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Total laparoscopic hysterectomy for endometrial cancer: Patterns of recurrence and survival
Abstract
The impact of laparoscopic surgery on the patterns of recurrence and on prognosis in patients with endometrial cancer remains unclear. The objective of the current study was to evaluate the effect of the laparoscopic approach on patterns of recurrence, disease-free (DFS), and overall survival (OS) in patients with endometrial cancer.
A retrospective review of patients presenting with stages 1-4 endometrial cancer who had a hysterectomy, bilateral salpingo-oophorectomy with or without surgical staging was performed. Patients either had a total laparoscopic hysterectomy (TLH) or a total abdominal hysterectomy (TAH). Patterns of recurrence, DFS and OS were the study endpoints.
The surgical intent was TLH in 226 patients (44.3%) and TAH in 284 patients (55.7%). TLH was converted to laparotomy in 11 patients. Patients for TLH were younger, heavier, and had a higher ASA score and were more likely to present with early-stage, well-differentiated tumors and were less likely to have undergone lymphadenectomy. Median follow-up was 29.4 months. DFS and OS were adversely and independently affected by increasing age, higher stage, higher grade, and by deeper myometrial invasion, whereas the intention to treat (TLH vs. TAH) did not influence DFS or OS. Patterns of recurrence were similar in both groups and no port-site metastasis was noted in the TLH group.
The incidence of port-site metastasis in early-stage endometrial cancer treated by TLH is low. Laparoscopic management does not seem to worsen the prognosis of patients with endometrial cancer.
... In fact, laparoscopy aided by magnification of small vessels provided by the recently designed optical systems decreases intraoperative blood loss. (5,11) Obermair et al. (18) documented significant decrease numbers of LNs on using the laparoscopic method yet, in our work, a larger count of LNs were involved in cases of the LPS group and might be explained by more ability to expose the operative field in addition to the advance achieved in the laparoscopic methods helping good dissection of the pelvic spaces as well as the fact that laparoscopy was often carried out by the same surgical group. The mean number of LNs restore in the pelvis was the same as data documented in other research (9,11,13,19) where lymphadenectomy was carried out completely via laparoscopy. ...
... Only few studies have concluded the survival of females having EC following LPS procedure compared with LPT. (6,9,11,13,16,18,19) The vast majority of these studies were retrospectively done except for 2 prospective randomized ones. (6,21) Obermair et al., (18) revealed in the results of a retrospective review on five hundred ten cases subjected to total LPS operation or LPT operation, that at 29-month follow-up the same pattern of recurrence and the same overall survival in the 2 groups. ...
... (6,9,11,13,16,18,19) The vast majority of these studies were retrospectively done except for 2 prospective randomized ones. (6,21) Obermair et al., (18) revealed in the results of a retrospective review on five hundred ten cases subjected to total LPS operation or LPT operation, that at 29-month follow-up the same pattern of recurrence and the same overall survival in the 2 groups. In a randomized study that compared the laparoscopic-vaginal techniques versus the tradetional transabdominal technique, Malur et al. (13) emphasized these results, yet on small numbers of cases. ...
... Indeed, whilst endometrial cancer is the first gynecologic cancer to be treated laparoscopically, a laparoscopic approach also is being used for the surgical management of malignant disease. Following the first report on the use of laparoscopic surgery for endometrial cancer by Childers et al. [12], the feasibility, safety, and efficacy of laparoscopic surgery in the surgical management of endometrial cancer has been reported in numerous retrospective studies13141516171819202122232425 , prospective nonrandomized studies26272829, or randomized, controlled trials (RCTs) [30–42, 43@BULLET@BULLET, 44@BULLET@BULLET, 45@BULLET@BULLET]. With advances in surgical technique and instrumentation, laparoscopic surgery recently has become widely used for the surgical management of endometrial cancer, with an increasing role being noted for treatment of the disease. ...
... Many retrospective studies13141516171819202122232425 , prospective nonrandomized studies26272829, and meta-analyses [49@BULLET, 50–52, 53@BULLET] published during the last decade have suggested that laparoscopic surgery has an improved outcomes profile in terms of estimated blood loss and transfusion requirements , recovery of bowel movement, postoperative hospital stay, and perioperative complications compared with laparotomy in the surgical management of endometrial cancer . These findings have been confirmed in recent RCTs comparing laparoscopy and laparotomy for surgical staging of endometrial cancer (Table 1) [30–42, 43@BULLET@BULLET, 44@BULLET@BULLET, 45@BULLET@BULLET]. ...
... There is no evidence that laparoscopic surgery compromises the survival of patients with endometrial cancer. Retrospec- tive13141516171819202122232425 or prospective, nonrandomized studies26272829 have shown comparable survival outcomes for laparoscopic surgery and laparotomy. Four RCTs reported the long-term survival outcomes after laparoscopic surgery compared with laparotomy in patients with endometrial cancer (Table 1) [33, 35, 36, 45@BULLET@BULLET]. ...
Surgical staging and management through laparotomy has been the “gold standard” for treatment of endometrial cancer. However, recent advances in laparoscopic surgical techniques and instrumentation have meant that all surgical procedures for the treatment of endometrial cancer can now be performed using laparoscopy, which has naturally led to an increase in its use for treating this condition. Indeed, laparoscopic surgery is now the preferred alternative to laparotomy for the surgical management of endometrial cancer. Laparoscopic surgery is associated with improved outcomes, less complications, and improved quality of life, without compromising survival of patients. This review provides an update on the role of laparoscopic surgery for the surgical management of endometrial cancer with particular emphasis on feasibility, safety, and efficacy, based on the results of randomized, controlled trials comparing laparoscopy and laparotomy for surgical staging of endometrial cancer.
... No statistically significant difference was detected between TLH and TAH, considering the final pathology results. However, there is a dilemma concerning the use of surgical methods for EC patients (32,33) . For this reason, some studies were performed to identify advantages of these surgical techniques. ...
... Zullo et al. (20) reported that LOS in TLH and TAH patients was 4.1 and 8.2 days, respectively. Similarly, Obermair et al. (33) , Bell et al. (36) , Frigerio et al. (37) , Soliman et al. (38) , Ghezzi et al. (39) , and Malzoni et al. (34) reported that TAH patients had a shorter LOS than TLH patients. The reduced hospital stay in TLH patients indicates lower cost and rapid recovery. ...
Introduction: This study aimed to compare histological grades in patients with endometrial cancer assessed by pre-and postoperative techniques. Methods: We retrospectively reviewed the records of 43 patients operated on for endometrial cancer between 2012 and 2019. The primary dependent variables included histological grade assessed by preoperative probe curettage and postoperative analysis of surgical specimens. The independent variables included age, surgery type (laparoscopy or laparotomy), pre-and postoperative hemoglobin levels, and the length of hospital stay. Results: The mean age was 62.14 ± 9.14 years, and the length of hospitalization time was 6.51 ± 3.46 days. The mean values of pre-and postoperative hemoglobin levels were 12.44 ± 1.51 mg/dL and 10.91 ± 1.28 mg/dL, respectively. According to the grading results of probe curettage, grade 1, 2, and 3 tumors were found in 21 (48.8%), 19 (44.2%), and 3 (7.0%) patients, whereas the paraffin sections revealed grade 1, 2, and 3 in 12 (27.9%), 22 (51.2%), and 9 (20.9%) patients, respectively. There was a fair but statistically significant agreement between the pre-and postoperative grading (kappa = 0.365, p = 0.001). Discussion: This study confirms literature reports that preoperative histological tumor grade fairly predicts final histological results. Caution is warranted when making clinical decisions solely based on probe curettage. Further improvements in preoperative diagnostic techniques in endometrial cancer are needed.
