Radical Vaginal Hysterectomy Research Articles

Abdominal vs vaginal hysterectomy: a comparative study of the postoperative quality of life and satisfaction

To compare the short-term results of the quality of life and satisfaction of patients submitted to total abdominal hysterectomy (TAH) and vaginal hysterectomy (VH) for benign uterine disease. Women referred for hysterectomy for uterine myoma were randomized to TAH (n=30) or VH (n=30). The exclusion criteria were uterine prolapse, indication associated surgical procedures and uterine size > or =300 cm3. After a month, follow-up questionnaires had a response rate of 100%, and consisted of an interview with application of SF-36 questionnaire (functional capacity, physical aspect and pain) and evaluation of satisfaction rate. There were no differences in the patients' mean age, parity, body mass index, preoperative hemoglobin levels and uterine size between groups. Lower postoperative quality-of-life scores were found in the TAH group when compared to the VH group in functional capacity (P=0.002), physical aspect (P=0.008) and pain (P=0.002). The general satisfaction rate with the surgery was similar in the two groups of patients (P=0.147). However, a higher rate of patients submitted to VH would choose the same therapeutic modality (65.5 vs 90%; P=0.021). A better postoperative quality of life (functional capacity, physical aspect and pain) and higher satisfaction rate was found in the VH when compared to TAH.

Laparoscopically Assisted Radical Vaginal Hysterectomy vs Radical Abdominal Hysterectomy for Cervical Cancer: A Match Controlled Study

Laparoscopically Assisted Radical Vaginal Hysterectomy vs Radical Abdominal Hysterectomy for Cervical Cancer: A Match Controlled Study

Laparoscopic-Assisted Vaginal Hysterectomy versus Abdominal Hysterectomy in Stages I and II Endometrial Cancer: Operating Data, Follow up and Survival

At Principe De Asturias Hospital in Madrid, Spain, between January 1997 and December 2003, 75 women with stage I or II endometrial cancer were treated either with laparoscopic-assisted vaginal hysterectomy and pelvic lymphadenectomy (n = 38) or with total abdominal hysterectomy and pelvic lymphadenectomy (n = 37). This article presents a comparison of these two groups. Patients were not randomized to treatment; abdominal surgeries were more frequent in the early years, and laparoscopic procedures more common in the later years. All patients underwent initial pelvic and abdominal washing and inspection followed by pelvic lymphadenectomy. Paraaortic lymphadenectomy was performed after hysterectomy if there were positive pelvic lymph nodes. In laparoscopic procedures, a 10-mm umbilical and another inter-xipho-umbilical port and two 5-mm punctures in each lower abdominal quadrant were used. Lymph nodes were collected in a bag that was placed in the pouch of Douglas at the beginning of the procedure and then removed through the 10-mm umbilical trocar. The uterine vessels were sutured by either the laparoscopic or vaginal route. A midline incision was used for abdominal procedures. Patients were seen at a follow-up visit every 6 months for 5 years and then once a year. The mean operating time for the laparoscopic vaginal hysterectomy (LPS) group was 165 minutes (range, 77-240 minutes) compared with 130 minutes (range, 60-180 minutes) for the abdominal hysterectomy (LPM) group (P <0.05). There were seven (19%) intraoperative complications in the LPM group, including blood loss greater than 1000 mL in three patients and bladder and bowel injury in two patients each. In the LPS group, two patients had excessive bleeding, two patients with an uncontrollable hypercapnia were converted to laparotomy, and one patient with a ureteral abnormality had a double-J catheter inserted to maintain patency (five total intraoperative complications; 13%). Postoperative complications were seen in 39% of the LPM group compared with 18% of the LPS group. Overall, nine women had an abscess or hematoma, which was in the abdominal incision in five LPM and one LPS patient and in the vaginal vault in three LPS patients. There were five instances of fever in the LPM group and three in the LPS group. One LPM patient had a deep vein thrombosis and three LPM patients had postoperative ileus greater than 3 days. Four women who had laparotomy required postoperative blood transfusion. Three patients in this group were readmitted to the hospital for treatment of abscess or fever. No patient in the laparoscopically treated group required transfusion or readmission. There were no differences between the two groups in the number or location of lymph nodes removed or in the pathologic results. Postoperative adjuvant radiotherapy was given to all patients with a pathologic diagnosis of stage IB,G2 or greater. After a mean follow up of 53 months (range, 5-90 months) in patients who had laparotomy, 30(81%) are free of disease, two (5%) are alive with recurrence, three (8%) are dead, and two have been lost to follow up. The mean follow up for women who underwent laparoscopy was 36 months (range, 9-65 months). Thirty-one (82%) of these women are alive, two (5%) are alive with disease, four (10.5%) are dead, and one has been lost to follow up. A total of four patients developed recurrent disease. There was one recurrence in the retroperitoneum, one in the lung (LPM group), one in the vaginal vault, and one bone metastasis (LPS group). All were alive at the time of publication.

