[Show abstract][Hide abstract] ABSTRACT: The purpose of this study was to analyze the quality of life in terms of sexual and reproductive outcome in patients suffering from early stage cervical cancer, submitted to an excisional cone as fertility-sparing treatment.
A multicenter retrospective analysis about specific dimensions of physical, psychological, reproductive and sexual functions after a cold-knife conization plus pelvic laparoscopic lymphadenectomy was conducted at Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome-Italy and at Division of Gynecology, European Institute of Oncology, Milan-Italy. The aim of this study was twofold. It aimed to analyze the quality of life in patients submitted to minimally invasive surgery and to compare these data with radical trachelectomy.
Twenty-three patients with an average age of 30 years decided to participate in this study. After the treatment, all women (100%) had regular menstruation, 7 (30.4%) had increased not invalidating dysmenorrhea; 1 (4.4%) experienced a cervical stenosis; 6 among 10 patients that tried to conceive (60%) obtained one spontaneous pregnancy; 4 more (40%) underwent in vitro fertilization and embryo transfer and only 1 of them (25%) was successful. About sexual assessment, 1 patient (4.4%) had trouble in lubricating, 3 (13%) had anxiety about performance, 6 (26.1%) complained of dyspareunia which was resolved within 3 subsequent months. All patients (100%) obtained a complete psychological and physical recovery.
This study demonstrated preliminary encouraging data about sexual and reproductive outcome after excisional conization. A comparison with trachelectomy surely needs longer follow-ups, more cases and prospective analyses.
Journal of reproduction & infertility. 01/2014; 15(1):29-34.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the feasibility and the predictive value of cone biopsy before performing radical hysterectomy in locally advanced cervical cancer patients showing complete clinical response to neo-adjuvant chemoradiation.
Between March 2010 to March 2012 74 consecutive FIGO stage IIA2-IIB patients were submitted to neo-adjuvant chemoradiation. All complete clinical responder patients were enrolled in this pilot trial.
Fifty-seven out of 74 patients (77%) showed complete clinical response and were enrolled in the study. Forty-two out of 57 patients (74%) underwent successful pre-completion surgery cone biopsy with a median cone's tissue diameter of 24 mm (range 18-35). In 33 out of 42 patients (58%) a complete pathological response was found. In the remaining 5 (9%) and 4 (7%) a microscopic partial and partial response was found, respectively. All 33 cases (58%) with negative cone showed complete pathological response in the radical hysterectomy specimens. Patients with microscopic residual tumor foci in the cone showed negative residual cervical and paracervical tissue at definitive diagnosis, whereas in patients with partial response macroscopic residual disease in the surgical specimens was found. The negative predictive value of cone biopsy, MRI and PET/CT in the prediction of pathological status of the cervical and paracervical tissue was 100%, 79% and 79%, respectively (Table 2).
In this study we observed that, in locally advanced cervical patients showing complete clinical response to neo-adjuvant chemoradiation, the cone biopsy feasibility was almost 75%, and that there is a complete pathological correspondence between cone and definitive pathology.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 07/2013; · 2.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: STUDY OBJECTIVE: To compare perioperative outcomes and postoperative pain of minilaparoscopic (M-LPS) and laparoendoscopic single-site total hysterectomy (LESS). DESIGN: Prospectively randomized study (Canadian Task Force classification II-2). SETTING: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome. PATIENTS: A total of 86 patients underwent total hysterectomy. Seventy-one met the inclusion criteria and were included in this study. Three of them refused randomization, 34 were randomly assigned to undergo to single-port hysterectomy and 34 to undergo to minilaparoscopy. INTERVENTIONS: The operative technique is the same in the 2 groups with the exception of videolaparoscopy, port type, and some specific instruments. All surgical procedures were performed with an intrauterine manipulator. Single-port hysterectomy was performed through a multichannel single trocar inserted in the umbilicus. Minilaparoscopic hysterectomy was performed through one optical transumbilical 5-mm trocar and three 3-mm suprapubic ancillary ports. MEASUREMENTS AND MAIN RESULTS: Sixty-eight patients met the inclusion criteria and were enrolled in the study. The baseline characteristics of the 2 groups were comparable. Median operative time was longer in LESS with respect to M-LPS (120 minutes vs 90 minutes; p = .038). There were no differences between the 2 groups for median estimated blood loss, ileus, and postoperative stay. Additional 5-mm port insertion was needed in 1 case (2.9%) in the M-LPS group and in 2 cases (5.9%) in the LESS group, respectively (p = .311). No patient had development of intraoperative or early postoperative complications. Patients in the M-LPS group experienced a minor pain at each evaluation, compared with patients who underwent LESS. The rescue analgesic requirement was similar in the 2 groups. CONCLUSIONS: Laparoscopic hysterectomy can be safely performed by M-LPS and LESS. M-LPS is associated with significantly lower operative time and less postoperative pain than LESS. Advantages of M-LPS hysterectomy than LESS have no noteworthy impact on the patients' early postoperative management. The decision on the best access to the hysterectomy might take into account the surgeon's skill and feeling with the different possible approaches.
