Tumor Spillage Research Articles

Consensus recommendations from the EXPeRT/PARTNER groups for the diagnosis and therapy of sex cord stromal tumors in children and adolescents.

As part of the European Union-funded project designated Paediatric Rare Tumours Network - European Registry (PARTNER), the European Cooperative Study Group for Pediatric Rare Tumors (EXPeRT) is continuously developing consensus recommendations in order to harmonize standard care for very rare solid tumors of children and adolescents. This paper presents the internationally recognized recommendations for the diagnosis and treatment of sex cord stromal tumors (SCST). The clinical approach to sex cord stromal tumors of the testis (TSCST) and ovary (OSCST) depends on histological differentiation and tumor stage. Virtually all TSCSTs present as localized nonmetastatic tumors, with excellent prognosis after complete resection. In contrast, the prognosis of OSCSTs may be adversely affected by tumor spillage during surgery or presence of metastases. In these cases, cisplatin-based chemotherapy is recommended. Of note, some SCSTs may develop in the context of tumor predisposition syndromes, for example, DICER-1, so that specific follow-up is indicated. SCSTs should be diagnosed and treated according to standardized recommendations that include reference pathology, genetic testing for tumor predisposition syndromes in selected cases, and stratified adjuvant chemotherapy in patients with unfavorable risk profile. To ensure high quality of diagnosis and therapy, patients should be enrolled into prospective registries.

Long-term oncological outcomes of the Agarwal loop-ligation technique for management of the distal ureter during laparoscopic radical nephroureterectomy.

To describe the Agarwal loop-ligation technique for the management of the distal ureter during laparoscopic radical nephroureterectomy (LRNU) for upper tract urothelial carcinoma (UTUC) and report on long-term oncological outcomes. In the Agarwal loop-ligation technique, the distal ureteric stump is controlled using endoscopic Endoloop® or PolyLoop® ligation to ensure en bloc excision of the bladder cuff and prevent spillage of upper tract urine into the perivesical space. A retrospective review of the medical records of 76 patients who underwent the Agarwal loop-ligation technique for UTUC at participating centres from July 2004 to December 2017 was performed. Data collected included demographics, perioperative, and long-term oncological outcomes. Survival was calculated using Kaplan-Meier survival analyses. A total of 76 patients were included. The median age was 71.5years and median operative time was 4.3h. The intramural ureter and bladder cuff were completely excised in all patients. Distal surgical margins were clear in all, with only two patients found to have tumour extending to the circumferential surgical margin. There were no cases of perivesical recurrence or port-site metastasis. The 5-year bladder, local, and contralateral recurrence-free survival was 59.6%, 89.0% and 93.5%, respectively. Metastasis-free survival at 5-years was 73.5%. The 5-year overall survival and cancer-specific survival rates were 70.3% and 84.7%, respectively. We have described the Agarwal loop-ligation technique for the management of the distal ureter in LRNU. This technique complies with oncological principles outlined in the European Association of Urology guidelines, which minimises tumour spillage. Long-term oncological outcomes are satisfactory, with no cases of perivesical recurrence detected in this series.

A modified technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation through a mini-laparotomy

Radical trachelectomy is an optional fertility-sparing treatment for early-stage cervical cancer, and recently, the minimally invasive approach (MIA) has become a major trend in radical trachelectomy. MIA radical trachelectomy requires a more careful surgical technique to avoid tumor spillage and exposure of the cancerous tissue under carbon dioxide pneumoperitoneum to reduce the risk of recurrence. We present a case of a 33-year-old nulliparous woman with stage IB1 cervical cancer who underwent MIA radical trachelectomy through a combination of laparoscopic surgery and mini-laparotomy, mainly to prevent postoperative complications and tumor spread during cervical amputation. A Papanicolaou test suggested the diagnosis of squamous cell carcinoma of the cervix without any symptoms such as atypical bleeding. The subsequent biopsy revealed squamous cell carcinoma with stromal invasion of the cervix. Cervical amputation was performed extracorporeally through a small incision in the lower abdomen. There were no perioperative complications. The patient was discharged on postoperative day 13. The final pathological evaluation revealed residual microinvasive cancer of the endocervical canal with clear margins, no lymphovascular space involvement, and 27 negative lymphatic nodes. The joint of the neo-cervix and vagina had healed completely without erosion or stenosis of the cervical canal, and no problems occurred during sexual intercourse. No cancer recurrence or menstrual disorders have been reported in the short postoperative period of 6 months. The surgical technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation may be an acceptable alternative to reduce the risk of recurrence by preventing intraperitoneal tumor spillage.