... In these studies, laparoscopic surgery involved less intraoperative blood loss and a shorter hospital stay than laparotomic surgery. [8][9][10][11][12][13] The Gynecologic Oncology Group LAP 2 study, which was a multicenter randomized trial comparing the treatment of endometrial cancer by laparoscopy versus laparotomy, demonstrated not only the short-term feasibility of laparoscopy but also its noninferiority with regard to the long-term prognosis compared with laparotomy. However, few studies have so far examined whether or not laparoscopic surgery can lead to intraperitoneal tumor cell dissemination. ...
... Several studies have demonstrated the feasibility of laparoscopic surgery for patients with endometrial cancer, showing not only the short-term feasibility of laparoscopy but also its noninferiority with regard to the long-term prognosis compared with laparotomy. [8][9][10][11][12][13][14] For these reasons, laparoscopic surgery has been performed increasingly frequently worldwide as therapy, especially in low-risk endometrial cancer patients. However, there is substantial variation between procedures, including the use of intrauterine manipulators, wrapping, or tying the uterine cervix and tubal ligation. ...
The aim of this study was to evaluate the dissemination of cancer cells at laparoscopic hysterectomy according to the intraperitoneal cytology.
Patients with endometrial cancer underwent total laparoscopic modified radical hysterectomy. Peritoneal wash cytology was performed on entering the peritoneal cavity before surgical preparation and just after hysterectomy.
Seventy-eight patients underwent laparoscopic hysterectomy for endometrial cancer. Among the 15 patients who had positive intraperitoneal cytology on entering the peritoneal cavity, 10 converted to negative intraperitoneal cytology after hysterectomy. In contrast, among the 63 patients who had negative intraperitoneal cytology on entering the peritoneal cavity, 2 converted to positive intraperitoneal cytology after hysterectomy.
While surgery can reduce the number of cancer cells in the peritoneal cavity, leakage can occur, as seen in some cases of hysterectomy. Careful washing must be performed after hysterectomy.
... 3 In lots of retrospective and prospective studies, laparoscopy has been showed with many advantages compared to laparotomy, such as smaller incision, less pain, and faster recovery. [4][5][6][7][8][9][10][11][12][13][14][15][16] It seems that laparoscopic surgery for EC also has similar recurrence rate and survival outcome with laparotomy procedure. [17][18][19] However, most of these studies have focused on patients with early stage or lowrisk disease and few specifically on patients with advanced stage or high risk. ...
... However, Obermair and Kalogiannidis reported lower number of lymph node dissections in the laparoscopy group. 6,11 In the present study, the mean number of dissected para-aotic lymph nodes was comparable between the 2 groups, but the pelvic lymph nodes were significant fewer in laparoscopy cohort than laparotomy. Actually, it remains controversially that whether lymphadenectomy has prognostic value for EC. ...
The aim of this study was to compare the long-term safety and efficacy of laparoscopic surgery and laparotomy for high-risk endometrial cancer (EC).
A retrospective analysis based on our decade of clinical data of patients with high-risk EC who were comprehensively surgically staged by laparotomy or laparoscopy was performed. The surgical outcomes were compared between different approaches using propensity score matching (PSM).
Eighty-one pairs of patients from the initial 220 enrolled ones were matched by PSM. The mean operative time is similar between laparotomy and laparoscopy groups (258 minutes vs. 253 minutes). The laparoscopy cohort has less blood loss (107 mL vs.414 mL, P < 0.01), shorter hospital stay (14.7 days vs. 17.7 days, P = 0.02) and significant fewer intraoperative complications (6.2% vs. 25.9%, P < 0.01). The pelvic lymph nodes dissected by laparoscopy (16.4) were significant less than that dissected by laparotomy (21.9). The 5- and 10-year survival rate for laparotomy were 89.2% and 75.8% compared with 85.3% and 85.3% for the laparoscopy. There was no significant difference in overall survival (P = 0.97).
Laparoscopy is as effective as laparotomy in the long term and can be safely carried out in patients with high-risk EC for surgery treatment.
... In a recent review about survival rate after 3-year follow-up revealed that DFS was similar between LS and LT groups (80-91% after 36 -78 months of median follow-up vs. 81-92% after 30 -80 months of median follow-up, respectively) [12]. Also Malur et al (2001), Obermair et al (2004) and Seracchioli et al (2005) found that survival rate was similar between groups [11,13,14]. In our study, only DFS was analyzed due to the absence of death in a follow-up period of 30 months, and we found that staging procedure had no effect on DFS. ...
... In a recent review about survival rate after 3-year follow-up revealed that DFS was similar between LS and LT groups (80-91% after 36 -78 months of median follow-up vs. 81-92% after 30 -80 months of median follow-up, respectively) [12]. Also Malur et al (2001), Obermair et al (2004) and Seracchioli et al (2005) found that survival rate was similar between groups [11,13,14]. In our study, only DFS was analyzed due to the absence of death in a follow-up period of 30 months, and we found that staging procedure had no effect on DFS. ...
Background: The aim of the present study was to compare the laparotomy (LT) and laparoscopy (LS) in patients who undergone surgical staging for early stage endometrium cancer.
Methods: Retrospective data were collected and analyzed for amount of intraoperative bleeding, complication rates, total resected and laterality specific number of lymph nodes and duration of operation in patients operated with either LT or LS.
Results: Seventy-nine stage I endometrium cancer patients were found to be eligible for the trial purposes: 58 (73.4%) treated by LT and 21 (26.6%) treated by LS. The number of lymph nodes was similar in LT (8.9 ± 5.3) and LS (9.2 ± 4.8) (P = 0.8). In LT group, there was no difference in the number of lymph nodes between the right and left sides (10 ± 5.8 and 8.7 ± 4.8 respectively, P = 0.19); in LS group, the number of lymph nodes resected from the right side was higher than the left side (9.8 ± 5 and 7 ± 3.5 respectively, P = 0.039). The amount of intraoperative bleeding and hospitalization period were significantly higher in LT group. Seventy-nine patients had a median follow-up of 30 months. The two groups were similar for disease-free survival (P = 0.46, log rank test).
Conclusions: There was no significant difference between the two methods in terms of number of total resected lymph nodes. In early stage endometrial carcinoma, LS has provided adequate staging and similar survival rates with LT.
