cancer: a multicentre retrospective study.

To compare oncological outcomes of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for low-risk cervical cancer. We retrospectively compared the 3-year overall survival (OS) and 3-year disease-free survival (DFS) of 1269 low-risk cervical cancer patients with FIGO 2009 stage IA2, IB1 and IIA1 with a tumour size < 2cm, no lymphovascular space invasion (LVSI), superficial stromal invasion and no lymph node involvement on imaging, and who received LRH (n = 672) and ARH (n = 597) between 2009 and 2018 at 47 hospitals. In the total study population, LRH and ARH showed similar 3-year OS (98.6% vs. 98.9%, P = 0.850) and DFS rates (95.7% vs. 96.4%, P = 0.285). LRH was not associated with worse 3-year OS (HR 0.897, 95% CI 0.287-2.808, P = 0.852) or DFS (HR 0.692, 95% CI 0.379-1.263, P = 0.230) as determined by multivariable analysis. After propensity score matching in 1269 patients, LRH (n = 551) and ARH (n = 551) still showed similar 3-year OS (98.4% vs. 98.8%, P = 0.704) and DFS rates (95.5% vs. 96.3%, P = 0.249). LRH was still not associated with worse 3-year OS (HR 0.816, 95% CI 0.262-2.541, P = 0.725) or DFS (HR 0.694, 95% CI 0.371-1.296, P = 0.251). Among patients with low-risk cervical cancers < 2cm, no LVSI, superficial stromal invasion, and no lymph node involvement on imaging, no significant differences were observed in 3-year OS or DFS rates between LRH and ARH.

Assessment of Pelvic Floor Function and Quality of Life in Patients Treated for Cervical Cancer: A Multicenter Retrospective Study

Objectives: Our study aimed to evaluate the quality of life (QoL) and pelvic floor function of cervical cancer (CC) patients after treatment. Design: This was a cross-sectional observational cohort study. Participants: The participants included in this study were CC patients who underwent radical hysterectomy (RH) from 2012 to 2018 at 18 medical centers across China. Methods: The validated versions of the Pelvic floor Distress Inventory-Short Form 20, Overactive Bladder Symptom Score, and Euro Qol Five-Dimension questionnaires were used to evaluate postoperative pelvic floor dysfunction (PFD) and QoL. Results: A total of 689 CC patients were enrolled. The incidence of stress urinary incontinence (SUI), incomplete urinary emptying, and constipation were 32.7, 27.7, and 28.6%, respectively. Multivariate analysis confirmed that laparoscopic RH (LRH) and vaginal wall resection greater than 3 cm were risk factors for lower urinary tract symptoms (LUTS). LRH and chemotherapy were risk factors for SUI. Chemoradiotherapy and LRH were risk factors for overactive bladder (OAB). A high body mass index and LRH were risk factors for more severe defecation symptoms. ARH and large amount of operative blood loss were risk factors for poor QoL. Conclusion: PFD is common in CC patients after treatment. LRH seems to increase the postoperative distress, including LUTS and defecation symptoms. Postoperative urinary incontinence and OAB are more bothersome for patients undergoing chemotherapy and radiotherapy. We recommend evaluating pelvic floor function as a standard assessment during follow-up.

Comparison of radical hysterectomy with pelvic lymphadenectomy and radical prostatectomy with lymphadenectomy: Medicare reimbursement 2010-2019