Journal of Minimally Invasive Gynecology 01/2013; · 1.61 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: To examine the surgical treatment and clinical outcome of elderly and very elderly advanced epithelial ovarian cancer patients. METHODS: We retrospectively analyzed FIGO stage IIIC-IV ovarian cancer patients, divided in elderly (Group A, >65 and <75 years) and very elderly patients (Group B, ≥75 years) treated by primary debulking surgery (PDS) or by interval debulking surgery (IDS) at the Catholic University at Rome and Campobasso, Italy. RESULTS: 164 patients were included: 123 (Group A) and 41 (Group B). Complete cytoreduction was achieved in 60 patients (60.6%) in Group A and in 20 patients (62.5%) in Group B (p = 0.75). In the remaining cases, optimal cytoreduction was performed (39 cases (39.4%) in Group A and 12 (37.5%) in Group B; p = 0.75). In Group A complete/optimal debulking was achieved in 53 patients (53.5%) at PDS and in 46 patients (46.5%) at IDS (p = 0.55). In the Group B a higher rate of patients was debulked at IDS with respect to PDS (10 (31.3%) vs. 22 patients (68.7%); p = 0.02). In Group A patients debulked at PDS showed better DFS (p = 0.007) and OS (p = 0.003) with respect to patients submitted to successful IDS, whereas in group B we did not observed any survival difference according to time of cytoreduction. CONCLUSIONS: Our data suggest that elderly and very elderly patients may tolerate radical and ultra-radical surgery. These patients should be managed in a gynecologic oncology unit, with prudent but complete approach.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 08/2012; · 2.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: OBJECTIVE: This study was designed to compare perioperative outcomes and postoperative pain of standard laparoscopic (S-LPS), minilaparoscopic (M-LPS), and laparoendoscopic single-site (LESS) hysterectomy. METHODS: A single-institutional, matched, retrospective, cohort study was performed. Between May 2010 and March 2011, 85 consecutive women were submitted to a total laparoscopic hysterectomy by S-LPS, M-LPS, and single-port LESS. Perioperative outcomes of these three techniques were analyzed and compared. RESULTS: Demographics and baseline characteristics of each group were absolutely comparable. The median operative time was longer [105 (range, 75-125) min] in the LESS group compared with the M-LPS group [90 (range, 60-120) min; p < 0.011] and S-LPS [80 (range, 50-110) min; p < 0.001]. No statistically significant differences have been reported for estimated blood loss or intra- and early postoperative complications. Postoperative pain control was better for LESS and M-LPS than S-LPS. CONCLUSIONS: M-LPS and LESS hysterectomy can be performed safely, and both seem to be associated with a halving of early postoperative pain with a lower request of analgesics.
[Show abstract][Hide abstract] ABSTRACT: To compare the peri-operative outcomes between total laparo-endoscopic single-site (LESS) and robotic approaches for the staging and treatment of early stage endometrial cancer patients.
A multicentre retrospective study involving three Italian gynaecological groups and one American centre. The peri-operative outcomes of LESS and robotic approach were compared in similar groups of patients, with regard to surgical outcomes and intra- and post-operative parameters and complications.
During the study period, 75 patients submitted to a total LESS hysterectomy and 75 patients received a total robotic hysterectomy. The median operative time - 122 versus 175 min (p=0.0001) - and the estimated blood loss - 50 versus 80 mL (p=0.03) - were slightly more favourable in the LESS group. The intra-operative complications were equally distributed (p=0.99); in the robotic group there were 4 (5.3%) post-operative grade IIIb complications versus 1 (1.3%) in the LESS group (p=0.172).