Recurrent Multinodular Pleomorphic Adenoma of Parotid Gland- A Case Report

Pleomorphic adenoma or benign salivary gland tumours predominantly affects the superficial lobe of parotid gland. It is a slow growing swelling with or without facial nerve involvement with female predilection in third and fifth decade of life. The origin of the tumour is both epithelial and connective tissue and hence it is of pleomorphic nature. After surgery, its recurrence rate varies considerably and seems to depend more on the surgical technique used. A 49-year-old male patient, presented with complaints of swelling in front of right ear and right parotid region for past eight years. He gave previous history of similar swelling in the right parotid region and history of previous surgery done elsewhere in 2009. Right superficial parotidectomy was done following which he was asymptomatic for two years. On examination of right parotid- a multilobulated irregular swelling was present in right parotid region and the swelling extended till the right ear lobule. The swelling hid previous surgical scar. Facial nerve was clinically intact. Fine Needle Aspiration Cytology (FNAC) was suggestive of Pleomorphic Adenoma. Magnetic Resonance Imaging (MRI) with contrast revealed that the lesions were arising from superficial lobe of the parotid gland. Right superficial parotidectomy was planned. Mass was excised and sent for histopathological examination and was reported to be Pleomorphic Adenoma. Patient is still on follow-up and no recurrence has been noted. The rate of recurrence depends on tumour spillage, intra-surgical rupture, or any histopathological feature. There is significant risk for local recurrence if the microscopic finger like formation (pseudopodia) of tumour tissue extends beyond the main mass.

Vaginal Closure Before Colpotomy with an Endo-Stapler to Prevent Tumor Spillage in Laparoscopic Surgery for Gynecological Malignancy.

Background and Objectives:The aim of this study was to define new techniques for performing vaginal closure with endo-staplers to prevent tumor spillage during laparoscopic surgeries for endometrial cancer and early stage cervical cancer.Methods:Thirteen patients were retrospectively studied for the use of endo-staplers for vaginal closure before colpotomy during laparoscopic surgeries for endometrial cancer and early stage cervical cancer to prevent tumor spillage.Results:There were no short-term or any long-term complication related to the use of the endo-staplers for colpotomy in the surgeries included in this study.Conclusion:Use of the endo-staplers to close the vagina before colpotomy according to the technique described is safe and feasible, with prevention of gross spillage of any malignant cells in the peritoneal cavity or vagina, which will further have a favorable oncologic outcome.

Surgical approach in early stage cervical cancer: the Asian view point

Objective: To examine the current practice of radical hysterectomy for early-stage cervical cancer in Asia after the Laparoscopic Approach to Cervical Cancer (LACC) trial. Methods: A cross-sectional study was conducted in Asia to examine the prevalence and management of women with early-stage cervical cancer. The study was conducted among gynecologic oncologists at leading hospitals in the Asian Society of Gynecologic Oncology Council members. A systematic literature review was performed to examine the association between survival outcomes and surgical approach after the LACC trial. Results: Seven countries participated voluntarily in the study. The incidence, mortality, and centralization of treatment in early-stage cervical cancer were different among the seven countries. The number of specialized centers per population density in Japan was higher than that in the other countries. Minimally invasive surgery (MIS) approach for cervical cancer was common in Korea (56%) and Hong Kong (80-90%), but not in the other countries (2-20%). In the systematic review, there was a significant difference in survival outcomes between MIS and open surgery (recurrence, hazard ratio 1.83, 95% confidence interval 1.27-2.62). MIS without a uterine manipulator or making a vaginal cuff closure produced similar recurrence rates compared with open surgery (MIS without uterine manipulator vs open-surgery: 10.5% vs 10.1%, and MIS with cuff closure vs open-surgery 7.2% vs 10.1%; all P > 0.05). Conclusion: The prevalence of MIS for early-stage cervical cancer varies across Asian regions after the LACC trial. Surgical methods to avoid tumor spillage may be useful for improving survival.