<h3>Objectives:</h3> To investigate differences in Medicare reimbursement between hysterectomy and prostatectomy (with lymphadenectomy) between Gynecology and Urology <h3>Methods:</h3> The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid was utilized to extract reimbursement data for the two CPT codes representing open radical hysterectomy with lymphadenectomy and laparoscopic radical hysterectomy with lymphadenectomy. Likewise, the CPT code representing open radical prostatectomy with lymphadenectomy and the two CPT codes representing laparoscopic radical prostatectomy and lymphadenectomy was also collected. There is no code that combines laparoscopic prostatectomy and lymphadenectomy, so the values were combined. Average annual and total percent change in reimbursement was calculated for each hysterectomy with lymphadenectomy and prostatectomy with lymphadenectomy. <h3>Results:</h3> Reimbursement for the open hysterectomy with lymphadenectomy decreased by an average of 13.72%, and for the open prostatectomy with lymphadenectomy by 27.88% from 2010 to 2019 with R-squared values of 0.98 and 0.92, respectively. Reimbursement rates from 2010 to 2019 for open procedures averaged $1,828.59 and $1,649.44, respectively. Reimbursement for laparoscopic hysterectomy with lymphadenectomy decreased by an average of 13.72% with an R-value of 0.98 and by 34.99% with an R-value of 0.94 for the laparoscopic prostatectomy with lymphadenectomy procedure. Reimbursement rates for laparoscopic procedures from 2010 to 2019 averaged $1,860.22 and $2,722.99, respectively. <h3>Conclusions:</h3> This study provides an analysis of trends in procedural Medicare reimbursement for oncologic procedures performed by gynecologic and urologic surgeons. Findings suggest that urologists are reimbursed slightly less for open radical prostatectomy with lymphadenectomy compared to their gynecology counterparts, while being reimbursed more for laparoscopic prostatectomy with lymphadenectomy compared to their gynecology counterparts. This is an area of concern since minimally invasive procedures have become the industry standard. Results suggest continuing disparities surrounding Medicare reimbursements for sex-specific procedures

The value of preoperative imaging for identification of metastatic disease and prediction of adjuvant therapy in clinical early-stage cervical cancer

Objectives: The FIGO 2018 revised cervical cancer (CC) staging includes radiologic and pathologic data. No standardized guidelines exist guiding routine pre-operative (pre-op) imaging in patients (pts) with presumed early stage disease. Adjuvant chemoradiotherapy (CRT) increases morbidity, highlighting the need for improved preoperative risk assessment. Identification of clinical scenarios where imaging may be omitted is needed for cost effectiveness. We evaluated the ability of preoperative imaging to predict need for adjuvant CRT in pts with clinical early stage CC. Methods: This is a retrospective review of all pts with CC treated surgically at our institution between 2010 and 2017. All pts had negative imaging or no imaging prior to surgery. Demographic and clinicopathologic data was abstracted from medical records. Included pts had squamous, adenocarcinoma, or adenosquamous histology treated primarily with abdominal, laparoscopic, or robotic radical hysterectomy. Pts were assigned to 1 of 2 groups: those who had pre-op imaging with MRI, CT, or PET, and those who had none. Primary outcome was percentage of pts requiring adjuvant CRT by imaging group. Secondary outcomes were rate of nodal metastasis, five year overall survival (OS), progression free survival (PFS), and treatment-related morbidity. Statistical tests used were chi-square, logistic regression, and Kaplan-Meier survival analysis. Results: Of 147 pts, 104 underwent pre-op imaging and 43 did not. Demographics did not differ between groups, except for more self-pay pts (16% vs 39.5%, p=0.002) and pts with adenocarcinoma (31% vs 44%, p=0.047) receiving no pre-op imaging. Pre-op imaging was not associated with a significant difference in the rate of adjuvant CRT (40% vs 35%, p=0.49), or nodal disease (15% vs 11.6%, p=0.55). There was no difference in rate of recurrence (15% vs 11.6%, p=0.55), OS (91% vs 89%, p=0.92), or PFS (76% vs 83%, p=0.66). Groups had similar rates of morbidity (35% vs 30%, p=0.53). Small tumor size predicted negative lymph nodes; 4.1% of pts with tumors less than 2cm had positive nodes on final pathology (OR=0.11, p=0.028). Many pts with clinical early stage disease do not receive surgery; thus, additional data was abstracted for pts with clinical stages I-IIA2 CC who underwent primary CRT. Of 92 pts who might otherwise have been eligible for surgical treatment, 39 (43%) had imaging findings suspicious for lymph node metastasis. Download : Download high-res image (144KB) Download : Download full-size image Conclusions: Though limited by sample size, approximately 20% of all clinically early stage pts in our cohort were upstaged by imaging and were not offered primary surgery. Imaging appears to be useful for initial disposition to primary surgery vs. CRT, but does not predict the need for adjuvant CRT, recurrence risk, or survival in pts treated with primary surgery. In pts with small tumors, (