The LESS and robotic approaches both appear reasonable and each may have benefits and limitations depending upon the patient population. Further studies are needed to validate these preliminary conclusions.
[Show abstract][Hide abstract] ABSTRACT: The weight of surgical radicality, together with a lack of anatomical theoretical basis for surgery and inappropriate practical skills, can lead to serious impairments to bladder, rectal, and sexual functions after laparoscopic excision of deep infiltrating endometriosis. Although the "classical" laparoscopic technique for endometriosis excision involving segmental bowel resection has proven to relieve symptoms successfully, it is hampered by several postoperative long-term and/or definitive pelvic dysfunctions.
In this prospective cohort study, we compare the laparoscopic nerve-sparing approach to the classical laparoscopic procedure in a series of 126 cases. Satisfactory data for bowel, bladder, and sexual function were considered as primary endpoints.
A total of 126 patients were considered for analysis: 61 treated with nerve-sparing radical excision of pelvic endometriosis with segmental bowel resection (group B), and 65 treated with the classical technique (group A). Intraoperative, perioperative, and postoperative complications were similar between the two groups. Mean days of self-catheterization were significantly lower in the nerve-sparing group (39.8 days) compared with the non-nerve-sparing group (121.1 days; p < 0.001). The relapse rate within 12 months after surgery was comparable between the two groups. Patients of group A suffered from urinary retention more frequently between 1 and 6 months (p = 0.035) compared with group B and did not experience any improvement between 6 months and 1 year (p = 0.018). Overall detection of severe bladder/rectal/sexual dysfunctions was significantly different between the two groups, and 56 patients of group A (86.2%) reported a significantly higher rate of severe neurologic pelvic dysfunctions vs. 1 patient (1.6%) of group B (p < 0.001).
Our technique appears to be feasible and offers good results in terms of reduced bladder morbidity and apparently higher satisfaction than the classical technique. Considering that this kind of surgery requires uncommon surgical skills and anatomical knowledge, we believe that it should be performed only in selected reference centers.
[Show abstract][Hide abstract] ABSTRACT: Rectosigmoidectomy (RR) with primary anastomosis or pelvic peritonectomy (PP) are often part of an optimal en bloc tumor resection in advanced ovarian cancer (AOC) patients with contiguous extension to or encasement of the reproductive organs, peritoneum of the cul-de-sac and sigmoid colon. We report our experience with two different surgical approaches in optimally cytoreduced AOC patients evaluating oncologic outcome and surgically associated morbidities
Data from all consecutive AOC patients undergoing PP or RR as part of the surgical procedure during primary cytoreduction from 2004 through 2009 were extrapolated and analyzed using the chi-squared test, Cox proportional hazard model and Kaplan-Meier method including log-rank test.
During the study period, we identified 187 AOC patients, fitting the inclusion criteria: 71 (38%) were submitted to RR and 116 (62%) were managed with PP. The estimated mean disease-free survival (DFS) was 30.7 months (95% CI 24.6-36.8) in the RR arm vs. 25.9 months in the PP arm (95% CI 21.9-29.9) (p 0.299); similarly, the estimated mean overall survival (OS) was 38.8 months (95% CI 33.4-44.2) in the RR arm and 48.2 months in the PP arm (95% CI 43.1-53.3) (p = 0.122). No statistically significant differences were found in terms of DFS and OS according to the mesocolic lymphnode status (p = 0.65 and p = 0.81, respectively).
In conclusion, the current study clearly supports evidence that survival rates are similar for patients who achieved optimal residual tumor (RT), independent to whether they had RR or PP.
European journal of surgical oncology: the journal of the European Society of Surgical Oncology and the British Association of Surgical Oncology 09/2011; 37(12):1085-92. · 2.56 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In the last few years, technical advances have produced a dramatic shift from traditional open surgery toward a minimally invasive approach, even in oncological procedures. We present our initial experience with laparoendoscopic single-site surgery (LESS) in the surgical treatment of early-stage endometrial cancer patients.
Between July 2009 and May 2010, 20 consecutive low-risk early endometrial cancer patients were enrolled in this single institution prospective cohort trial.
The median age of the patients was 57 years (range = 42-68) and median body mass index was 24 kg/m(2) (range = 21-30). Median operative time was 105 min (range = 85-155) and median estimated blood loss was 20 ml (range = 10-180). The larger skin and fascial incision required for the single-port approach was 2.5 cm (median = 2.2 cm; range = 2.0-2.5). No laparoscopic/laparotomic conversion was registered, and no insertion of additional ports was necessary. Median ileus was 16 h (range = 12-20) and median time to discharge was 1 day (range = 1-2). All patients were completely satisfied with the cosmetic results and postoperative pain control.
