Radical Hysterectomy For Cervical Cancer Research Articles

Early prediction of urinary retention following radical hysterectomy by 18F-FDG PET/CT imaging.

Radical hysterectomy for early cervical cancer is associated with postoperative bladder dysfunction. Postoperative imaging by 18F-FDG PET/CT scanning is often performed to rule out recurrence. Since women are instructed to empty the bladder before imaging, we aim to study if scanned abnormal residual bladder volume is associated with future urinary symptoms. Women who underwent radical hysterectomy for cervical cancer between July 2010 and January 2019 were included in the study. Multi-Modality Tumor Tracking® (MMTT) was used to measure residual urinary volume on 18F-FDG PET/CT scans before and after hysterectomy. Demographic, clinical parameters, and urinary tract signs and symptoms, were evaluated among the cohort. Overall, 64 patients were included. Among those, in 24 (38%) the bladder volume reached ≥150 cm3 on postoperative 18F-FDG PET/CT scans. Of these, 9 (37.5%) had voiding difficulties of some degree. In 3 (12.5%) women, the 18F-FDG PET/CT scan has preceded their complaints of voiding difficulties by 2-4 months. Of the 40 women (62%) whose postoperative bladder volumes were <150 cm3, only 1 (2.5%) had urinary retention. Rate of symptomatic voiding difficulties was higher in the post-void volume ≥150 cm3 group; 13 (54.1%) vs. 6 (15.0%), P<0.002, Odds Ratio 95% Confidence Interval 6.6 (2.0-21.8), P=0.001. Measuring bladder volume on postoperative 18F-FDG PET/CT may facilitate early identification of urinary retention, possibly enabling early treatment and possibly preventing complications.

ASO Visual Abstract: Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study

ASO Visual Abstract: Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study

Robotic radical hysterectomy versus open radical hysterectomy for cervical cancer: a single-centre experience from India.

To compare the disease-free survival (DFS) and overall survival (OS) at 3years and 5years in patients undergoing treatment for early-stage cervical cancer with either robotic (RRH) or open radical hysterectomy (ORH). This retrospective study compared all patients with stage IA1 (lymphovascular invasion), IA2, IB1, IB2 and II A cervical cancer in accordance with International Federation of Gynaecology and Obstetrics staging (FIGO 2009) of cancer of the cervix uteri. Patients who underwent Radical Hysterectomy at our centre from January 2011 till January 2018 were included in the study. One hundred and eighty-nine patients ( ORH = 67, RRH = 122) were included. The median follow-up time was 46.3months in RRH group and 70.0months in the ORH group. The 3-year DFS was comparable in both the arms, 91.5% in RRH and 91.6% in ORH. The 5-year DFS was 88.9% and 85.9% in robotic and open approaches, respectively (P = 0.258), hazard ratio (HR) 0.616 (CI = 0.266-1.427). The 3-year overall survival for robotic approach was 93.4% and for open was 95%, whereas 5-year overall survival was 84.7% and 87.4% in robotic and open approaches, respectively (P = 0.813). The median estimated blood loss for robotics was lower (100ml vs 300ml, P < 0.001) and median operative time was less (162.5min vs. 180min, P = 0.005) in robotics. The patients in RRH cohort had shorter median hospital stay (3.9days vs. 6.3days, P < 0.001). Robotic radical hysterectomy had comparable survival outcomes to open radical hysterectomy in cancer cervix. RRH is associated with improved peri-operative surgical outcomes and better resource utilisation.

Minimally Invasive Surgery and Surgical Volume-Specific Survival and Perioperative Outcome: Unmet Need for Evidence in Gynecologic Malignancy.