A comparison of laparoscopically-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

Objective：The aim of this study was to compare peri-operative morbidity and safety of patients treated by laparoscopicallyassisted radical vaginal hysterectomy (LARVH) with laparoscopic pelvic lymphadenectomy (LPL) and radical abdominal hysterectomy (RAH) with pelvic lymph node dissection (PLND) in early stage of cervical cancer. Methods：Since September 2004, all patients with FIGO stage Ia-IIa cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Two surgeons at our center have performed LARVH by Schneider method on all surgically appropriate patients. Results：Between September 2004 and May 2005, 26 patients were performed LARVH with LPL, 30 patients were performed RAH with PLND. There were no differences in estimated blood loss, the number of lymph nodes, duration of hospital stay and postoperative complications. But operative time was significantly prolonged in LARVH group. Intraoperative complications in the LARVH with LPL group included: bladder injuries (2), shift to laparotomy due to ureter injury (1). There was one case of vesicovaginal fistula in the RAH group. Conclusion：LARVH with LPL in early stage of cervical cancer is a safe and technically effective alternative to RAH. Despite the inherent limitations of LARVH with LPL and its associated learning curve, the procedure conveys many advantages over the open laparotomy technics in terms of postoperative wound pain and recovery. However further study is needed to evaluate long-term recurrence rate and survival rate.

Recurrence in a Schuchardt incision after Schauta–Amreich radical vaginal hysterectomy for cervical cancer

A Schuchardt incision is frequently performed to facilitate access to the parametrium during radical vaginal hysterectomy for cervical cancer. We report an adenocarcinoma recurrence in a Schuchardt incision 12 months after radical vaginal hysterectomy for FIGO stage IB1 cervical cancer. Histology of the primary tumor had shown a well-differentiated adenocarcinoma and poorly differentiated squamous cell carcinoma of the cervix 2.6 cm in maximum diameter. After further surgical therapy and adjuvant radiotherapy, the patient died of disease 51 months after the initial operation. Cervical cancers can implant and recur in perineal incisions. Thus, it appears prudent to avoid such incisions or, if they are made, to irrigate them copiously before closing them.

Pelvic lymphadenectomy for cervical cancer: Extraperitoneal versus laparoscopic approach

Objective To compare the extraperitoneal versus the laparoscopic technique in performing pelvic lymphadenectomy in a series of patients undergoing a radical vaginal hysterectomy for locally advanced cervical cancer. Study design Retrospective study with 42 patients undergoing a radical vaginal hysterectomy for cervical cancer. Patients from group A (20 patients) had a laparoscopic lymph node dissection and patients belonging to group B (22 patients) had an extraperitoneal lymphadenectomy. Historical data, clinical and surgical characteristics, perioperative and post-operative complications were analyzed. Follow-up was conducted according to the oncologic requirements. Results No significant difference was observed between the two groups in terms of blood loss, post-operative pain, transfusions, hospital stay and post-operative hematomas. The extraperitoneal group (group B) significantly showed a reduced operating time, a greater number of nodes removed ( p < 0.05). The only lymphocyst occurred in group B. Conclusions Extraperitoneal pelvic lymphadenectomy can be considered an adequate technique to complement radical vaginal operations for cervical cancer.