You're sending me home with a catheter? A retrospective review of trial of void after radical hysterectomy

Objectives: To compare adverse urinary outcomes between women who had a radical hysterectomy with a trial of void (TOV) in the immediate post-operative hospitalization vs those who had a TOV after discharge from the hospital. Methods: Retrospective cohort study of patients who underwent laparoscopic, robotic, or abdominal radical hysterectomy from January 1, 2010 to January 1, 2020 at an academic tertiary referral center. Patients were stratified according to whether their first TOV took place before (pre-discharge TOV) vs after (post-discharge TOV) discharge from the index hospitalization. Outcomes including the percentage of patients who failed the initial TOV, re-presentation with urinary retention, presentation to an Emergency Department for a urinary concern within 30 days of surgery, symptomatic dysuria within 30 days of discharge, and de novo urinary dysfunction were analyzed. We hypothesized that urinary outcomes following pre-discharge TOV would lie within a 10% non-inferiority margin of outcomes following post-discharge TOV. A p Results: Eighty patients were included in the analysis. Mean age was 49.5 (SD 14.5) years, with a mean BMI of 30.2 (SD 6.8). The most common indication for radical hysterectomy was cervical cancer 60/80 (75.0%), followed by uterine (14/80; 17.5%) and ovarian (4/80; 5%). 13/80 (16.3%) patients had pre-procedure urinary dysfunction, with no significant differences between groups (p >0.05). 35/80 patients underwent abdominal procedures, 14/80 laparoscopic, and 31/80 robotic, with more robotic patients having a post-discharge TOV (p=0.007). 38/80 (47.5%) patients had a pre-discharge TOV, of which, 2/38 (5.3%) failed. Additionally, 1/38 (2.6%) patient passed a pre-discharge TOV, but subsequently re-presented with urinary retention. 42/80 (52.5%) patients had a post-discharge TOV, of which, 4/42 (9.5%) failed. When comparing patients who underwent pre- vs post-discharge TOVs, there were no significant differences in TOV failure (-4.2% difference; CI -15.6 to 7.1%; p=0.68). Additionally, there were no differences in re-presentation with urinary retention (2.6% pre-discharge vs 0% post-discharge, 2.6% difference; CI -2.5 to 7.7%; p=0.48), presentation to an Emergency Department for a urinary concern (7.9% pre-discharge vs 11.9% post-discharge, -4.0% difference; CI -17.0 to 9.0%; p=0.72), symptomatic dysuria (0% pre-discharge vs 2.4% post-discharge; -2.4% difference, CI -7.0 to 2.2%), or de novo urinary dysfunction (30.6% pre-discharge vs 42.5% post-discharge; -11.9% difference, CI -33.4 to 9.5%;p=0.34). None of these differences had confidence intervals that exceeded the 10% non-inferiority margin. Conclusions: After radical hysterectomy, completion of a pre-discharge TOV is not associated with a ≥10% increased likelihood of an adverse urinary outcome. Providers may consider a pre-discharge TOV to improve quality of life.