This study examined the effect of hospital surgical volume on oncologic outcomes in minimally invasive surgery (MIS) for gynecologic malignancies. The objectives were to assess survival outcomes related to hospital surgical volume and to evaluate perioperative outcomes and examine non-gynecologic malignancies. Literature available from the PubMed, Scopus, and the Cochrane Library databases were systematically reviewed. All surgical procedures including gynecologic surgery with hospital surgical volume information were eligible for analysis. Twenty-three studies met the inclusion criteria, and nine gastro-intestinal studies, seven genitourinary studies, four gynecological studies, two hepatobiliary studies, and one thoracic study were reviewed. Of those, 11 showed a positive volume–outcome association for perioperative outcomes. A study on MIS for ovarian cancer reported lower surgical morbidity in high-volume centers. Two studies were on endometrial cancer, of which one showed lower treatment costs in high-volume centers and the other showed no association with perioperative morbidity. Another study examined robotic-assisted radical hysterectomy for cervical cancer and found no volume–outcome association for surgical morbidity. There were no gynecologic studies examining the association between hospital surgical volume and oncologic outcomes in MIS. The volume–outcome association for oncologic outcome in gynecologic MIS is understudied. This lack of evidence calls for further studies to address this knowledge gap.

ASO Author Reflections: Minimally Invasive Radical Hysterectomy in Cervical Cancer: A Brazilian Multicentric Cohort Study (CIRCOL).

ASO Author Reflections: Minimally Invasive Radical Hysterectomy in Cervical Cancer: A Brazilian Multicentric Cohort Study (CIRCOL).

Open Versus Minimally Invasive Radical Hysterectomy in Cervical Cancer: The CIRCOL Group Study.

To analyze the survival outcomes of patients in a Brazilian cohort who underwent minimally invasive surgery (MIS) compared with open surgery for early stage cervical cancer. A multicenter database was constructed, registering 1280 cervical cancer patients who had undergone radical hysterectomy from 2000 to 2019. For the final analysis, we included cases with a tumor ≤ 4 cm (stages Ia2 to Ib2, FIGO 2018) that underwent surgery from January 2007 to December 2017. Propensity score matching was also performed. A total of 776 cases were ultimately analyzed, 526 of which were included in the propensity score matching analysis (open, n = 263; MIS, n = 263). There were 52 recurrences (9.9%), 28 (10.6%) with MIS and 24 (9.1%) with open surgery (p = 0.55); and 34 deaths were recorded, 13 (4.9%) and 21 (8.0%), respectively (p = 0.15). We noted a 3-year disease-free survival (DFS) rate of 88.2% and 90.3% for those who received MIS and open surgery, respectively (HR 1.32; 95% CI: 0.76-2.29; p = 0.31) and a 5-year overall survival (OS) rate of 91.8% and 91.1%, respectively (HR 0.80; 95% CI: 0.40-1.61; p = 0.53). There was no difference in 3-year DFS rates between open surgery and MIS for tumors ≤ 2 cm (95.7% vs. 90.8%; p = 0.16) or > 2 cm (83.9% vs. 85.4%; p = 0.77). Also, the 5-year OS between open surgery and MIS did not differ for tumors ≤ 2 cm (93.1% vs. 93.6%; p = 0.82) or > 2 cm (88.9% vs. 89.8%; p = 0.35). Survival outcomes were similar between minimally invasive and open radical hysterectomy in this large retrospective multicenter cohort.

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.

Increased incidence of neurogenic bladder after radical hysterectomy for cervical cancer: A nationwide population-based cohort study.

The effect of radical hysterectomy for patients with cervical cancer on voiding function remains controversial. The purpose of this study was to examine the association between radical hysterectomy for patients with cervical cancer and the odds of developing neurogenic bladder by using data from the National Health Insurance Research Database (NHIRD) in Taiwan. We identified 17 936 patients who underwent radical hysterectomy for cervical cancer between 2000 and 2013 among inpatients registered in the Longitudinal Health Insurance Database in Taiwan. Of the patients, those diagnosed as having cervical cancer without radical hysterectomy were selected and compared as a matched control group. Patients diagnosed as having cervical cancer before the index date, those with neurogenic bladder dysfunction before tracking, and those aged <20 years were excluded. The hazard ratios (HRs) of neurogenic bladder and other variants of interest were further calculated using a multivariate Cox regression analysis. The cutoff p value of <0.05 was regarded as statistically significant. The adjusted HR (aHR) of subsequent neurogenic bladder was higher in the hysterectomy group (aHR = 1.205; 95% CI, 1.086-1.440; p = 0.029) than in the control group during the follow-up period. As to the age subgroups, the patients aged 20 to 44 years (aHR = 3.321, p = 0.001) had a significantly increased risk of developing neurogenic bladder after radical hysterectomy as compared with those aged 45 to 64 years (aHR = 1.193, p = 0.012). Patients with cervical cancer undergoing radical hysterectomy have an increased risk of neurogenic bladder, which may result from nerve denervation caused by the operation. These patients should be informed of the potential risk of voiding dysfunction during discussion of the subsequent management for cervical cancer.