Hystérectomie élargie par voie basse ou opération de Schauta-Stoeckel

Radical vaginal hysterectomy, also named Schauta's operation, is an old concept. The current use of this surgery has benefited from laparoscopy advances, in particular from laparoscopy-assisted full lymphadenectomies. The procedure begins with a laparoscopic pelvic lymph-node dissection and a laparoscopic assistance of the subsequent vaginal operative steps leading to radical colpohysterectomy, including the resection of the proximal parametrium (Piver II type radical hysterectomy). Indications of radical vaginal hysterectomy are early cervical cancer (stage IA2 or IB1). This surgical technique may result in reduced per and post operative morbidity in comparison with the abdominal approach (Wertheim procedure). Over all, a good knowledge of Schauta's operative technique allows achieving radical trachelectomy, an operation that preserves the fertility of young patients affected by an early cervical cancer.

An easier ureteral tunnel approach during laparoscopic-assisted radical vaginal hysterectomy

Identification and mobilization of the ureters is the most difficult part of the Schauta operation and is the most risky and time-consuming step in laparoscopic radical hysterectomy. Since February 2003 we have used a modified technique of laparoscopic radical hysterectomy for managing seven cases of stage IB1 cervical cancer. This technique is based on that described by Querleu–Dargent, but it includes a modified step to treat the parametria and the ureteral tunnel. Both ureters are identified and isolated by placing vessel loops. The ends of the vessel loop are placed into the vagina through the anterior colpotomy previously performed. Once in the vaginal route, gentle traction of the vessel loops allows easy identification and dissection of the ureter. Caudal parametrial management is the most time-consuming of the laparoscopic approaches, and a high risk of ureteral damage is always present. Depending on vaginal conditions, managing the proximal parametrium and ureters is difficult, and Schuchardt’s incision may be necessary. Laparoscopic vessel loop isolation of the ureters allows easier and safer vaginal management of the ureteral tunnel during laparoscopic vaginal radical hysterectomy.

Laparoscopic hysterectomy: Challenges and limitations

Twenty years after the first description of vaginal hysterectomy with laparoscopic assistance by Kurt Semm in 1984 (1), and 16 years after the publication of the so‐called laparoscopically assisted vaginal hysterectomy (LAVH) by Harry Reich in 1989 (2), it is time to review and evaluate the real benefits of laparoscopic hysterectomy. Although laparoscopic surgery is well accepted by gynaecologists worldwide for the treatment of certain gynaecological conditions, laparoscopic hysterectomy in Germany, and probably worldwide, is still only performed by a few specialists. Highly skilled surgical techniques, longer operating time and expensive technology are suggested to be the deterring factors. Laparoscopic hysterectomy, in its different forms, is an attractive and safe procedure for the management of benign gynaecological conditions and many authorities recommend its use on a larger extent. On the other hand, in our opinion, the use of laparoscopic hysterectomy for oncological indications is still controversial. Extensive experience of over 15 years, of the first author, in practising and teaching various forms laparoscopic hysterectomy, namely, laparoscopically assisted vaginal hysterectomy (LAVH), total laparoscopic hysterectomy (TLH), classic intrafascial supracervical hysterectomy (CISH) and laparoscopic supracervical hysterectomy (LSH), has led us to the firm conclusion that these techniques are advantageous to patients if performed for the appropriate indication. In particular, subtotal or supracervical hysterectomy, with the cervix remaining in its place, is associated with fewer complications and a very favourable outcome for the patient. Radical laparoscopic vaginal hysterectomy (RLVH), the last variant in our exposé, is only successful in an expert's hands. The surgical techniques of these varieties of laparoscopic hysterectomies will be described and illustrated in detail in this paper.