... 5 In the early to mid-2000s, randomized controlled studies confirmed its feasibility, safety, and shortand long-term outcomes. [6][7][8][9][10][11][12][13] In 2005, the Food and Drug Administration (FDA) cleared the da Vinci robotic computerbased platform (Intuitive Surgical Inc, Sunnyvale, CA) for gynecology, adding another tool to our armamentarium in the management of endometrial cancer. Its safety and feasibility were evaluated in retrospective, prospective, and single and multicenter reports and in metaanalyses. ...
... 22 The rate of port site metastasis in these patients ranged from 0e2.5%; GOG LAP 2 reported 0.24% incidence of port site metastasis. 7,11,12,22 A systematic review that included 16 noncomparative studies reported an overall recurrence rate of 13% for all patients with a median time of recurrence of 13-22 months. 18 In our study, the recurrence rate was 14.8% and 12.1% for the robotic and laparoscopic groups, respectively, with a median time of recurrence of 19 and 11 months for the robotic and laparoscopic groups, respectively. ...
The purpose of this study was to compare the survival of women with endometrial cancer managed by robotic and laparoscopic assisted surgery.
Retrospective study conducted at two academic centers. Primary outcomes were overall survival, disease free survival, and disease recurrence.
Between 2003 and 2010, 415 women met the study criteria. One hundred and eighty three women had robotic and 232 women had laparoscopic assisted surgery. Both groups were comparable in age, body mass index, comorbid conditions, histology, surgical stage, tumor grade, total nodes retrieved and adjuvant therapy. With a median follow-up of 38 months (range 4-61 months) for the robotic and 58 months (range 4 to 118 months) for the traditional laparoscopic group, there were no significant differences in survival (3-year survival 93.3% and 93.6% for robotic and laparoscopic group respectively), disease free survival (DFS) (3-year-DFS 83.3% and 88.4% for robotic and laparoscopic group respectively), and tumor recurrence (14.8% vs. 12.1 %). Univariate and multivariate analysis showed that surgery is not an independent prognostic factor of survival.
Robotic assisted surgery yields equivalent oncologic outcomes when compared to traditional laparoscopic surgery for endometrial adenocarcinoma.
... The average age at diagnosis was 61 [14]. As many as 20% of women are premenopausal and about 5% are under 40 [15]. Therefore, it is of great clinical signi cance to understand the temporal and spatial trends of uterine cancer incidence, risk factors, and future incidence prediction. ...
Background: Uterine cancer is the most common gynecological malignancy and the fourth most common cancer in women. However, the global burden of uterine cancer has not been estimated, and projections of future disease development are lacking.
Methods: Methods: We collected detailed information on the etiology of uterine cancer between 2000 and 2019 from the 2019 Global Burden of Disease Study. Estimated annual percentage changes (EAPCs) of age-standardized incidence rates (ASR) of uterine cancer by region and etiology were calculated to quantify temporal trends in uterine cancer ASR. Predicting future trends in uterine cancer using the EAPC package.
Results: Globally, uterine cancer cases increased from 244,441 in 2000 to 435,041 in 2019, an increase of 78%. During this period, overall ASR increased by an average of 4% per year. The most pronounced increases are usually seen in countries with high sociodemographic indices, such as the United States. The high body-mass index had a significant effect on disability-adjusted life years(DALYs), Deaths, years lived with disability(YLDs), and years of life lost(YLL)s, and 40.2% of DALYs, 39.8% of Deaths, 43.5% of YLDs, and 39.8% of YLLs were attributed to the high body-mass index. EAPC was significantly correlated with ASR (2000) and Human Development Index (HDI) (2019), respectively. Using BAPC models to predict future uterine cancer incidence will continue to rise
Conclusion: The number of uterine cancer cases is on the rise globally. Overall, we observed a higher incidence trend in countries with higher socio-demographic index. High body-mass index is an important risk factor for uterine cancer. This suggests that current prevention strategies should be repositioned and, in some countries, more targeted and specific strategies should be developed to prevent the increase in uterine cancer.
... A combination of a Hegar dilator with a McCartney tube (LiNA Medical), with their joint xation similar to laparoscopically assisted vaginal hysterectomies (LAVH), is also used to perform TLH and robotically assisted hysterectomies [19,20]. ...
Background
Endometrial cancers are among the epithelial malignancies of the lining in the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI – lymphovascular space invasion) is considered a risk factor for the course of the disease. In our study, we investigated the potential effect of an intrauterine manipulator on the presence of LVSI in a definitive preparation.
Methods
Based on the inclusion and exclusion criteria, we were retrospectively evaluating 170 female patients. During endoscopic procedures we use a uterine manipulator. As the primary objectives were determined to be the finding of the difference in the incidence of LVSI in female patients with and without an intrauterine manipulator. As the secondary objective was set to determine the effect of a type of an intrauterine manipulator on the incidence of LVSI. Tertiary we analysed grading of tumor, myometrial invasion and method of obtaining primary histology in connection to the incidence of LVSI.
Results
We used logistic regression to identify the risk factors for LVSI. Using a manipulator during a surgery was not associated with the occurrence of LVSI (with a manipulator vs. without, 11.5% vs. 21.7%; OR 1.8; 95% CI 0.73–4.39; p = 0.199). The type of method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (hysteroscopy vs. curettage; OR 4.27; 95% CI 1.39–13.07; p value = 0.011); grading and TNM (especially the grading G2 and G3 and TNM 1b).
Conclusions
In our study we have not confirmed the effect of a uterine manipulator on the possible increase of LVSI positive cases. Similar results have been published in other studies.
The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Further studies will be needed to confirm this phenomenon.
... The laparoscopic technique has been proved to be an effective and safe alternative to the open operation in several retrospective and prospective investigations. When compared to laparotomy, the majority of these studies reveal a considerable reduction in treatment-related morbidity, with shorter hospital stays, less discomfort, and faster return to normal activities [13][14][15][16][17][18][19][20][21][22][23]. ...
... The laparoscopic technique has been proved to be an effective and safe alternative to the open operation in several retrospective and prospective investigations. When compared to laparotomy, the majority of these studies reveal a considerable reduction in treatment-related morbidity, with shorter hospital stays, less discomfort, and faster return to normal activities [13][14][15][16][17][18][19][20][21][22][23]. ...
Hysterectomy is one of the most prevalent surgical procedures in the United States. Vaginal hysterectomies have been successfully performed for nearly two centuries. Abdominal hysterectomy remains the most prevalent surgical strategy, with laparotomies accounting for well Review Article Bishrah et al.; JPRI, 33(46A): 607-614, 2021; Article no.JPRI.74640 608 over half of all hysterectomies With technology advancement more and more better surgical procedures are being developed which are less invasive and have less complications, Abdominal total Hysterectomy was for many years the gold standard for many cases until development of Total Laparoscopic Hysterectomy, which overall has better recovery time, less blood loss, less tendency of infection and less minor complications. This review aims to compare abdominal total hysterectomy and total laparoscopic hysterectomy in terms of recovery and complications.
... Several studies showed the advantages of the laparoscopic technique over conventional laparotomy. The main short-term advantages relate to pain reduction and better postoperative quality of life [9][10][11] . Some risks, such as urinary tract or intestinal injury and tumor dissemination, may also be associated with the minimally invasive techniques. ...