Multivisceral resection of locally advanced colorectal cancer in an African referral centre

Colorectal cancer (CRC) is common and often presents with advanced disease in Africa. Multivisceral resection (MVR) improves survival in locally advanced (T4b) CRC. The aim was to describe the management and outcomes of patients with clinical T4b CRC without metastatic disease who underwent MVR. A retrospective review of patients with T4 CRC who underwent MVR between January 2008 and December 2013. Four hundred and ninety-four patients were included. Of the 158 with suspected T4 cancer, 44 had MVR, of which one was excluded due to metastases. The mean age was 64 years. The male to female ratio was 1:1. The most commonly resected extra-colorectal structure was the abdominal wall (21%). The median survival was 68 months (SD 13.9). The 5-year disease free (DFS) and overall survival (OS) were 46% and 55%, respectively. Survival of patients with colon and rectum cancer was similar. Intraoperative tumour spillage, vascular/perineural invasion, and anastomotic leakage were independent predictors of survival. Multivisceral resection of locally advanced (T4b) CRC is feasible in the African context. Complete resection improves survival and should be the goal.

Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer.

Background:We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer.Methodology:Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage.Results:All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6–14). All drains and urethral catheters were removed after a median of 7 days (range 5–11) and 16 days (range 12–21), respectively. A median of 26 (range 20–32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease.Conclusion:We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.

Minimally Invasive Approach for Wilms Tumor Treatment in a Small Child - A Case Report

Wilms tumor is the most common malignant primary tumor in children. Open traditional approach is often aggressive and offers a burden on the patient's life, imposing longer hospital stays, scarring, and higher levels of complications. Here, we present a case of a small child with Wilms tumor on the right kidney that was successfully treated with minimally invasive surgery, with no tumor spillage or rupture, hospital discharge in the next day, and good oncological outcome, with 1-year recurrence-free follow-up. We also show a comprehensive literature review of similar cases, expecting to push forward medical awareness about this approach.

Comparison of single-port laparoscopy and laparotomy in early ovarian cancer surgical staging.

ObjectivesThe aims of this study were to assess the feasibility of single-port laparoscopic surgical staging (SPLS) in early ovarian cancer and to compare the surgical outcomes of SPLS with those of staging laparotomy.MethodsBetween January 2014 and December 2018, 40 patients underwent SPLS and 41 patients underwent staging laparotomy at Yonsei Cancer Center. The patients were diagnosed with International Federation of Gynecology and Obstetrics (FIGO) stage I ovarian cancer. Variables such as patient age, body mass index (BMI), tumor size, FIGO stage, and perioperative surgical outcomes and survival outcomes of SPLS and laparotomy were compared.ResultsThe total operation time was similar between the 2 groups (SPLS: 201.4 vs. laparotomy: 203.0 minutes, P=0.806). The median tumor diameters in the SPLS and laparotomy groups were 11.0 (2.5–28 cm) and 15.4 (6–40 cm), respectively (P=0.001). The SPLS group had lower tumor spillage rate (5.0% vs. 19.5%, P=0.047), less intraoperative blood loss (102.0 vs. 371.5 mL, P<0.001), less postoperative pain, and shorter postoperative hospital stay (5 vs. 9.5 days, P<0.001). The intraoperative major complication rate was similar between groups (2.5% vs. 4.9%, P=0.571). There was no significant difference in progression-free survival between the 2 groups (P=0.945). There were no deaths in either group.ConclusionSPLS is feasible in early ovarian cancer and has better perioperative surgical outcomes, in some aspects, than staging laparotomy without compromising survival outcomes. SPLS could be performed in patients suspected to have early ovarian cancer.