Tumor histology and survival after minimally invasive radical hysterectomy for early-stage cervical cancer: a systematic review and meta-analysis

Objectives: A recent randomized controlled trial of minimally invasive (MIS) radical hysterectomy versus open surgery for early-stage cervical cancer has demonstrated higher recurrence and lower survival with MIS. However, given the lower operative morbidity of MIS, multiple groups have attempted to define subgroups of patients who may be able to undergo laparoscopic or robotic radical hysterectomy safely in retrospective cohort studies. Methods: We conducted a systematic review and meta-analysis of cohort studies and randomized controlled trials from 1990 to 2020 comparing MIS radical hysterectomy to open radical hysterectomy in early-stage cervical cancer (PROSPERO 2020 CRD42020173600). Cancer histology, laparoscopic or robotic approach, and overall survival (OS), progression-free survival (PFS), and recurrence rate were recorded for each study. We conducted a random-effects meta-analysis with inverse-probability weighting. Results: 41 studies including 22,593 unique women (10,686 MIS, 47%) were eligible for analysis; 6 reported outcomes by histology. Squamous cell carcinoma was the most common histology (79%). For adenocarcinoma, meta-analysis of 3 studies no differences in recurrence (RR 0.87, 95% CI 0.41-1.85), PFS (RR 0.98, 95% CI 0.07-1.89), or OS (RR 1.41, 95% CI 0.56-2.27) between open and MIS surgery. For SCC, two studies showed no change in PFS, and one large study reported decreased OS (HR 1.65, 95% CI 1.17-2.33). One small study found no difference in PFS or OS for neuroendocrine tumors of the cervix. One large study showed decreased OS with robotic versus open radical hysterectomy (HR 1.61, 95% CI 1.2-2.2), but no difference with laparoscopic versus open surgery (HR 1.50, 95% CI 0.97-2.3). Download : Download high-res image (132KB) Download : Download full-size image Conclusions: This meta-analysis contributes to examination of current evidence on surgical approach to early-stage cervical cancer. Our results suggest that there is no histological group for which MIS radical hysterectomy is superior to open radical hysterectomy, and equivalent to inferior outcomes with robotic or conventional laparoscopic surgery versus open surgery. Subgroup analysis generally showed equivocal or inferior outcomes with MIS compared to open surgery, though results remain limited by sample size.

Machine Learning Models to Predict Survival Outcomes According to the Surgical Approach of Primary Radical Hysterectomy in Patients with Early Cervical Cancer

Simple SummaryAn increased risk of relapse and death from minimally invasive radical hysterectomy has been reported in some patients with early cervical cancer. Thus, the development of an intuitive and precise decision-aid tool, which estimates recurrence and mortality rates by surgical approach, is necessary. To develop models predicting survival outcomes according to the surgical approach, we collected clinicopathologic and survival data of patients with 2009 FIGO stage IB cervical cancer who underwent a radical hysterectomy. Using only variables that could be obtained preoperatively, we developed various models predicting the probability of 5-year progression-free survival and overall survival. Among them, hybrid ensemble models, combined with logistic regression and multiple machine learning models, achieved the best predictive performance. The developed models are expected to help physicians’ and patients’ decision making related to the surgical approach for primary radical hysterectomy.We purposed to develop machine learning models predicting survival outcomes according to the surgical approach for radical hysterectomy (RH) in early cervical cancer. In total, 1056 patients with 2009 FIGO stage IB cervical cancer who underwent primary type C RH by either open or laparoscopic surgery were included in this multicenter retrospective study. The whole dataset consisting of patients’ clinicopathologic data was split into training and test sets with a 4:1 ratio. Using the training set, we developed models predicting the probability of 5-year progression-free survival (PFS) and overall survival (OS) with tenfold cross validation. The developed models were validated in the test set. In terms of predictive performance, we measured the area under the receiver operating characteristic curve (AUC) values. The logistic regression models comprised of preoperative variables yielded AUCs of 0.679 and 0.715 for predicting 5-year PFS and OS rates, respectively. Combining both logistic regression and multiple machine learning models, we constructed hybrid ensemble models, and these models showed much improved predictive performance, with 0.741 and 0.759 AUCs for predicting 5-year PFS and OS rates, respectively. We successfully developed models predicting disease recurrence and mortality after primary RH in patients with early cervical cancer. As the predicted value is calculated based on the preoperative factors, such as the surgical approach, these ensemble models would be useful for making decisions when choosing between open or laparoscopic RH.