Total laparoscopic radical parametrectomy

Although the surgical approach to early invasive cervical carcinoma may result in a better functional quality of life, the majority of patients with occult cervical cancer posthysterectomy still are treated with radiation therapy. Obviously, a radical operation still is considered a technically difficult task. Recently, laparoscopic-assisted vaginal radical parametrectomy (LAVRP) has been reported as an alternative treatment for this situation. In laparoscopic-assisted vaginal radical hysterectomy (LARVH), parts of the procedure are performed vaginally. We modified LAVRP in treating cervical cancer as through the laparoscope completely total laparoscopic radical parametrectomy (TLRP). The major advantage of TLRP for occult cervical cancer is that the entire surgery is performed under direct observation. It may reduce the possibility of visceral organ injury during vaginal procedures and could minimize the vaginal bleeding from vaginal dissection. Our preliminary experiences suggest that TLRP is feasible for carefully selected candidates.

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study

Objectives The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches. Methods All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period. Results Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences ( P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group ( P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group ( P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH). Conclusions Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low—suggesting improved quality of life—without compromising survival.

Introduction of transperitoneal lymphadenectomy in a gynecologic oncology center: analysis of 650 laparoscopic pelvic and/or paraaortic transperitoneal lymphadenectomies

Objective.Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies. We evaluated the feasibility and oncologic value of laparoscopic transperitoneal pelvic and paraaortic lymphadenectomy in correlation to complication rate and body mass index. Methods.Between August 1994 and September 2003, pelvic and/or paraaortic transperitoneal laparoscopic lymphadenectomy was performed in 650 patients at the Department of Gynecology of the Friedrich-Schiller University of Jena. Retrospective and prospective data collection and evaluation of videotapes were possible in 606 patients. Laparoscopic lymphadenectomy was part of the following surgical procedures: staging laparoscopy in patients with advanced cervical cancer (n = 133) or early ovarian cancer (n = 44), trachelectomy in patients with early cervical cancer (n = 42), laparoscopic-assisted radical vaginal hysterectomy in patients with cervical cancer (n = 221), laparoscopy before exenteration in patients with pelvic recurrence (n = 20), laparoscopic-assisted vaginal hysterectomy or laparoscopic-assisted radical vaginal hysterectomy in patients with endometrial cancer (n = 112), and operative procedures for other indications (n = 34). Results.After a learning period of approximately 20 procedures, a constant number of pelvic lymph nodes (16.9–21.9) was removed over the years. Pelvic lymphadenectomy took 28 min, and parametric lymphadenectomy took 18 min for each side. The number of removed paraaortic lymph nodes increased continuously over the years from 5.5 to 18.5. Right-sided paraaortic, left-sided inframesenteric and left-sided infrarenal lymphadenectomy took an average of 36, 28, and 62 min, respectively. The number of removed lymph nodes was independent from the body mass index of the patient. Duration of pelvic lymphadenectomy was independent of body mass index, but right-sided paraaortic lymphadenectomy lasted significantly longer in obese women (35 vs. 41 min, P = 0,011). The overall complication rate was 8.7% with 2.9% intraoperative (vessel or bowel injury) and 5.8% postoperative complications. No major intraoperative complication was encountered during the last 5 years of the study. Conclusion.By transperitoneal laparoscopic lymphadenectomy, an adequate number of lymph nodes can be removed in an adequate time and independent from body mass index. The complication rate is low and can be minimized by standardization of the procedure.