Lytic Effects of Water on Bladder Cancer Cell Lines – Implications for Clinical Use of Water Irrigation to Reduce Recurrence

Recurrence of bladder cancer (BC) following initial management with transurethral resection of bladder tumour (TURBT) is observed in 15-60% of patients. Intraoperative tumour spillage can be a concern during TURBT, given that it can lead to tumour cell re-implantation and local recurrence. Immediate post-TURBT instillation of chemotherapy is effective at reducing recurrence, but remains underutilised. There is evidence that mechanically washing out free-floating tumour cells with bladder irrigation may be a comparable but less expensive or toxic alternative. Irrigating with sterile water may be more effective compared to iso-osmotic irrigants (such as saline) by virtue of causing additional osmotic cytolysis, but this has not been well characterised. This in vitro study aimed to ascertain the time-course of osmotic effects of water on BC cell lines to guide its meaningful clinical usage. In-vitro studies were conducted on HT1197 and HT1376 BC cell lines, red blood cells, and white blood cells. Each cell line was exposed to either water, 0.9% saline or 1.5% glycine. Cell counts (in triplicate) were performed at 10, 20, and 40 minutes, and then hourly for up to 5 hours using a haemocytometer. Cell viability was determined using Trypan blue. In both BC cell lines, saline and glycine caused respectively ∼50% and 65% reduction in the number of viable cells after a minimum of 1 hour of exposure (p<0.0001 vs time 0). Conversely, the effect of water was rapid, inducing 100% cell lysis in under 20 minutes (p = 0.0001 vs time 0), while saline and glycine had no measurable effect in this timeframe (p = 0.9255 and 0.0662 vs time 0, respectively). For red blood cells and white blood cells, water also precipitated cell lysis within 10 minutes, whilst saline and glycine had minimal effect. These results suggest that water has a rapid osmolytic effect upon BC cells. If confirmed using ex vivo samples from patients, this suggests that a short period of irrigation with water may potentially be effective in reducing BC recurrence.

Role of uterine manipulator during laparoscopic endometrial cancer treatment.

Endometrial cancer (EC) is the most frequent gynecologic malignancy with 61,000 new cases diagnosed per year in the USA. Gynecologic Oncology Group (GOG) LAP2 randomized study demonstrated a superimposable 5-year overall survival between laparotomic and laparoscopic approaches in EC treatment. In this context the uterine manipulator (UM) represents a valuable tool in order to increase the ergonomics of surgical gesture during a laparoscopic total hysterectomy. Despite the proven safety of the minimally invasive approach in EC treatment, neither the indication whether to use or not, nor the recommendation concerning a specific type of UM are provided by international guidelines. This narrative review aims to collect all the main findings in the literature about UM use to investigate its safety in EC patients. Based on the analysis of the literature research, the main results were categorized into two manipulator-related problems: the iatrogenic LVSI, and the retrograde tumor spillage. LVSI is defined as the presence of tumor cells within an endothelium-lined space. An electronic search was performed using the following keywords: ‘uterine manipulator’, and ‘endometrial cancer’. The electronic database search provided a total of 93 studies. Of whom, 12 case reports, 5 studies not in English language, and 65 works not fitting the review scope were excluded from the analysis. Eleven studies were considered eligible for the purpose of the study. The most recent studies have highlighted the safety of the uterine manipulator in the early-stage EC laparoscopic treatment. All types of manipulators are considered to be fairly safe but its application should be tailored according to tumor dimension and grade of myometrial infiltration.

Partial cystectomy for muscle-invasive bladder cancer: a review of the literature.

The radical cystectomy (RC) for muscle-invasive bladder cancer is one of the most morbid and complex urologic procedures performed today. To avoid these complications, the partial cystectomy (PC) has been offered as an alternative in carefully selected patients as a means of achieving equal oncologic efficacy with less morbidity. Selection criteria should include solitary tumors without concomitant carcinoma in situ (CIS) and amenable to resection with 1–2 cm margins in a normally functioning bladder. In addition to the standard work-up, random bladder and prostatic biopsies may be performed. The PC can be performed through an open, laparoscopic, or robot-assisted approach, each with acceptable outcomes. A number of techniques have been developed to identify and resect the tumor completely with negative margins, while preventing tumor spillage within the abdomen. While there are no randomized trials, single institution series have demonstrated acceptable oncologic outcomes in appropriately selected patients. Therefore, offering PC in the appropriate candidate, including those patients who do not accept or are unfit for the associated morbidity of a RC, represents an acceptable alternative.