Comparison of Surgical Outcomes of Total Laparoscopic Hysterectomy and vNOTES Hysterectomy for Undescended-Enlarged Uteri

Aim This study aimed to compare the surgical outcomes of laparoscopic hysterectomy (LH) and vaginally assisted natural orifice transluminal endoscopic surgery (vNOTES) hysterectomy procedures in women with undescended-enlarged uteri. Materials and methods This cross-sectional study was conducted with 78 women who underwent LH (48 patients) or vNOTES hysterectomy (30 patients) for benign gynecological pathologies. The dimension of the uterus, operation time, intraoperative blood loss, the presence of peri-, postoperative complications, conversion to laparotomy, pre-, postoperative hemoglobin (Hb), and hematocrit (Hct) levels, postoperative hospital stay, total dose of postoperative analgesics, VAS scores at the postoperative 6th and 24th hours, and the final pathology reports were recorded. Results There was no significant difference between LH and vNOTES hysterectomy groups regarding age (47 vs. 47.5 years, p = 0.92), parity (2 vs. 2, p = 0.74), and BMI (30.8 vs. 28.2 kg/m2, p = 0.31). The patients in the vNOTES hysterectomy group had significantly shorter durations of surgery (45 vs. 160 min) and hospitalization (48 vs. 72 h) than the LH group (p < 0.001, p < 0.001, respectively). The 24th hour VAS score was lower (VAS score 2 vs. 3, p = 0.003) in favor of the vNOTES hysterectomy group. In matched group analysis, the 24th hour VAS score (2 vs. 3, p = 0.008), operation time (45 vs. 157, p < 0.001), and hospitalization (48 vs. 72, p < 0.001) were lower in the vNOTES hysterectomy group than the LH group. Conclusion vNOTES hysterectomy provides favorable outcomes compared to conventional LH considering the shorter operation time, hospitalization, and lower 24th h VAS score.

Oxycodone Use During the Postoperative Period After Hysterectomy for Benign Indications.

The objective of this study was to estimate the amount of oxycodone tablets required for pain control in the 2-week postoperative period after laparoscopic hysterectomy (LH) and vaginal hysterectomy (VH) for benign disease. We conducted a prospective cohort study of English-speaking women 18 years or older undergoing hysterectomy for benign indications. Participants completed a pain survey at baseline and daily for 2 weeks postoperatively. In addition, they recorded the number of oxycodone tablets and other pain medications taken daily for 2 weeks. The primary outcome was the median number of oxycodone tablets (5 mg) consumed after LH or VH during 2 weeks postoperative. Eighty-one women underwent VH and 82 underwent LH. Women who underwent VH were older (mean ± SD, 64.2 ± 10.3 years vs 47.5 ± 7.7 years), more parous (2 [interquartile range (IQR), 2-3] vs 2 [IQR, 1-2]), and less likely to be sexually active (51.9% vs 79.3%, P < 0.02). Women in the VH group also had significantly lower baseline pain levels (0 [IQR, 0-1] vs 1 [IQR, 0-4], P < 0.001). All VH participants had surgery for prolapse, whereas only 12.2% in the LH group had surgery for this indication (P < 0.001). Most in the LH group had surgery for fibroids (61%) or abnormal uterine bleeding (15.9%). Women in the VH group consumed significantly less oxycodone tablets postoperatively (median, 4.5 [IQR, 1-9] vs 7 [IQR, 2-18]; P = 0.047) and took oxycodone for less days after discharge (median, 1 [IQR, 0-3] vs 3 [IQR, 1-6]; P < 0.001). Women consume less oxycodone after minimally invasive hysterectomy than previously thought. Those who undergo VH may consume less oxycodone than those who undergo LH.

Comparison of Postoperative Ovarian Reserve Function Following Laparoscopic Hysterectomy and Laparoscopic Myomectomy: A Prospective Comparative Pilot Study.