Laparoendoscopic single-site surgery could represent a surgical option for extra-fascial hysterectomy in early-stage endometrial cancer patients, with the potential to further decrease invasiveness of the conventional laparoscopic approach.
[Show abstract][Hide abstract] ABSTRACT: To prospectively estimate the agreement between a fellow in training in gynecologic oncology and a senior surgeon performing a laparoscopic score to describe peritoneal carcinosis diffusion in patients with advanced ovarian cancer.
Single-institutional non-inferiority trial.
University hospital tertiary care center.
Ninety consecutive patients with primary advanced ovarian cancer.
The patients underwent staging-laparoscopy by a fellow in gynecologic oncology and a senior surgeon, sequentially and blindly. Single laparoscopic parameters (omental cake, peritoneal and diaphragmatic carcinosis, mesenteric retraction, bowel stomach infiltration, superficial liver metastasis) and a comprehensive laparoscopic score (PIV) were assessed in each procedure and registered.
No differences in the score discriminating performance for predicting optimal cytoreduction were observed between fellows' and seniors' evaluations.
The median number of staging laparoscopies performed by each fellow was 30 (range 28-32). The median score was 6 (0-10) for the fellows and 6 (0-14) for senior surgeons (p=ns). Results were superimposable in 57 of 90 patients (63.3%). Dividing the study period into two blocks, cases 1-45 and cases 46-90, differences were equally distributed over time (16.6 vs. 20%; p=0.9). The area under the curve of the receiver operating characteristic (ROC) curves for the score of fellows and seniors was 0.86 and 0.89, respectively (p=ns).
The laparoscopic assessment of peritoneal cancer diffusion according to a laparoscopic score can reliably be carried out by a fellow in gynecologic oncology after 12 months' experience without significant differences from a senior surgeon's assessment.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the effectiveness of our training method for basic "hands-on" laparoscopic courses.
A prospective observational study between September 2008 and December 2010 at Catholic Laparoscopy Advanced Surgery School of the Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Sacred Heart-Rome, was conducted. Each course lasted for 3 days, divided into theoretical and practical parts, ending with a live surgery. Gynecologists who attended our 'hands-on' laparoscopic courses had no or minimum experience with laparoscopic technique. The teachers were expert laparoscopists of our Division, and every single group of participants had the same tutor for the entire course. Trainees completed self-assessment anonymous questionnaire of laparoscopic knowledge, before and immediately after the course.
During the study period, we performed 20 basic courses, enrolling 120 consecutive gynecologists. Among them, 114 (95%) decided to participate. Average age was 41 years (range 35-60 years) and 108 (94.7%) trainees were Italian. The subjective assessment showed an immediate improvement of motor skills.
Laparoscopic training course can improve both theoretical knowledge and motor skills. Such courses result in a short-term subjective improvement.
Archives of Gynecology 06/2011; 285(1):155-60. · 0.91 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To describe a case series of early-stage cervical cancer patients treated with excisional cone instead of radical trachelectomy as fertility-sparing surgery.
Early-stage cervical cancer (International Federation of Gynecology and Obstetrics stage IA2-IB1), age ≤ 45 years, tumor ≤ 20 mm.
Cold-knife conization and laparoscopic pelvic lymphadenectomy.
Recurrence and pregnancy rate.
There were 17 patients: 4 (23.5%) IA2, 13 (76.5%) IB1; 12 (70.5%) squamous cell carcinoma, 4 (23.5%) adenocarcinoma, and 1 (6%) glassy cell tumor. Four cases (23.5%) involved lymphovascular space invasion. The median number of lymph nodes removed was 18 (range 13-51). None of the patients received neoadjuvant chemotherapy, and two patients (12%) received three courses of adjuvant chemotherapy. No recurrences were observed after a median follow-up of 16 months (range 8-101 months). Two of five patients (40%) attempting to conceive had a spontaneous pregnancy and delivery.
In selected and informed patients, conization and laparoscopic pelvic lymphadenectomy seems to be feasible as a fertility-sparing surgical approach.