Long Term Outcomes And Patterns Of Failure After Single Fraction Preoperative Radiosurgery For Brain Metastases

Postoperative (post-op) radiosurgery (SRS) after resection of brain metastases (BM) is associated with up to 30% risk of leptomeningeal disease (LMD). Approximately 60-70% of LMD is nodular pattern in this setting, which is thought to be associated with surgical tumor spillage. We have previously demonstrated that preoperative (pre-op) SRS is a feasible alternative to post-op SRS. Herein we report patterns of failure and long terms outcomes for patients (pts) treated with pre-op SRS. The records for pts with BM treated with pre-op SRS and planned surgical resection were reviewed. Pts with classically radiosensitive tumors, prior or planned adjuvant whole brain radiotherapy (WBRT), or no cranial imaging ≥ 1 month after surgery were excluded. Pre-op SRS dose was based on lesion size and was reduced approximately 10-20% from standard. No gross tumor volume (GTV) margin expansion was used. Surgery generally followed within 48 hours. Overall survival (OS) was estimated using the Kaplan-Meier method. Intracranial event rates were estimated using cumulative incidence with competing risk of death. Radiographic pattern of LMD was classified as classical “sugarcoating” (cLMD) vs. nodular (nLMD). The study cohort consisted of 141 pts with 150 lesions treated with single fraction pre-op SRS followed by planned surgery between 2005 – 2018. Most pts had a single BM (67%), underwent gross total resection (GTR, 96%), and had non-small cell lung cancer (41%). Median interval between pre-op SRS and surgery was 2 days, median SRS dose was 15 Gy, and median GTV volume was 8.4 cc (approximately equivalent to 2.5 cm diameter lesion). The 2-year cavity local recurrence (LR) rate was 23% overall and 20% in pts status post GTR. Five of 6 pts status post subtotal resection experienced LR. Multivariate analysis demonstrated GTR and renal cell histology as significantly associated with reduced risk of LR. SRS dose, lesion volume, and time between pre-op SRS and surgery were not significant. The 2-year LMD rate was 5%. Two of the 9 patients with LMD (22%) had nLMD while 78% had cLMD. The 2-year radiation necrosis (RN), symptomatic RN, and non-LMD distant brain failure rate was 7%, 4%, and 58%, respectively. Median OS was 19 months. Thirty-seven pts with 40 lesions had long term (≥2 years of cranial imaging) follow-up. In this subset, the 5-year cavity LR, symptomatic RN, and LMD rate was 25%, 8%, and 12%, respectively. Single fraction pre-op SRS is an effective treatment for surgically resected BM with low rates of cavity LR, RN, and LMD. LMD after pre-op SRS seems to be distinct from post-op SRS with a lower overall rate and lower proportion of nLMD pattern, which supports pre-op SRS sterilization of surgical tumor spillage. Outcomes in pts with long term imaging follow-up are consistent with the overall cohort. These data support further studies of pre-op SRS, including a randomized trial of pre-op vs. post-op SRS.

A Phase II Study on the Safety of Minimally Invasive Surgery Using Endoscopic Stapler to Prevent Tumor Spillage in Cervical Cancer

Study Objective The Laparoscopic Approach to Cervical Cancer (LACC) trial demonstrated that patients treated with minimally invasive surgery (MIS) techniques resulted in poorer outcomes than those treated with laparotomic techniques. In order to overturn the suggestion that MIS is inferior to laparotomic techniques, we designed and are now performing a phase II study on the safety of laparoscopic or robotic radical surgery using endoscopic stapler for inhibiting tumor spillage of cervical neoplasms (SOLUTION trial). Design A 42-year-old patient with cervical cancer clinical stage IB3 underwent robotic radical hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic sentinel lymphadenectomy with additional steps to improve surgical and morbidity outcomes. Setting In a Trendelenburg position, the patient is placed under general anesthesia. Patients or Participants This study is a prospective, multi-center phase II trial recruiting patients with early-stage cervical cancer. Interventions Key points of the operation are as follows: First, we perform tubal ligation and vaginal tube insertion, and then intracorporeal colpotomy using an endoscopic stapler to prevent tumor spillage into the peritoneal cavity. Second, we resected the stapled vaginal stump to retrieve the tumor specimen, and then close the vaginal stump again with continuous suture. Finally, we perform washing cytology three times: after trocar site insertion, intracorporeal colpotomy, and vaginal stump closure to check tumor spillage. Measurements and Main Results Ten patients so far have been enrolled in this study and all have received this surgery successfully without positive washing cytology, indicating no tumor spillage during the surgery. We plan to enroll a total of 120 patients within three years. Conclusion This is a feasible study design that can be performed with MIS, which is why it is valuable to prove its efficacy and safety through a phase II trial in order to overcome the limitations of MIS suggested in LACC trial. (SOLUTION ClinicalTrials.gov number, NCT04370496)