Objective:
A surgery is essential for the management of early endometrial carcinoma. Due to the comorbidities associated with the disease, the complications of surgery are common. Laparoscopic surgery may reduce surgical complications but also have oncological risks. We aimed to compare recurrence and overall survival (OS) associated with laparoscopy and laparotomy for early endometrial cancer.
Methods:
We included women treated for presumed early endometrial carcinoma at the Clinics Hospital of Ribeirão Preto Medical School from January 1998 to December 2017. We designed a 1:2 propensity score-matched case-control and compared the patients' characteristics, short-term outcomes, recurrence, and OS.
Results:
A total of 252 women were included in this study, 168 underwent laparotomy, and 84 underwent laparoscopy. The two groups were well balanced according to most of the variables, and obesity was a characteristic of patients in both groups. Laparoscopy was associated with increased surgical time (194.7 min vesus 165.6 min; p<0.001) and reduced rate of surgical complications (6.5% versus 0; p=0.038). Laparoscopic surgery was not associated with the risk of tumor recurrence (HR: 0.41, 95%CI 0.14-1.19, p=0.100) or all-cause mortality (HR: 0.49, 95%CI 0.18-1.35, p=0.170).
Conclusion:
Laparoscopy was safe in terms of oncological outcomes and was associated with a lower rate of surgical complications. Our data support the use of minimally invasive surgery as the preferential approach in the management of early endometrial carcinoma.
... The studies conducted in North America also showed shorter postoperative stay as compare to European studies may be because of the different health insurance status. 6,7 Many other studies also reported that intra-operative blood loss is lesser in the Laparoscopic surgery (average 120ml). 8 The benefits of laparoscopic procedures in improving patient safety, efficacy, and cost-effectiveness have led several national organizations, including the American College of Obstetricians and Gynecologists (ACOG) and American Association of Gynecologic Laparoscopists (AAGL,) to advocate for the use of minimally invasive approaches. ...
Hysterectomy is one of the most frequently performed gynaecological procedurein female. Objectives: The purpose of this study was to compare the outcome between totallaparoscopic hysterectomy and abdominal hysterectomy regarding blood loss during surgery,surgical time and postoperative hospital stay. Settings: Department of Gynecology & ObstetricsAllied Hospital, Faisalabad Medical University, Faisalabad. Period: 1st January 2016 - 31stDecember 2016 (1 Year). Study Design: Randomized control Study. Material & Methods: Theethical committee of Faisalabad Medical University, Faisalabad approved the study protocol. Thepatient demographical characteristics were similar in both groups. 112 patients were enrolled.Including 56 case of total laparoscopic hysterectomy and 56 cases of abdominal hysterectomywhich meets inclusion criteria. Result: Average blood loss in TLH was 83.09+10.74ml while itwas 387.88+59.54ml in TAH. When both groups were compared regarding operative time, itwas 76.73+20.2min in TLH while it was 84.7+19.9 in TAH. Postoperative stay in the hospitalwas 1.25+0.44 days in TLH while it was 5.72+0.83 in TAH. Conclusion: The laparoscopichysterectomy is a modern surgical method in current gynecological practice. With increasingexperience and good collaboration of surgical team, time duration can be shortened and bloodloss can be reduced to negligible.
... Asociada a linfadenectomía, para el manejo del cáncer de endometrio, ha demostrado ventajas respecto a la laparotomía, en relación a tiempo de hospitalización, pérdida sanguínea, dolor postoperatorio y reincorporación a la actividad diaria. Las complicaciones y tasas de recurrencia son semejantes (23)(24)(25)(26)(27) . El tiempo operatorio es mayor en el abordaje laparoscópico, pero está en relación directa con la curva de aprendizaje. ...
La cirugía laparoscópica ha ido incursionando en la ginecología oncológica desde los años 80. Aunque su aplicabilidad aún es controversial, la evidencia de los últimos años permite una fuerte consideración de la técnica sin dejar de reflexionar sobre los posibles efectos adversos y las consecuencias de un manejo inadecuado. Métodos: Se ha revisado la literatura para mencionar los datos respecto a indicaciones, resultados a largo plazo, estudios comparativos y avances. Presentamos nuestra casuística. Resultados: La literatura resalta la factibilidad y3 ventajas de la laparoscopia sobre la laparotomía respecto a sangrado intraoperatorio, dolor postoperatorio, días de hospitalización posquirúrgicos y la reincorporación a las actividades diarias. Los resultados de sobrevida son similares. La linfadenectomía aórtica extraperitoneal es una nueva herramienta útil en el manejo de neoplasias ginecológicas. La laparoscopia está siendo ampliamente usada en el manejo del cáncer de cuello uterino, endometrio y ovario, así como nuevas técnicas están surgiendo como la exenteración pélvica o la quimioterapia intraperitoneal con hipertermia por laparoscopia. Conclusiones: La literatura demuestra el creciente interés de la técnica en el mundo y debería ser parte de las habilidades del ginecólogo oncólogo. La morbilidad y el riesgo de recurrencia no deberían ser afectados. El valor costoeficacia puede estar representado por la disminución de la hospitalización postoperatoria, aunque el tiempo operatorio aumente inicialmente. Es importante, además, una adecuada preparación para evitar el manejo subóptimo de las neoplasias ginecológicas.
... Similar results were demonstrated in other European studies. However, the duration of hospitalization in North American studies is usually shorter compared with Euro-pean, may be because of the different health insurance status [18,19] . According to previous study it has been reported that intraoperative and perioperative blood loss is lesser in the LAVH group compared to the abdominal surgery [20] . ...
... Mario Malzoni et al did not find significant difference in disease free survival while Tae Wook et al also reported no statistically significant difference between both groups with regards to disease free and overall survival. Obermair et al reported similar patterns of recurrence and overall survival among both groups in a retrospective study of 510 patients.23 Walker at al reported 3 yrs overall survival of 89% in TLH group and 89.9% in abdominal group from the LAP 2 study conducted by gynecologic oncologic group.24,25 ...
Background: Aim was to study the feasibility of total laparoscopic pan hysterectomy in patients with early stage endometrial cancer.Methods: Retrospective and prospective study of 100 patients with clinical early stage endometrial cancer was done in Bombay Hospital & Research Center over 3 years. 44 patients underwent total laparoscopic hysterectomy while 56 patients underwent abdominal pain hysterectomy. Pelvic lymphadenectomy was performed in patients with myometrium invasion greater than 50%, size of tumor >2 cm, non-endometroid pathology, Grade 3.Results: The mean operating time was 2 hours in the abdominal hysterectomy group and 2.5 hrs. In the laparoscopic group. Average blood loss was 350 ml in the abdominal (Abd) group & 250 ml in the laparoscopic (lap) group. Which was comparable. The abdominal hysterectomy group experienced more postoperative pain than the laparoscopy group. However, cost wise laparoscopy group incurred more expenditure than the abdominal group. Among the post-operative complications, nausea vomiting, paralytic ileus and wound dehiscence were significantly more in the abdominal group as compared to the laparoscopy group.Conclusions: Morbidity is much less in laparoscopy route compare to open abdominal hysterectomy with equivalent survival.