Fertility and sterility 03/2011; 95(3):1109-12. · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To evaluate whether the systematic use of an intrauterine manipulator influences the accuracy of frozen section analysis in early-stage endometrial cancer.
Case-control study (Canadian Task Force classification II-1).
Three hundred fourteen consecutive women with early-stage endometrial cancer.
Between January 2004 and December 2009, 314 women with early-stage endometrial cancer underwent staging at laparoscopy (case group) or laparotomy (control group). All women in the case group underwent total laparoscopic hysterectomy using an intrauterine manipulator.
The positive predictive value of frozen section analysis for myometrial infiltration, histotype, and grade of differentiation was 97.2%, 100%, and 97.2%, respectively. The correct diagnosis rate was of 85.7%. The accuracy of frozen section analysis, rate of correct diagnosis, and rate of tumor vascular invasion did not seem to be significantly modified by systematic use of an intrauterine manipulator for total laparoscopic hysterectomy compared with total abdominal hysterectomy in early-stage endometrial cancer staging.
Frozen section analysis of early-stage endometrial cancer is highly accurate, and systematic use of an intrauterine manipulator does not represent a bias for correct evaluation of the specimen.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the efficacy of discoid resection for the treatment of deep infiltrating endometriosis and whether it could be considered to be a valid alternative to the rectosigmoid segmental resection.
Departments of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, and Catholic University of the Sacred Heart, Rome, Italy.
Women with deep infiltrating and intestinal endometriosis divided into study group (48 patients) and control group (88 patients).
All patients underwent laparoscopic endometriosis excision plus discoid rectosigmoid resection (study group) or segmental resection (control group).
Short- and long-term outcomes.
In the study group, median operating time was 200 minutes, with a median estimated blood loss of 203 mL. Median ileus was 3 days with a median postoperative hospitalization of 7 days. Early complications were observed in six patients (12.5%), and in two of them (4.16%) a surgical management was necessary. Median follow-up period was 33 months, and five recurrences (10.4%) were registered. In the control group, no significant differences were noticed except for longer operative time, more temporary ileostomy, postoperative fever, and long-term bladder dysfunctions.
Laparoscopic mechanical discoid resection is feasible, markedly improved endometriosis related symptoms, and could be considered as a worthy alternative to classic segmental resection in selected patients.
Fertility and sterility 05/2009; 94(2):444-9. · 3.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This case report describes a total laparoscopic hysterectomy of a large uterus of a woman who recently underwent neurosurgery for a grade IV glioblastoma. Because of a severe anaemia due to chronic vaginal haemorrhage for a fibromatosis uterus, she was not able to start a chemotherapic oncological protocol. We thus decided to perform a total hysterectomy through a laparoscopic approach in order to reduce the hospital stay and to ensure a quick recovery. We studied a surgical but also anaesthesiological strategy in order to obtain a good result with no or as few as possible complications.
[Show abstract][Hide abstract] ABSTRACT: To evaluate prospectively the efficacy of laparoscopic ureterolysis versus ureteroureterostomy in women with ureteral endometriosis.
Department of Obstetrics and Gynecology, Ospedale Sacro Cuore of Negrar, Verona, Italy, a tertiary care endometriosis referral center.
Endometriotic patients with moderate-severe ureter dilatation.
All women underwent laparoscopic endometriosis excision and concomitant laparoscopic ureterolysis, ureteroureterostomy, nephrectomy, or laparotomic ureterocystoneostomy.
Clinical outcomes were evaluated.
Fifty-six patients with preoperative or intraoperative evidence of moderate-severe ureter dilatation were enrolled. Dysmenorrhea (91%) and dyspareunia (68%) were the symptoms more frequently reported; only two patients had typical obstructive uropathy pain. In 35 cases, laparoscopic ureterolysis, in 17 laparoscopic ureteroureterostomy, in 2 laparotomic ureterocystoneostomy, and in 2 laparoscopic nephrectomy was performed. 11 out of 35 (31.4%) major complications occurred in the ureterolysis group, and 2 out of 17 (11.7%) in the ureteroureterostomy group. Median follow-up time was 21 months. Ureteral endometriosis recurrence was surgically detected in three patients who underwent conservative ureteral surgery.
Preoperative planning should be rigorous, and complete surgical excision of ureteral endometriosis should be ensured by a team of experts familiar with endometriosis, its multiple manifestations, and its management.
Fertility and sterility 12/2008; 93(1):46-51. · 3.97 Impact Factor