Transumbilical Laparoendoscopic Single-Site Radical Hysterectomy without Uterine Manipulator and with Vaginal Closure

Study Objective Minimally invasive surgery (MIS) of radical hysterectomy (RH) was reported with inferior oncologic outcomes according to the New England Journal of Medicine (NEJM). Then some studies suggested that the no-touch technique may be a useful procedure to prevent tumor spillage as well as improve survival, and the procedures were improved continuously. Therefore, we performed RH targeting early-stage cervical cancer through laparoendoscopic single-site (LESS) approach with enclosed colpotomy and without uterine manipulator. Design A presentation of the surgery through this technical video. Setting A Hospital. Patients or Participants A 48-year-old postmenopausal woman was diagnosed as cervical cancer with stage IB1(FIGO 2018). Interventions After fully informed of the benefits and risks of different surgical approaches (open laparotomy and MIS), she agreed with the MIS. Measurements and Main Results The type C radical hysterectomy via LESS approach was performed successfully, the final pathologic findings confirmed stage IB1 cervical carcinoma. The patient recovered fast and well with slight pain, and the incision scar was hidden perfectly for cosmetic purpose. Conclusion This video demonstrated that LESS-RH with vaginal closure and without manipulator was feasible and safe. Suspension skills played a significant role in the LESS-RH. Besides, this surgery procedure also involved 4 specific techniques to prevent tumor spillage, including creation of a vaginal cuff, avoidance of interoperate uterine manipulator, standard extent and bagging of the specimen. These adaptations were meant to minimize tumor manipulation and disruption, for reducing the increased risk of recurrence. However, further verifications were still required.

Laparoscopic Radical Hysterectomy with Enclosed Colpotomy Using Surgical Stapler for Early-Stage Cervical Cancer

Study Objective To report the application of Ethicon Endo-Surgery re-usable linear cutter (Ethicon endocutter) in vaginal closure without usage of uterine manipulator to prevent tumor spillage in laparoscopic radical hysterectomy for early-stage cervical cancer. Design A step-by-step explanation of the procedures using a video. Setting Hospital for women's health teaching and research. Patients or Participants This is a 41-year-old woman with clinical stage IBI cervical squamous cell cancer. Interventions After the contraindication was removed, laparoscopic type C radical hysterectomy with pelvic lymph node dissection and ovarian transposition were performed, the surgery was finished without usage of uterine manipulator. The patient signed an informed consent that allows us to use her clinical data. Measurements and Main Results In this method, after completion of the radical hysterectomy procedures, an Ethicon endocutter was placed into abdominal cavity through a 12-mm trocar. The uterus was elevated with fixed sutures on the uterus. Then, the stapler was placed. Before the surgical stapler was fired to close the vagina, we should checked that no other unintended structure was included in the jaws of the stapler. After being fired, the stapler places 2 triple-staggered rows of titanium staples and simultaneously knife blade cuts between them. Once the vagina has been divided, the stapler was released. The upper part of the vaginal cuff was excised and checked by pathology as a surgical margin, and the uterus was removed through the vagina. Finally, the vaginal cuff was closed with absorbable barbed sutures. Conclusion Vaginal closure with Ethicon endocutter before colpotomy is a useful and effective procedure to block vaginal cuff and prevent tumor spillage during laparoscopic radical hysterectomy of cervical cancer.