... The type of nodal metastases was also similar in both groups. Obermair, Koskas, and Gao reported fewer lymph nodes removed in the laparoscopy group compared to the laparotomy group [14][15][16]. Other series have demonstrated that the two techniques are comparable in terms of retrieved lymph nodes [1-3, 8, 9]. ...
Purpose
We aimed to evaluate weather survival is impaired in stage IIIC endometrial cancer patients treated with minimally invasive surgery as compared to laparotomy.
Methods
We analyzed surgical data and oncologic outcome of histologically proven stage IIIC endometrial cancer patients who were treated at our institution via laparotomy or via laparoscopic surgery. All the patients underwent a systematic pelvic and para-aortic lymphadenectomy and a complete tumor resection. Perioperative morbidity and overall survival of the patients subjected to the two surgical approaches were compared.
Results
Sixty-six patients with stage IIIC endometrial cancer were identified. Of these, 15 patients were operated via laparotomy and 51 via laparoscopy. The two groups were similar with regards to median age at diagnosis, BMI, histotype, number of affected lymph nodes, and median maximal diameter of the affected lymph nodes. Patients undergoing laparoscopic surgery had fewer perioperative complications, a smaller estimated blood loss, and were subjected less frequently to transfusions. Overall survival at 60 months of follow-up did not differ between the two groups. At uni- and multivariate analysis, surgical approach did not affect survival. Only age was a variable associated with overall survival.
Conclusions
Minimally invasive surgery has better perioperative outcomes and does not impair survival in stage IIIC endometrial cancer patients. Age at diagnosis is the only factor independently affecting survival.
... Laparoscopic surgery required almost one hour more to complete when compared to laparotomy. These findings are in accordance with the LAP2 study and other previous studies (2,9,10). Interestingly, Boosz et al reported there was no statistically significant difference between the two groups with regard to operation times in their population. ...
Objective: The aim of the study was to compare the safety of the laparoscopic and open method for endometrial cancer staging.Methods: Between January 2015 and August 2017, we reviewed 121 women with endometrial cancer treated by open (n=81) or laparoscopic (n=40) approach, retrospectively. Two groups were compared in terms of operating times, intraoperative and postoperative complications, perioperative and postoperative features such as hemoglobin values, the lengths of hospital stay, and adjuvant therapy. All of the patients underwent a hysterectomy and bilateral salpingo-oophorectomy; and when indicated, omentectomy and lymphadenectomy were performed.Results: There were no significant differences between the two groups with regard to the number of parities, body mass index, menopausal status, age, the American Society of Anesthesiologists (ASA) scores, the requirement of lymphadenectomy, and hospital stay. There were significant statistical differences between groups in terms of operation time and difference of hemoglobin (p<0.001, p=0.013; respectively). Laparoscopic surgery had a longer operative time than laparotomy, and difference of hemoglobin in the laparotomy group is more than the laparoscopy group. Patients who underwent staging with laparotomy had bowel injury (1.2%), wound infection (13.6%), and postop ileus (8.6%) while in the laparoscopy group patients had wound infection (2.5%) and postop ileus (5%). There were no statistically significant differences between the two groups in terms of the intraoperative (p=1) and postoperative complications (p=0.101 for wound infection, p=0.716 for postop ileus). The groups were similar in terms of the histological grade, FIGO stage, histologic subtype, the rate of lymphovascular invasion, the depth of myometrial invasion, the total number of lymph nodes resected in lymph node dissections, the rate of lymph node metastasis, the location of the tumor, cervical stromal invasion, and the adjuvant therapy such as chemotherapy and brachytherapy. None of the patients in both groups had a recurrence and long-term lymphatic complication such as lymphocyst, lymphedema. Conclusion: Our current data demonstrated that the laparoscopic approach can be performed without loss of safety with similar complication rates in patients with endometrium cancer. Additionally, the laparoscopy was not inferior to the laparotomy in terms of efficacy.
... Many authors omit this step which argument in favor or against might be considered. [20,32,33] . In the trial of LAP2, longer operation time besides less complications and hospital stay were confirmed. ...
... Laparoscopic hysterectomy could also pose greater risks of complications in obese patients, have a higher risk of intraoperative injuries, or result in port-site metastases. 5 Three large randomized trials suggested that total laparoscopic hysterectomy may be equally safe as total abdominal hysterectomy 6 and may have short-term advantages, including less pain, better quality of life, 7-9 decreased risk of surgical adverse events, 10 and economic savings. 11 These short-term advantages have supported the global trend to adopt laparoscopic hysterectomy despite little data to confirm its efficacy in regard to disease-free and overall survival. ...
... Laparoscopic hysterectomy could also pose greater risks of complications in obese patients, have a higher risk of intraoperative injuries, or result in port-site metastases. 5 Three large randomized trials suggested that total laparoscopic hysterectomy may be equally safe as total abdominal hysterectomy 6 and may have short-term advantages, including less pain, better quality of life, 7-9 decreased risk of surgical adverse events, 10 and economic savings. 11 These short-term advantages have supported the global trend to adopt laparoscopic hysterectomy despite little data to confirm its efficacy in regard to disease-free and overall survival. ...
... In these studies, laparoscopic surgery involved less intraoperative blood loss and shorter hospital stays than laparotomic surgery. [16][17][18][19][20][21] The Gynecologic Oncology Group's LAP 2 study, which was a multicenter randomized trial comparing treatment of endometrial cancer performed by laparoscopy versus laparotomy, demonstrated not only the shortterm feasibility of laparoscopy but also its noninferiority with regard to long-term prognosis, compared with laparotomy. In this study, both pelvic lymphadenectomy and para-aortic lymphadenectomy were performed in 91.5% of laparoscopy patients and in 95.8% of laparotomy patients. ...
Background: Intracystic papillary carcinoma (IPC) is a distinctive variant of a papillary ductal neoplasm confined to a dilated cystic space. This rare mammary tumor typically appears as a discrete solitary mass in the central region of the breast in a postmenopausal woman. This article presents the case of a female patient with a giant IPC. Relevant literature is briefly reviewed.
Case: A 65-year-old woman was admitted for the management of a palpable mass of the left breast. On clinical examination, it was noted that the entire left breast was replaced by an extremely large, irregularly shaped, relatively mobile lesion. The mass was almost fixed to surrounding tissues including skin and pectoral muscle. Due to the size of the tumor the patient underwent a left modified radical mastectomy.
Results: The final histopathologic diagnosis was defined as an IPC. Concomitant vascular invasion or metastasis to 19 removed lymph nodes were not noted.