This prospective study aimed to investigate the impact of laparoscopic hysterectomy (LH) and laparoscopic myomectomy (LM) on ovarian reserve by comparing serum anti-Mullerian hormone (AMH) changes following surgery. Serum AMH levels were measured preoperatively (AMH0), and 7 days (AMH1), 2 months (AMH2), and 6 months (AMH3) after LH and LM in 79 premenopausal women (LH = 59; LM = 20). AMH0, AMH1, AMH2, and AMH3 were significantly higher in the LM group than in the LH group (p = 0.012, 0.001, 0.001, and 0.015, respectively). Since there are differences in indications between myomectomy and hysterectomy, logically, women who underwent myomectomy were younger and had higher AMH baseline levels. In addition, AMH changes at 7 days postoperatively from the baseline level were significantly decreased in the LH group compared to those in the LM group (p = 0.042). However, AMH changes at 2 months and 6 months postoperatively, compared to the baseline level, were not different between the two groups (p = 0.053 and 0.752, respectively). Moreover, the significant decrease in AMH (more than 60% decrease from the baseline level) was not different at 7 days, 2 months, and 6 months postoperatively between the two groups (p = 0.415, 487, and 0.364, respectively). Our data suggest that serum AMH levels were significantly decreased directly after LH, which suggests that LH may have adverse effects on ovarian reserve. However, mid-term follow-up showed that the damaged ovarian reserve in women who underwent LH may be partially restored in 6 months.

Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator

ObjectiveTo demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach. Materials and methodsThe laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded. ResultsAll the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14–23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up. ConclusionsThis surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.

Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery versus single-port laparoscopy: Comparison of early outcomes.

The study objective was to compare intraoperative and early postoperative outcomes among patients who underwent hysterectomy via transvaginal natural orifice transluminal endoscopic surgery (and single-port lararoscopy for presumed benign gynecologic disorders). We retrospectively reviewed 40 patients who underwent single-port laparoscopic hysterectomy and 20 patients who underwent hysterectomy via natural orifice transluminal endoscopic surgery. Patients' age, body mass index, history of previous delivery and surgery, total operation time (from skin incision to closure), intraoperative and postoperative complications conversion to another surgical procedure, drop of hemoglobin level, postoperative pain at 1 and 18 h, average hospital stay, and clinical outcomes were analyzed. Hysterectomy via transvaginal natural orifice transluminal endoscopic surgery was superior to single-port hysterectomy concerning the length of hospitalization (p < 0.001) and visual analog scale at 1h (p=0.024) and 18 h (p < 0.001). In transvaginal natural orifice transluminal endoscopic group, postoperative complications were lower than single-port laparoscopy group (p=0.023). In transvaginal natural orifice transluminal endoscopy, group conversion to a standard vaginal hysterectomy occurred in two cases (10%). Four patients in the single-port laparoscopic hysterectomy group had umbilical herniation, three had port-site infections, and two patients had vaginal cuff hematoma. These patients required rehospitalization. Despite hysterectomy via transvaginal natural orifice transluminal surgery has not yet found its place in routine practice in gynecology departments, it could be a prominent alternative approach to other minimally invasive surgical procedures in selected patients with many advantages including lesser pain and lower complication rates compared with single-port laparoscopic hysterectomy.

The long-term urinary dysfunction after type C2 radical hysterectomy in patients with cervical cancer