Long term outcome of Wilms' tumor in tertiary care hospital

Background: Nephroblastoma, or Wilms’ tumor, is an embryonal tumor that develops from remnants of the immature kidney. It is the most common renal tumor of childhood. The aim is to analyze the long term outcome in Wilms’ tumor in perplex situations as double moiety and to correlate with multiple organ defects.Methods: It is a combined perspective and retrospective study that pediatric urology outpatient department (OPD) at the Institute of Child Health and Hospital for Children, Madras Medical College, Chennai. The study included patients with Wilms, who attended the pediatric surgery during the ten years, from March 2008 to February 2011. The patients were subjected to detailed clinical examination and relevant investigations were performed.Results: Among patients with stage I–II fumarate hydratase (FH) tumors, the relative risk (RR) of relapse and death were increased for loss of heterozygosity (LOH) 1p only (RR=2.2 for relapse; RR=4.0 for death), for LOH 16q only (RR=1.9 and RR=1.4), and LOH for both regions (RR=2.9 and RR=4.3) in comparison with patients lacking LOH at either locus.Conclusions: Stage I and II have a good prognosis. Stage III and IV need close surveillance since they have a high rate of recurrence. Stage V has a bad prognosis. Stage IV Wilms need lung irradiation. Neoadjuvant chemotherapy reduces tumor spillage in stage III and IV.

Controversies in management of the bladder cuff at nephroureterectomy.

Upper tract urothelial carcinoma (UTUC) accounts for roughly 5% of urothelial carcinomas. Historically, the gold standard for high-risk or bulky low-risk UTUC was an open radical nephroureterectomy with formal bladder cuff excision (BCE). The development of novel endoscopic, laparoscopic, and robotic techniques has transformed this operation, yet no level I evidence exists at present that demonstrates the superiority of one strategy over another. While new approaches to nephroureterectomy in the last decade have shifted the management paradigm to decrease the morbidity of surgery, controversy continues to surround the approach to the distal ureter and bladder cuff. Debate continues within the urologic community over which surgical approach is best when managing UTUC and how various approaches impact clinical outcomes such as intravesical recurrence, recurrence-free survival (RFS) and disease-specific mortality (DSM). When focusing on the existing treatment algorithm, key metrics of quality include (I) removal of the entire specimen en bloc, (II) minimizing the risk of tumor and urine spillage, (III) R0 resection, and (IV) water-tight closure allowing for early use of prophylactic intravesical chemotherapy. In the absence of robust evidence demonstrating a single superior approach, the urologic surgeon should base decisions on technical comfort and each patient’s particular clinical circumstance.

Surgical aspects, violations and outcomes of Wilms tumor\u2014a multicenter study in a resource-limited country

BackgroundWilms tumor is the commonest malignant renal neoplasm in children. Surgery plays a pivotal role in the management, and evidence-based guidelines for surgical resection have been established by the major international groups. Any deviation from the protocol is considered as a violation. The goal of this study was to evaluate outcomes of the patients with unilateral Wilms tumor treated at a developing country and to analyze surgical violations (SV) and their impact on the prognosis. A retrospective review was conducted for 37 patients who were presented to our hospitals and underwent nephrectomy for WT from January 2016 to December 2018. All participating centers adopt Children’s Oncology Group protocol. The SV were analyzed by logistic regression. Overall survival (OS) and event-free survival (EFS) were estimated by the Kaplan-Meier method.ResultsThere were 12 (32.4%), 11 (29.7%), 10 (27%), and 4 (10.8%) stages I, II, III, and IV, respectively. Their median age at time of diagnosis was 3.1 years. Upfront nephrectomy was performed for 30 cases. Six patients had tumor relapse (2 lungs and 4 local recurrences) at a median follow-up of 15.7 months. Out of the relapsed patients, two had unfavorable histology, and regarding their staging, four were stage III, one was stage II, and one was stage IV. Thirty-month OS and EFS were 84.3% and 81.1%, respectively. Twenty-seven SV occurred within 25 patients. Lack or inadequate lymph node sampling represented 74.07% (20/27), intraoperative tumor rupture and spillage accounted for 18.52% (5/27), and unwarranted preoperative biopsy happened in 7.41% (2/27). The SV were not correlated with mortality (p value = 0.381); however, they had a significant impact on the relapse (p value = 0.001). On further analysis; tumor rupture and spillage was a predictor for recurrence reaching a statistical significance (p value = 0.003), whereas the other violations were not.ConclusionsFavorable outcomes could be achieved by compliance with evidence-based guidelines even in a resource-limited country like ours. Violations were correlated with relapse; however, only tumor rupture and spillage was of statistical significance in multivariate analysis. Failure of lymph node documentation was the main problem encountered, and it should be avoidable in future practice.