Conclusions: Because of its relevant growth pattern and indolent clinical behavior, IPC is conventionally regarded as a variant of intraductal papillary carcinoma with an absence of myoepithelial cells. There have been several cases that indicated a slow evolution of the mass, verifying the perception that IPC is associated with a favorable clinical outcome. Differential diagnoses include colloid or medullary carcinoma, invasive ductal carcinoma, hematoma, benign cyst, or adenofibroma. Axillary lymph-node metastases and markers related to invasion have been documented. Due to the rarity of the tumor and variability observed in treatment strategies, only a few surveys have assessed the significance of lymph-node status and the role of adjuvant treatment. (J GYNECOL SURG 2017:1)
... The complication rate for TLH has gradually been decreased with increased surgical experience at our institute, thus, less experienced gynecologic surgeons may experience higher complications when attempting TLH. Regarding a previous study, there is no clear evidence on the superiority of the hysterectomy methods one to another.13 Most cases were multipara. ...
Background: Routes for hysterectomy include abdominal, vaginal, laparoscopic, or combined approaches. Traditional abdominal hysterectomy (AH) is one of the most common gynaecological surgical procedures in the treatment of benign gynaecological diseases. However, AH as the most invasive procedure, is associated with some limitations such as abdominal trauma, intraoperative and postoperative complications, and slow postoperative recovery.
Methods: All the patients attending Gynecology outpatient department with symptoms were assessed with history and clinical examination by the Consultant Gynecologist and investigated. Those requiring hysterectomy were analyzed by the Consultants for the approach depending on the indication for the surgery, nature of the disease and patient characteristics.
Results: The most common indication for hysterectomy was prolapsed uterus (29.4%) followed by menstrual disorders (25.8%), leiomyoma (22.9%), and PID (12.3%).
Conclusions: Hysterectomy is successful in relieving pain, carcinomas and obstetric complication.
... In these studies, laparoscopic surgery involved less intraoperative blood loss and shorter hospital stays than laparotomic surgery. [16][17][18][19][20][21] The Gynecologic Oncology Group's LAP 2 study, which was a multicenter randomized trial comparing treatment of endometrial cancer performed by laparoscopy versus laparotomy, demonstrated not only the shortterm feasibility of laparoscopy but also its noninferiority with regard to long-term prognosis, compared with laparotomy. In this study, both pelvic lymphadenectomy and para-aortic lymphadenectomy were performed in 91.5% of laparoscopy patients and in 95.8% of laparotomy patients. ...
The rate of intraoperative complications was not significantly different between the groups (5.6% versus 8.1%; p = 0.7). Two vessel injuries and 1 compartment syndrome occurred in the laparoscopic group, and 6 vessel injuries, 1 ureter injury, and 1 obturator nerve injury occurred in the laparotomic group. The 2 patients with vessel injuries in the laparoscopic group were converted to laparotomy for hemostasis; the conversion rate of laparoscopic para-aortic lymphadenectomy was 3.7%.
Postoperatively, there were 1 urinary-tract infection, 1 case of pelvic cellulitis, 3 cases of venous thrombosis, and 3 cases of pulmonary embolus in the laparotomic group. No complications described above occurred in the laparoscopic group. Bowel obstruction and urinary fistula did not occur in either group. While no cases of ileus occurred in the laparoscopic group, 10 occurred in the laparotomic group. There were 2 wound infections in the laparoscopic group and 3 in the laparotomic group. There were 2 cases of lymphocyst in the laparoscopic group and 1 in the laparotomic group. The rate of chyle or lymphhorrhea was higher in the laparoscopic group than in the laparotomic group (18.5% versus 7.1%; p = 0.02). These symptoms resolved spontaneously in a few days with observation and basic support. The rate of lymphedema was lower in the laparoscopic group than in the laparotomic group (3.7% versus 13.1%; p = 0.07). The laparoscopic group tended to have shorter hospital stays than the laparotomic group (8.4 ± 5.7 days versus 16.1 ± 8.0 days; p < 0.01). The medium (quantile) duration of follow-up was 364 (110–681) days in the laparoscopic group and 693 (267–1222) days in the laparotomic group. The recurrence rate was not significantly different between the groups in the above time period (7.4% versus 14.3%; p = 0.2).
... The conclusion was that the incidence of PSM in early-stage endometrial cancer treated by TLH is low. 66 ...
Despite the low frequency, port-site metastases are associated with poor outcomes in patients and account for significant patient morbidity. They remain a challenging complication of laparoscopic procedures for gynecologic malignancies. A comprehensive, systematic search for published studies was conducted using the PubMed databases. Various mechanisms of port-site metastases are addressed in the relevant literature. The review of the articles points out that in the development of port-site metastases, the major role is played by biologically aggressive diseases, tumor manipulation, wound contamination, and surgery-related factors. The advantages of laparoscopic oncologic surgery are unquestionable. Further investigations of the mechanisms of port-site metastasis would contribute to the prevention of this insidious pathology.
... Ya yın lan mış ça lış ma la ra gö re en domet ri um kan se ri cer ra hi sin de la pa ros ko pi ve la paro to mi ara sın da prog noz açı sın dan fark bu lun ma mak ta dır. 60 ci no ma of the En do met ri um) (LA CE) ça lış ma sı, stan dart açık cer ra hi yak la şım ile TLH'yi pros pek tif ola rak kar şı laş tı ran ve ha len yü rü tü lmekte olan bir ça lış ma dır. 61 An cak 2004 Ji ne ko lo jik On ko log lar Birli ği üye le ri ve eği tim prog ra mı içe ri sin de ki ka tı lımcı lar ara sın da ya pı lan bir araş tır ma ya gö re, ka tı lım cı la rın sa de ce %10'u en do me ti um kan se ri teda vi sin de la pa ros ko pi yi kul lan makta dır. ...
... Similar results were demonstrated in other European studies. However, the duration of hospitalization in North American studies is usually shorter compared with European, may be because of the different health insurance status [13,14]. According to previous study it has been reported that intraoperative and perioperative blood loss is lesser in the LAVH group compared to the abdominal surgery [15]. ...
Aim: The purpose of this study was to confirm the positive intraoperative and postoperative outcomes of total laparoscopic hysterectomy (TLH) and total abdominal hysterectomy (TAH). Material and Method: We presented surgical procedures performed at Namik Kemal University Faculty of Medicine, Department of Obstetrics and Gynecology between September 2010 and December 2012, 47 patients who underwent TLH and 30 patients who underwent TAH were included in the present study. Results: Operating time in TLH group was significantly longer than in the TAH group (202.56±61.53 vs 138.06±40.52 min). There were no significant differences between the two groups regarding complications, conversion to laparotomy, intraoperative bleeding. We observed no differences in reoperation and transfusion rates between the two groups. Duration of hospital stay was statistically shorter in TLH group compared to the TAH group (3.93±0.70 vs 5.26±1.63 day). Discussion: Laparoscopic hysterectomy, compared to laparotomy regarding equal outcomes and lower perioperative morbidity, improvement of quality of life, shorter hospital stay and faster return to activity.
... Uterine cancer is the tenth most common cancer in Saudi Arabia; it is also the second most common gynecologic malignancies in women and endometrial carcinoma is the most common histologic type (1) . For endometrial carcinoma, surgery is the primary treatment involving a total abdominal hysterectomy, bilateral salpingooophorectomy (TAH+BSO), pelvic and paraaortic lymphadenectomy, and pelvic washings, with five year survival rates of 78% (2,3) . Randomized trials by Post-operative Radiation therapy in endometrial carcinoma (PORTEC) and Gynecological Oncology Group 99 (GOG-99) have shown significant reduction of the risk of pelvic and vaginal recurrence by adjuvant radiotherapy, although a survival benefit is not yet proven (4,5) . ...