Risk factors for catheter-associated urinary tract infections following radical hysterectomy for cervical cancer

Objectives: Radical hysterectomy is the mainstay of treatment for early-stage cervical cancer. Urinary tract dysfunction is one of the most common complications after radical hysterectomy, and prolonged catheterization has previously been defined as a significant risk factor for catheter-associated urinary tract infections (CAUTI). The purpose of this study was to determine the rate of CAUTI after radical hysterectomy for cervical cancer and identify additional risk factors for developing CAUTI in this population. Methods: We reviewed patients who underwent a radical hysterectomy for cervical cancer from 2004-2020 after institutional IRB approval. All patients were identified from our institution's Gynecologic Oncology surgical database. Inclusion criterion was radical hysterectomy for early-stage cervical cancer. Exclusion criteria included inadequate hospital follow-up, insufficient records of catheter use in the electronic medical record, urinary tract injury, and preoperative chemoradiation. CAUTI was defined as an infection diagnosed in a catheterized patient or within 48 hours of catheter removal, with significant bacteriuria (>103 cfu/mL) and symptoms or signs attributable to the urinary tract. Data analysis was performed using comparative analysis and univariate and multivariate logistic regression using Excel, GraphPad, and SPSS. Results: A total of 276 patients were identified. After applying exclusion criteria, 160 patients were included in the data analysis. The distribution of patients across FIGO stage is as follows: IA1 4.5% (n=4), IA2 6.3% (n=10), IB1 75.6% (n=121), IB2 13.8% (n=22), IIA2 1.9% (n=3). The mean length of indwelling catheter use was 9.3 days (range 0-33 days). 28.8% of patients (n=40) had a urinary catheter placement more than 1 time prior to passing a voiding trial. 12.6% of patients (n=20) were diagnosed with CAUTI. Minimally invasive surgery (MIS) was associated with longer catheterizations compared to an open approach (mean 12.8 days vs 6.9 days, p Conclusions: Catheterization over five days significantly increased the risk for CAUTI development after radical hysterectomy for cervical cancer. Smoking history, increased age, and minimally invasive surgical route are independent predictors for CAUTI. Earlier catheter removal should be encouraged in patients with these risk factors.

Minimally invasive radical hysterectomy for cervical cancer: a systematic review and meta-analysis

<h3>Objectives:</h3> Recent studies have identified higher recurrence and lower survival with a minimally-invasive approach (MIS) versus abdominal approach to radical hysterectomy for early-stage cervical cancer. We aim to compare recurrence rate, progression-free survival, and overall survival for cervical cancer after MIS versus abdominal radical hysterectomy. <h3>Methods:</h3> We searched Medline, Embase, Central, and the Cochrane Library to identify studies from 1990 to 2020 that included women with stage 1 or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or progession-free survival (PFS) and overall survival with MIS versus abdominal hysterectomy (PROSPERO 2020 CRD42020173600). <h3>Results:</h3> 50 studies, including 22,593 women with cervical cancer, met inclusion criteria. 29% of studies had less than 30 months of follow-up and 14% had 60+ months of follow-up. Of the 37 studies reporting PFS, 29 reported no difference and 8 reported decreased PFS with MIS approach. Of the 37 studies reporting OS, 2 studies reported improved OS with MIS approach, 31 reported no difference, and 4 reported decreased overall survival with MIS approach. For progression-free survival, the odds were non-significantly worse for women undergoing MIS radical hysterectomy (OR 1.25, 95% CI 0.98-1.52, 14 studies) when all studies were included. When limited to studies with 30+ months follow-up, the odds of progression-free survival were worse with MIS radical hysterectomy (OR 1.39 for 30+ months, 95% CI 1.09-1.70, 12 studies; OR 1.49 for 48+ months, 95% CI 0.94-2.03, 4 studies). For overall survival, the odds were not significantly different for MIS vs. abdominal hysterectomy (OR 0.82, 95% CI 0.58-1.06, 14 studies). When limited to studies with longer follow-up, the odds of overall survival remained non-significantly different for MIS vs. abdominal (OR 0.90 for 30+ months, 95% CI 0.53-1.26, 11 studies; OR 0.94 for 48+ months, 95% CI 0.42-1.46, 4 studies; OR 1.70 for 60+ months, 95% CI 0.62-2.78, 2 studies). <h3>Conclusions:</h3> In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse progression-free survival compared to open radical hysterectomy for cervical cancer in studies with 30+ months of follow-up. The emergence of this finding with longer follow-up highlights the importance of high-quality studies to guide cancer and surgical treatment.