Radical hysterectomy (RH) may cause lower urinary tract symptoms (LUTS) for patients with cervical cancer. Few data are available on the long-term LUTS of these patients and whether the symptoms relate to the route of surgery remain unclear. Here, we assessed the long-term urinary dysfunction in cervical cancer patients after RH based on a self-reported questionnaire. A total of 168 patients after type C2 RH, either by laparoscopy (LRH) or laparotomy (ARH), were analysed. The median length of follow-up was 54 ± 8.35 months. The total incidence of urinary dysfunction was around 40%. Patients with LRH had more intermittent stream and feeling of incomplete emptying than those in ARH group. Our data indicate the irreversible damage of RH to urinary function of cervical cancer patients, who should be informed of the long-term and high incidence of urinary dysfunction after RH when they choose surgical treatment. Impact Statement What is already known on this subject? Radical hysterectomy (RH) with pelvic lymphadenectomy is standard surgical care for patients with cervical cancer. RH could induce urinary dysfunction, including bladder sensation loss, hypertonic and hypotonic bladder, urinary incontinence, etc. Studies mainly focus on short- or mid-term urinary dysfunction and stated that spontaneous recovery of urinary function is to be expected within 6–12 months after surgery. What the results of this study add? The lower urinary tract symptoms last for years after type C2 RH, indicating the irreversible damage of RH to urinary function of cervical cancer patients. The incidence of bladder dysfunction is increased in patients submitted to laparoscopic RH compared to abdominal RH. What the implications are of these findings for clinical practice and/or further research? Cervical cancer patients should be informed of the long-term and high incidence of urinary dysfunction after RH when they choose surgical treatment.

Laparoscopic Radical Hysterectomy Results in Higher Recurrence Rate Versus Open Abdominal Surgery for Stage IB1 Cervical Cancer Patients With Tumor Size Less Than 2 Centimeter: A Retrospective Propensity Score-Matched Study.

ObjectiveTo compare the oncologic outcomes between laparoscopic and open radical hysterectomy in patients with stage IB1 cervical cancer lesion less than 2 cm.MethodsPatients diagnosed FIGO (2009) stage IB1 (tumor diameter <2 cm) and underwent radical hysterectomy in our hospital between March 2008 and November 2018 were studied. A propensity-matched comparison (1:2) was conducted to minimize selection biases. Demographic and baseline oncologic characteristics were balanced between groups. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan–Meier model, along with univariable and multivariable regression analysis.ResultsA total of 261 patients were enrolled in this study after propensity-matching, with 174 in the open group and 87 in the laparoscopic group. Disease relapsed in seven patients in laparoscopy group, and the recurrence rate was 8.0% (7/87). There were eight patients underwent abdominal radical hysterectomy experienced recurrence, and the recurrence rate was 4.6% (8/174). The multivariate analysis model revealed that laparoscopic operation was associated with higher risk of recurrence than abdominal radical hysterectomy (HR, 3.789; 95% CI, 1.143–12.559; p = 0.029). There were five patients or 2.9% (5/174) died in open surgery group and the corresponding percentage in laparoscopy group was 2.3% (2/87). No difference was found in OS between the two groups (HR, 1.823; 95% CI, 0.2673–12.44; log-rank p = 0.5398). All the recurrence occurred within two years after operation in the laparoscopy group, among which pelvic recurrence (85.7%) was dominant.ConclusionTraditional laparotomy radical hysterectomy has a lower recurrence rate when compared with laparoscopic operation in those cervical cancer patients with a foci diameter less than 2 cm. However, no detrimental effect on survival was found in minimal invasive operation group. Further multi-center prospective trials are needed to confirm our results on a large scale.

Quality of life after laparoscopic hysterectomy versus abdominal hysterectomy

BackgroundLaparoscopic surgery has been described as a minimally invasive surgery. The purpose of this study is to clarify its minimal invasive features using a patient questionnaire on the postoperative quality of life (QOL) over various time periods following either laparoscopic hysterectomy (LH) or abdominal hysterectomy (AH) and to compare the results.MethodsThis study enrolled 28 patients who underwent total hysterectomy for uterine fibroids in 2012 (14 AH cases and 24 LH cases) were enrolled in this study. The 36-Item Short Form Survey (SF-36) questionnaire was completed on postsurgical day 3; weeks 1, 2, and 4; and month 6. The results were compared between the two groups.ResultsPatients who underwent LH scored significantly higher on physical functioning on postoperative day 3 and week 2; physical role and bodily pain on day 3 and week 1; general health on postoperative day 3, weeks 1, 2, and 4, and month 6; social functioning on day 3; and emotional role on day 3 and week 1. No significant differences were found between vitality and mental health at any time point or in the categories above at any other time point.ConclusionsPostoperative QOL in LH cases was improved on day 3 and week 1; however, no significant differences between the LH and AH groups were found in most categories at week 4 and month 6. LH leads to superior short-term QOL early in the postoperative period relative to AH.