Rate of major complications is higher in laparoscopic than abdominal hysterectomy but quality of life improves with both procedures

Question Is the risk of major complications greater following laparoscopic hysterectomy compared with abdominal and vaginal hysterectomy for non-malignant conditions? Study design Two parallel, multi-centre randomised trials. Main results More major complications were experienced with laparoscopic hysterectomy compared with abdominal hysterectomy (11.1% vs 6.2%; mean difference 4.9%, 95% CI 0.9% to 9.1%, number needed to harm 20). There was no significant difference in complication rates between laparoscopic and vaginal hysterectomy groups (complication rate 9.5% for both groups). Pain scores were higher following abdominal hysterectomy compared with laparoscopic hysterectomy (mean difference 0.4, 95% CI 0.09 to 0.7). There was no detectable difference in the vaginal trial. Quality of life at 12 months improved with all interventions. Authors’ conclusions Major complications were more common following laparoscopic hysterectomy compared with abdominal hysterectomy. The vaginal trial was inconclusive.

A comparison of laparascopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

Objectives. The aim of this study was to compare peri-operative morbidity and recurrence-free survival of early-stage cervical cancer patients treated by laparoscopic-assisted radical vaginal hysterectomy (LARVH) with time-matched radical abdominal hysterectomy (RAH) controls at our center. Methods. Since July 1984, all patients with FIGO stage IA/IB cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Since November 1996, one surgeon at our center has performed LARVH on all surgically appropriate patients. Non-parametric tests were used. Differences between medians were compared using Wilcoxon Rank Sum test. Statistical analysis used the Kaplan–Meier method to calculate disease-free survival. Differences between survival curves were compared with the log rank test. Statistical significance was defined as P < 0.05. Results. Between November 1996 and December 2003, 71 and 205 patients have undergone LARVH and RAH, respectively, for FIGO stage IA/IB carcinoma of the cervix. Both groups were similar with respect to age and Quetelet index. There were no differences in tumor size, histology, grade, depth of invasion, lymph node metastases, or surgical margins. All laparoscopic procedures were completed successfully with no conversions to laparotomy. Intra-operative morbidity characteristics analyzed (LARVH vs. RAH) were blood loss 300 ml vs. 500 ml ( P < 0.001), operative time 3.5 h vs. 2.5 h ( P < 0.001), and intra-operative complications 13% vs. 4% ( P < 0.03). Intra-operative complications in the LARVH group included: cystotomy (7), ureteric injury (1), and bowel injury (1). There was no difference in transfusion rates. There was no difference between post-operative infectious and non-infectious complications (LARVH vs. RAH), 9% vs. 5% and 5% vs. 2%, respectively. The median time to normal urine residual was 10 days vs. 5 days ( P < 0.001), and the median length of hospital stay was 1 day vs. 5 days ( P < 0.001). Twenty-two percent of patients received post-operative radiotherapy for high-risk features in both groups. After a median follow-up of 17 and 21 months, there have been 4 recurrences in the LARVH group and 13 in the RAH ( P = NS). The overall 2-year recurrence-free survival was 94% and 94% in the LARVH and RAH groups, respectively ( P = NS). Conclusion. Our data demonstrate that early cervical cancer can be treated successfully with LARVH with similar efficacy and recurrence rates to RAH. The major benefits are less intra-operative blood loss and shorter hospital stay. It is a safe procedure with low overall morbidity and complication rates. However, at present, LARVH is associated with an increase in intra-operative complications, and patients may have an increased time to return to normal bladder function.

Risk Factors for Febrile Morbidity After Hysterectomy

Peipert, Jeffrey F.; Weitzen, Sherry; Cruickshank, Courtney; Story, Errett; Ethridge, Daniel; Lapane, Kate

Laparoscopic-Assisted Radical Vaginal Hysterectomy: Prospective Evaluation of 200 Patients With Cervical Cancer

Hertel, Hermann; Köhler, Christhardt; Michels, Wolfgang; Possover, Marc; Tozzi, Roberto; Schneider, Achim

Tension-free vaginal tape and associated procedures: a case control study.