Chinese expert consensus on nerve-sparing radical hysterectomy for cervical cancer

Cervical cancer is the most common gynecologic malignancy. Radical hysterectomy for early-stage cervical cancer could cause damage to pelvic autonomic nerves, leading to postoperative urination, defecation and sexual dysfunction. In order to improve the postoperative quality of life, the international Querleu-Morrow (Q-M) surgical classification system recommends the nerve-sparing radical hysterectomy (type-C1) as the mainstay operation. The Gynecologic Oncology Group affiliated to Chinese Obstetricians and Gynecologists Association has invited a number of domestic specialists and conducted in-depth discussions on key issues such as anatomical basis, surgical indications, techniques, postoperative evaluation for nerve-sparing radical hysterectomy. Finally, the specialists reach a consensus to guide the standardized application of this procedure in China.

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.

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.

Laparoscopic appendectomy for metastatic cervical cancer presenting as appendicitis

BackgroundMetastatic lesions to the appendix are rare. They usually present with acute appendicitis or remain asymptomatic and are diagnosed incidentally. Metastases to the appendix have been reported from a number of primary tumor sites including ovary, colon, gastric and lung. We report a laparoscopic appendectomy for a metachronous metastatic lesion to the appendix from the uterine cervix.Case presentationA 68-year-old woman, who underwent radical hysterectomy for cervical cancer 16 years previously, presented with nausea and gradually worsening right lower quadrant abdominal pain. Abdominal computed tomography scan showed an enlarged appendix and periappendiceal fat stranding. She was diagnosed with appendicitis and underwent laparoscopic appendectomy. Pathological findings showed adenocarcinoma in the submucosa and muscularis propria. Gastrointestinal endoscopy and positron emission tomography with computed tomography (PET–CT) did not show other lesions. Immunohistochemical analysis showed cytokeratin 7 (CK7) positive, cytokeratin 20 (CK20) negative, estrogen receptor (ER) 70–80% and progesterone receptor (PgR) 40–50%. The ER and PgR expression was similar to the cervical lesion 16 years previously, and the diagnosis was a metastatic lesion to the appendix from the uterine cervix.ConclusionsMetastasis to the appendix from cancer of the uterine cervix is a rare lesion.

Standardization and experience may influence the survival of laparoscopic radical hysterectomy for cervical cancer

ObjectiveMinimally invasive radical hysterectomy has been shown to be associated with poorer outcome in an influential prospective, randomized trial. However, many centers worldwide performing minimally invasive radical hysterectomy have data and experience that prove otherwise. We aim to review surgical and oncologic outcomes of patients operated by Laparoscopic Radical Hysterectomy in a tertiary hospital, by experienced surgeons and standardization in radicality, for cervical carcinoma Stage 1A1-1B1 from January 2009 to May 2014. Materials & methodsStandardised surgical technique with Parametrium & Paracolpium resection approach was adopted by qualified and experienced Gynecologic/Gyne-Oncologic Endoscopic & Minimally Invasive Surgeons in performing Laparoscopic Radical Hysterectomy for Cervical Cancer stage 1A1-1B1 from January 2009–May 2014, involving 53 patients. Electronic Medical Record system (EMR) Of Chang Gung Memorial Hospital(Tertiary Referral Centre), Department of Obstetrics & Gynecology was accessed for surgical and oncologic outcomes. ResultsFifty-Three patients operated from January 2009 to May 2014 were followed up for an average of 96.7 months with longest follow-up at 127 months. There were no cases of recurrence or death reported. 5 Year – Survival Rate and 5 Year Disease-Free Survival Rate were 100%. Two patients received post-operative pelvic radiation concurrent with chemotherapy using Cisplatin due to greater than 1/3 cervical stromal invasion. ConclusionIt is vital to standardize minimally invasive surgical techniques for early stage cervical cancer, with focus on adequate radicality and resection which may contribute to excellent survival outcomes. Further international multi-center randomized trial (Minimally Invasive Therapy Versus Open Radical Hysterectomy In Cervical Cancer) will provide justification for continued practice of MIS in early stage cervical cancer.