Abstract
Purpose: We aimed to evaluate long-term treatment outcomes and toxicity profile of postoperative radiotherapy (PORT) in Saudi women with uterine cancers.
Methods and Materials: Medical records of patients with histopathologically proven uterine cancers were reviewed and identified those who received PORT (45-50.4 Gy in 25-28 fractions) followed by vaginal brachytherapy (15-20 Gy in 3 to 4 sessions) after total abdominal hystrectomy and bilateral salpingo-oophorectomy (TAHBSO) in our center between August 2007 and April 2012. Data regarding the safety profile, locoregional control (LRC) or distant metastases control (DMC) and overall survival (OS) rates were analyzed.
Results: Median follow-up period was 60 months (range, 12-70) for 89 patients. Predominant histological type was endometrial (59 patients), followed by carcinosarcoma (17 patients) and leiomyosarcoma (13 patients). Median age at time of diagnosis was 57.6, 56 and 51.1 years for endometrial, carcinosarcoma and leiomyosarcoma respectively. LRC rates were 80.9%, 87.1% and 100% for leiomyosarcoma, carcinosarcoma and endometrial carcinoma respectively (p 0.4). DMC rates were 69.3%, 45% and 16.3% for endometrial, leiomyosarcoma and carcinosarcoma respectively (p 0.0001). Five-year OS rates were 71.1%, 60% and 16.3% for endometrial, leiomyosarcoma and carcinosarcoma respectively (p 0.001). Coxproportional hazard ratio model showed body mass index, FIGO stage, lymphovascular invasion in endometrial carcinoma, tumor size in leiomyosarcoma and histology in carcinosarcoma important prognostic factors for LRC. Acute grade 3 and 4 proctitis/enteritis seen only in 4 patients (4.5%) and late toxicities were minimal.
Conclusion: PORT in Saudi women with uterine cancers showed better LRC, DMC and OS rates with minimal toxicity
... Various study groups found no significant differences between laparoscopy and laparotomy for the treatment of uterine cancer with regard to oncological safety. Recurrence-free survival after laparoscopy to treat endometrial cancer was reported to be 90-100 % and 92-95 % after laparotomy [6,[11][12][13][14][15][16][17][18][19][20][21]. Several randomised studies found no difference between laparoscopic and abdominal hysterectomy with regard to either total survival rates or recurrence-free survival rates [14,20,21]. ...
Introduction: Endoscopy has begun to play an increasingly important role in the surgical therapy of uterine cancers. To date, there is no data on the use of laparoscopy to treat endometrial cancer (EC) and cervical cancer (CC). Method: A Germany-wide, anonymised survey was done of all gynaecological clinics/endoscopy clinics, using a standardised questionnaire. Results: A total of 128 clinics responded: 16 university clinics (12.5 %), 30 hospitals offering maximum care (23.4 %), 66 general hospitals (51.5 %), 5 outpatient clinics (3,9 %), 4 physicians in private practice affiliated to hospitals (3.1 %) and 7 hospitals (5.4 %) which did not indicate status. Laparoscopy was used in the treatment of 82 % of all EC and 54 % of CC. Surgery for EC was done completely laparoscopically in 58 % of cases and with laparoscopic assistance using a vaginal approach in 32 % of cases. If lymphadenectomy (LNE) was additionally performed, this was done abdominally in 42 % of cases and laparoscopically in 53 %. Cervical cancer was treated by laparoscopic radical hysterectomy (HE) in 44 % of cases and by radical HE using a vaginal approach in 14 %. 4 % of hospitals reported the use of other endoscopic methods (e.g. DaVinci). While the majority of hospitals (43.3 %) treated more than 75 % of EC patients using laparoscopy, in many clinics (38.3 %) less than 25 % of CC patients were treated using endoscopy. Discussion: Laparoscopy is used more often in EC surgery as compared to surgery for CC. However, there are still major differences between hospitals with regard to case numbers, the number of uterine cancers treated using endoscopic surgery, and the type of endoscopic surgery.
... Surgery is the primary treatment involving a total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and pelvic washings, with five year survival rates of 78% [4,5]. Randomized trials by Post-operative Radiation therapy in endometrial cancer (PORTEC) and Gynecological Oncology Group 99 (GOG-99) have shown significant reduction of the risk of pelvic and vaginal recurrence by adjuvant radiotherapy, although a survival benefit is not yet proven [6,7]. ...
Background
Aim was to evaluate the impact of body mass index (BMI) on locoregional control (LRC), distant metastasis control (DMC), disease free survival (DFS) and overall survival (OS) in patients with endometrial carcinoma (EC) treated with adjuvant radiotherapy.
Materials and methods
Between June 2006 and July 2011, 66 patients with EC received adjuvant radiotherapy. Median age was 58.02 years (40-88). Mean BMI was 35.9 kg/m2 (23-72); BMI < 24 kg/m2 (normal weight) in 3 (4.5%), BMI 25-30 kg/m2 (overweight) in 19 (28.8%), BMI 31-40 kg/m2 (obese) in 20 (30.3%) and BMI > 40 kg/m2 (morbid obese) in 24 (36.4%).
Results
Median follow-up was 55 months (6-60). The Kaplan-Meier estimates of LRC, DMC, DFS and OS were 83.3%, 74%, 78.6% and 66.3% respectively. Patients with BMI > 30 kg/m2 showed inferior LRC (74.5%-80%) with p 0.003 and inferior OS (55%-61.4%) with p value 0.001. No influence of BMI on DMC and DFS was seen { hazard ratios of 0.97 (0.78-1.24) and 0.99 (0.81-1.26) respectively}. There was positive correlation of daily treatment setup errors with BMI > 30 kg/m2 (p 0.001). No correlation with found between BMI and radiation toxicity.
Conclusion
Patients with EC and high BMI had inferior LRC and OS. Emphasis shall be given on adjustment of setup errors during radiotherapy and on implementation of a national obesity prevention program.
... Endometrial carcinoma (EC) is the tenth most common and the second most common gynecologic malignancy in women in the Saudi Arabia [1]. Surgery is the primary treatment involving a total abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic and para-aortic lymphadenectomy, and pelvic washings, with five year survival rates of 78% [2,3]. Randomized trials by Post-operative Radiation therapy in endometrial cancer (PORTEC) and Gynecological Oncology Group 99 (GOG-99) have shown significant reduction of the risk of pelvic and vaginal recurrence by adjuvant radiotherapy, although a survival benefit is not yet proven [4,5]. ...
Background: Aim was to evaluate the additional benefit of adjuvant chemotherapy in patients of early stage
endometrial carcinoma (EC) with adverse features.
Materials and methods: Between June 2006 and July 2011, 56 patients with EC after surgery were randomized to receive either adjuvant radiotherapy (RT) [35 patients] or adjuvant sequential chemotherapy and radiotherapy (CRT) [21 patients]. Median age was 57.6 years (40-80). Predominant stages were FIGO IB (44.6%) and IIA (26.7%). Mean body mass index was 35.9 kg/m2 (23-72).