We compare objective and subjective cure rates after tension-free vaginal tape procedures performed alone or in conjunction with vaginal procedures. One hundred eighty-six women underwent a tension-free vaginal tape procedure for stress or mixed urinary incontinence. One hundred women treated with tension-free vaginal tape alone (group 1) were compared with 40 women treated with tension-free vaginal tape and concomitant vaginal hysterectomy (group 2), and 46 patients treated with tension-free vaginal tape and pelvic floor reconstruction (group 3). Patient outcomes, surgical difficulties and complications are reported. Postoperative voiding diaries, standing stress-test results, and patient satisfaction were compared. There were no significant differences among the three groups in terms of age, menopausal status, BMI, previous incontinence surgery, or the type and degree of incontinence. Parity was significantly higher in the group treated with tension-free vaginal tape and pelvic floor reconstruction ( p=0.04 ). The overall perioperative complication rate was 15.6%. Women treated with tension-free vaginal tape and hysterectomy (group 2), and those treated with tension-free vaginal tape and pelvic floor reconstruction (group 3) had a significantly higher incidence of bladder injury (17.9% and 13%, respectively, versus 5% in group 1; p=0.05 ). Estimated blood loss and the frequencies of postoperative urgency and voiding disorders did differ significantly between women treated with tension-free vaginal tape alone and those who underwent associated procedures. The mean follow-up time was 24.5+/-2.6 months. No difference in the objective cure rate was found between the tension-free vaginal tape group and the other two groups (93% versus 97.5% and 91.1%; p=0.3 ). No difference in the subjective cure rate was found between the tension-free vaginal tape group and the groups undergoing associated procedures (72% versus 72.5% and 68.8%; p=0.4). Pelvic floor defects, benign uterine disorders and stress urinary incontinence can be safely treated with tension-free vaginal tape and vaginal procedures during the same surgical procedure.

New approaches for the management of cervical cancer

Since the introduction of the Pap test by George Papanicolaou, the incidence of cervical cancer has fallen and mortality has decreased, in parallel with effective treatment of the precancerous and in situ stages of the disease. However, women who are not diagnosed through screening usually present with advanced disease. Early invasive disease can be treated successfully with radical abdominal hysterectomy and pelvic lymphadenectomy or with radiotherapy. A surgical alternative is radical trachelectomy, which can preserve fertility in young women. Advances in the techniques of laparoscopy facilitate procedures, such as radical vaginal hysterectomy with laparoscopic lymphadenectomy, that decrease intra-abdominal scarring and length of hospital stays. The presence of lymph node metastases alters the type of therapy. A range of methods is available to assess lymph nodes, including positron emission tomography, a new approach that may be of value. Radiotherapy alone may not be successful in women with locally advanced disease and adding chemotherapy may eradicate systemic micrometastases that are not affected by radiation. Single-agent cisplatin is the current agent of choice for adding to radiotherapy but new agents are being evaluated. Persistent infection with human papillomavirus (HPV) is associated with the development of cervical cancer. Vaccines against HPV are being developed and clinically tested and hopefully in the future it may be possible to eradicate cervical cancer.

Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer

Objective The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors. Methods Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98). Results Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%. Conclusion Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.

Technical modification of the nerve-sparing laparoscopy-assisted vaginal radical hysterectomy type 3 for better reproducibility of this procedure☆

Objective The goal of this work is to make the technique of nerve-sparing laparoscopy-assisted vaginal radical hysterectomy (LAVRH) type 3 easier and less time consuming. Methods Compared with the original LAVRH type 3, laparoscopic preparation of the cardinal ligament is extended to the transection of the upper part of the rectovaginal ligament. In vaginal approach, the preparation begins not as originally with the bladder pillar and ureter, but with transection of the rest of the rectovaginal ligament followed by dorsal eversion of the uterus and, lastly, transection of the bladder pillar with preparation of the ureters. Results Thirty-two consecutive patients underwent the modified nerve-sparing LAVRH type 3. The mean operative time for the vaginal part of the procedure was 54.3 min, whereas for the original technique for LAVRH type 3, the mean operative time was 143.6 min. Conclusion Prior transection of the rectovaginal ligament in the vaginal approach with dorsal eversion of the uterine fundus makes preparation of the ureter and transection of the bladder pillar easier and significantly less time consuming than in the original LAVRH type 3.