Clostridium difficile infection occurred after radical hysterectomy for cervical cancer—a case report

: Clostridium difficile infection (CDI) is a global health challenge. In recent years, the incidence of CDI is increasing rapidly. Clostridium difficile (C. difficile) is now a common cause of nosocomial infection. Surgery is a known risk factor for the development of CDI. However, the rate of CDI that occurred after Gynecological surgeries has been reported significantly less. We presented a case of a 44-year-old woman with FIGO stage IB1 invasive cervical cancer who suffered from high fever, chills and severe diarrhea after receiving laparoscopic radical hysterectomy with bilateral salpingectomy and pelvic lymph node dissection. The symptoms of surgical complications and bowl diseases overlap with those of patients in the case. CDI in gynecological surgery patients is often misdiagnosed and ignored due to the absence of prominent symptoms and signs, as well as the low rate of positive examination results. Therefore, it is necessary for early confirmation and treatment of CDI. PCR and two-step algorithm (GDH detection followed by nucleic acid amplification test) have been reported to be the rapid and accurate laboratory examination for the diagnosis of CDI. Owing to the rare property of this disease, we present this case to underscore the importance of early diagnosis and intervention for CDI after gynecological surgeries.

Proteomic analysis of the influence of CO2 pneumoperitoneum in cervical cancer cells.

The effect of CO2 pneumoperitoneum (CDP) on the oncology outcomes of patients undergoing laparoscopic radical hysterectomy for cervical cancer remains unclear. In this study, we investigated the effects of CDP on the proliferation of cervical cancer cells and examined the molecular mechanism. We established an in vitro CDP model to study the effects of CDP on the proliferation of cervical cancer cells by Cell Counting Kit-8 (CCK-8) assay, xenografted tumor assay. Tandem mass tag-based quantitative proteomics were used to study the proteomic changes in HeLa cells after CDP treatment. Western blot assay was used to detect the expressions of PI3K/Akt signaling pathway proteins. CDP increased cell proliferation after a short period of inhibition in vitro and promoted tumorigenesis in vivo. Proteomic analysis showed that the expression levels of 177 and 309 proteins were changed significantly 24 and 48 h after CDP treatment, respectively. The acidification caused by CO2 inhibited the proliferation of cervical cancer cells by inhibiting the phosphorylation of PI3K and Akt. CDP promoted the proliferation of human cervical cancer cells after a short time of inhibition. The mechanism of which is related to the inhibition of phosphorylation of the PI3K/Akt signaling pathway.

Surgery for cervical cancer: consensus & controversies.

Surgery plays an important role in the management of early-stage cervical cancer. Type III radical hysterectomy with bilateral pelvic lymph node dissection using open route is the standard surgical procedure. There is level I evidence against the use of laparoscopic/robotic approach for radical hysterectomy for cervical cancer. Emerging data support the use of sentinel lymph node biopsy and nerve sparing radical hysterectomy in carefully selected patients with early-stage disease. In locally advanced cervical cancer patients, the use of neoadjuvant chemotherapy (NACT) followed by radical surgery yields inferior disease-free survival compared to definitive concurrent chemoradiation therapy. Therefore, definitive concurrent chemoradiation is the standard treatment for locally advanced disease. Fertility preserving surgery is feasible in highly selected young patients. Role of less-radical surgical procedures in patients’ with low-stage disease with good prognostic factors is under evaluation.