Sexual, bladder and bowel function following different minimally invasive techniques of radical hysterectomy in patients with early-stage cervical cancer

PurposeDespite the establishment of radical surgery for therapy of cervical cancer, data on quality of life and patient-reported outcomes are scarce. The aim of this retrospective cohort study was to evaluate bladder, bowel and sexual function in women who underwent minimally invasive surgery for early-stage cervical cancer.MethodsFrom 2007–2013, 261 women underwent laparoscopically assisted radical vaginal hysterectomy (LARVH = 45), vaginally assisted laparoscopic or robotic radical hysterectomy (VALRRH = 61) or laparoscopic total mesometrial resection (TMMR = 25) and 131 of them completed the validated German version of the Australian Pelvic Floor Questionnaire (PFQ). Results were compared with controls recruited from gynecological clinics (n = 24) and with urogynecological patients (n = 63).ResultsGroups were similar regarding age, BMI and parity. The TMMR group had significantly shorter median follow-up (16 months versus 70 and 36 months). Postoperatively, deterioration of bladder function was reported by 70%, 57% and 44% in the LARVH, VARRVH and TMMR groups, respectively (p = 0.734). Bowel function was significantly worse after TMMR with a higher deterioration rate in 72 versus 43% (LARVH) and 47% (VARRVH) with a correspondingly higher bowel dysfunction score of 2.9 versus 1.5 and 1.8, respectively and 1.8 in urogynaecological patients. Sexual dysfunction was common in all surgical groups. 38% considered their vagina too short which was significantly associated with deep dyspareunia.Compared with controls, surgical groups had significantly increased PFQ scores.ConclusionPelvic floor dysfunction commonly deteriorates and negatively impacts on quality of life after minimally invasive radical hysterectomy, especially bowel function after TMMR. Pelvic floor symptoms should routinely be addressed pre- and postoperatively.

Analysis of related risk factors of lung metastasis after laparoscopic radical hysterectomy of cervical cancer.

To explore the risk factors of lung metastasis in patients after laparoscopic radical hysterectomy (LRH) of cervical cancer (CC).The clinical data of CC patients with clinical stage of IA1–IIA2 diagnosed in our hospital from April 2007 to October 2015 were collected. According to the situation of metastasis, the patients were divided into lung metastasis (n = 73) and non-lung metastasis group (n = 2076). The clinical data were compared between 2 groups, and logistic stepwise regression model was used to analyze the risk factors of lung metastasis in patients with CC after LRH.The incidence of lung metastasis after LRH of CC was 3.39%, and 67.13% of patients with lung metastases had no obvious clinical symptoms. 15.06% patients had lung metastasis in the first year, 38.35% in the second year, 43.83% in the third year and later. The postoperative lung metastasis of CC was related to tumor diameter (P < .001), pathological type (P < .001), interstitial invasion depth (P < .001), pelvic lymph node metastasis (PLNM, P < .001), vascular tumor thrombus (P = .011), tumor uterine invasion (P = .002), and abnormal preoperative tumor markers (P = .015). However, it was not related to age, clinical stage, tumor growth pattern, tumor differentiation, and para-aortic lymph node metastasis (P > .05). Logistic regression analysis revealed non-squamous cell carcinoma (P = .022), tumor diameter ≥4 cm (P = .008), interstitial invasion depth >2/3 (P = .003), PLNM (P = .007), and tumor uterine invasion (P = .037) is an independent risk factor for lung metastasis after LRH of CC.Non-squamous cell carcinoma, tumor diameter ≥4 cm, tumor interstitial invasion depth >2/3, PLNM, and tumor uterine invasion are independent risk factors for lung metastasis after LRH of CC.