A Novel Direct Approach to the Deep Uterine Vein in Laparoscopic Radical Hysterectomy

To describe a direct approach to the deep uterine vein in laparoscopic radical hysterectomy. Demonstration of the laparoscopic technique with narrated video footage. Securing sufficient radicality is extremely important when performing a radical hysterectomy for cervical cancer, either by laparotomy or by minimally invasive surgery. The nerve-sparing Okabayashi radical hysterectomy (NS-RH) was originally aimed at achieving both radical resection and function preservation [1-3]. A key procedure when performing NS-RH is intraoperative identification of the relationship between the deep uterine vein and pelvic splanchnic nerve fibers [4]. With this in mind, a safe and easy method for identifying the crossing point of the deep uterine vein and pelvic splanchnic nerve in the initial phase of the surgery may greatly improve the safety and efficacy of functional preservation in NS-RH. Herein, we describe a minimally invasive "direct approach" to the deep uterine vein. Before undergoing the pelvic lymphadenectomy, all steps of laparoscopic radical hysterectomy were performed. First, we identified the ureter on the posterior peritoneum, and the peritoneum was dissected just above the ureter. By continuously exploring the pelvic cavity along the ureter, especially through the opening of the space below the ureter in a cranial to caudal direction, we could easily identify the deep uterine vein. This procedure also exposed the fibers of the hypogastric nerve, clarifying the relationship of these structures. Because the relationship between the deep uterine vein and nerve fibers is the most important guidepost of this surgery, their identification in the early phase of the surgery enables us to perform the subsequent procedure precisely and securely. This direct approach to the deep uterine vein can be easily and safely performed.

Salvage Concurrent Chemoradiotherapy Should be Considered for Local Recurrence after Radical Hysterectomy in Cervical Cancer

Little is known about the impact of salvage chemoradiotherapy on the long-term outcomes of cervical cancer patients with recurrence after radical hysterectomy. This study aims to evaluate the efficacy and safety of salvage chemoradiotherapy and share our own experience. 95 cervical cancer patients with local recurrence received salvage chemoradiotherapy between January 2011 and November 2018. All patients had not received adjuvant pelvic radiotherapy before. The dose of residual tumor and metastatic lymph nodes were all boosted to 64-82Gy (EQD2, a/β = 10) after pelvic irradiation in 50Gy/25F. The boost techniques were three-dimensional conformal radiotherapy, intensity-modulated radiotherapy or brachytherapy. Cisplatin-based chemotherapy was given concurrent with radiotherapy. Kaplan-Meier survival curve was used to analyze the outcomes of the patients. The median age of all patients was 51 years (range: 26-75 y). Median time from surgery to recurrence was 19.2 months (range：0.6-131.8 months). 91 patients had squamous cell carcinoma (95.8%), and 4 patients had adenocarcinoma (4.2%). The maximum diameter of residual mass with≥3cm occurred in 51 cases (53.7%). There were 26 cases (27.4%) with lymph node metastasis and 10 cases (10.5%) with adjacent organ invasion. 80 patients (84.2%) had received total radiation dose of 64-70Gy (EQD2, a/β = 10) for recurrent lesions, while 15 patients (15.8%) got 71-82Gy. 75 patients (78.9%) received concurrent chemotherapy. The median follow-up time was 32.7 months (range: 3.4-100.6 months). 13 patients died during follow-up. Kaplan-Meier survival curve analysis showed that the 3-year overall survival （OS）, disease-free survival (DFS), distant metastasis-free survival (DMFS), and local control （LC） were 87.5%, 84.6%, 84.8%, and 92.3%, respectively. 3-year OS for patients with vs without adjacent organ invasion was 58.7% and 94.8%, respectively (P < 0.001). 3-year OS for patients with or without lymph node metastasis was 50.5% and 91.8%, respectively (P = 0.007). 3-year OS for patients with mass ≥3cm or < 3cm was 80.5% and 95.4%, respectively (P = 0.018). The higher radiotherapy dose did not improve the local control rate. And the 3-year local control rate (LC) with total irradiation dose of 64-70Gy and 71-82Gy was similar 92.3% (p = 0.913). The number of patients with grade 3 or 4 myelosuppression during treatment was 40 cases (42.1%), and grade 3 or 4 gastrointestinal toxicity was 1 case (1.1%). There was no grade 3 or 4 late complication, according to RTOG toxicity grading. Salvage concurrent chemoradiotherapy for patients with local recurrence after radical hysterectomy showed favorable clinical outcomes without severe complications.