Results: Median follow-up was 55 months (6-60). The Kaplan-Meier estimates for loco regional control (LRC), distant metastasis control (DMC) and overall survival (OS) for RT and CRT arms were; 85.7% vs. 74.2% (p 0.04), 85.7% vs. 85.7% (p 0.9) and 82.8% vs. 81% (p 0.8) respectively. Patients in CRT arm had earlier and higher pelvic recurrences {hazard ratios of 2.21 (1.45-7.85)}. Acute hematological grade3 toxicity was higher in CRT arm (9.5%) and no difference in acute or delayed non-hematological toxicities was seen between two arms.
Conclusion: Adjuvant chemotherapy in patients with EC after surgery is associated with inferior LRC and
no additional benefit in DMC and OS. If adjuvant chemotherapy is considered it shall be given after adjuvant
radiotherapy.
Endometrial cancer is a common female gynecological neoplasia and its incidence rate has increased in the past years. Due to its predominant symptoms, most women will present uterine bleeding. It is usually diagnosed at an early stage and surgery has an important role in the treatment plan. The prognosis and quality of life of these patients can be quite favorable, if proper treatment is offered by surgeons. Traditionally, more invasive approaches and procedures were offered to these patients, but recent data suggest that more conservative and minimal invasive choices can be adopted in the treatment algorithm. Minimal invasive surgery, such as laparoscopy and robotic surgery, should be considered as an acceptable alternative, compared to laparotomy with less comorbidities and similar oncological and survival outcomes. Furthermore, sentinel lymph node biopsy has emerged in the surgical staging of endometrial cancer, in order to replace comprehensive lymphadenectomy. It is associated with less intra- and postoperative complications, while preliminary data show no difference in survival rates. However, sentinel lymph node biopsy should be offered within a strict algorithm, to avoid residual metastatic disease. The aim of this review is to analyze all the available data for the application of minimal invasive surgery in early endometrial cancer and especially the role of sentinel lymph node biopsy.
Objective To evaluate the influence of intrauterine (IU) or non-IU manipulators on oncological outcome in early-stage, low-grade endometrioid endometrial cancer (EEC). Design Retrospective cohort study Setting Nationwide population-based study in the Netherlands Population Women with FIGO stage I, low-grade EEC who received total laparoscopic hysterectomy between 2010 and 2020. Methods Patient data were identified from the Netherlands Cancer Registry. Data regarding hospital manipulator preferences were retrieved through an online survey. Patients were categorized based on hospital manipulator preference. Survival analyses were performed using univariable and multivariable cox regression analysis. Main outcome measures Recurrence of cancer, disease-free survival (DFS), overall survival (OS), site of recurrence, and manipulator preference according to type of hospital. Results Of the total study population (N = 5,205), 1524 (29.3%) patients underwent surgery in hospitals that used non-IU manipulators and 3681 (70.7%) in hospitals that used IU manipulators. Recurrence of cancer was experienced by 195 patients, 49 (3.2%) in the non-IU group and 146 (4.0%) in the IU group. No significant difference in site of recurrence was observed (p=0.778). After adjusting for potential confounders, type of uterus manipulator did not affect DFS (hazard ratio [HR] 0.93, 95% confidence interval [CI] 0.78–1.11) and OS (HR 0.90, 95% CI 0.75–1.09). Conclusion IU manipulators are not inferior to non-IU manipulators with respect to oncological outcome in early-stage, low-grade EEC.
Background:
It is widely accepted total laparoscopic hysterectomy (TLH) and vaginal hysterectomy are less invasive procedures compared to total abdominal hysterectomy (TAH). However, rates of TAH remain unreasonably high.
Aim:
To pilot-test a model of training for practising obstetricians and gynaecologists (O&Gs) in TLH.
Materials and methods:
Training of participating O&Gs was conducted across four hospitals in Queensland, Australia, while other O&Gs were observed as contemporary controls. Type of hysterectomy, details of the surgery, including adverse events, were collected from hospital medical records.
Results:
Eleven O&Gs completed the pre-intervention and intervention training periods, and nine completed the post-intervention follow-up. TLH rates increased from 24% prior to 75% during and 68% after intervention. Overall, the uptake rate of TLH showed a two-fold increase during the intervention period (2.08, 95% CI: 1.16-8.56, P < 0.001) and a 12% increase was retained during the follow-up period (1.12, 95% CI: 0.54-4.02, P = 0.427). Pre-intervention, across all sites, 24% of hysterectomies were performed via TAH by the participating specialist trainees, which decreased to 13% during the intervention and 14% during follow-up. The rate of adverse events decreased from 13.5% at pre-intervention, to 6.4% during and 4.2% post-intervention. By comparison, no change in surgical approach or rate of adverse events was observed in the control group.
Conclusions:
The implementation of a formal and structured surgical training program teaching TLH resulted in important benefits to trainees, patients and society in the four trial hospitals.
Background
Endometrial cancers are among the epithelial malignancies of the lining of the uterine cavity. The invasion of carcinoma into the lymphovascular space (LVSI) is considered a risk factor for the course of the disease.
Material and methods
We evaluated 170 female patients. Our primary objective was to find any difference in the incidence of LVSI in female patients treated with and without an intrauterine manipulator. In addition, we analyzed the effect of the type of intrauterine manipulator used on the incidence of LVSI, tumor grading, myometrial invasion, and the method of obtaining primary histology with regard to the incidence of LVSI.
Results
Using a manipulator during surgery was not associated with LVSI (with a manipulator vs. without, 11.5 vs. 21.7%; OR 1.8; 95% CI 0.73–4.39; p = 0.199). However, the method used to obtain the primary histology had a statistically significant effect on the incidence of LVSI in our set (p-value = 0.011).
Conclusions
In our study, we did not confirm the effect of a uterine manipulator on the possible increase of LVSI positive cases. The secondary analysis indicated a higher incidence of LVSI in the female patients diagnosed with curettage than in those who underwent hysteroscopy. Trail registration: Trail is registered in ClicincalTrails.gov with identifier: NCT05261165.
Objective:
The aim was to investigate the acute effect of kinesthetic motor imagery of the 2-minute walk test on hemodynamic and cardiopulmonary variables in patients with heart failure.
Methods:
Twenty participants were recruited for the analysis of these variables before and after the execution and imagination of the 2-minute walk test, with the number of laps executed and imagined being recorded.
Results:
The main results observed showed that (1) there was no difference in the number of laps executed and imagined (p=0.41), indicating that the participants actually imagined the test and (2) the motor imagery of the 2-minute walk test immediately increased (p<0.001) the heart and respiratory rates.
Conclusion:
The motor imagery seems to have acute effects on the cardiopulmonary anticipatory responses of a patient with heart failure.
OBJECTIVE: The aim of this study was to determine the prospective capacity and impact of donor risk index, preallocation survival
outcomes following liver transplant, donor model for end-stage liver disease, and balance of risk on patients’ 30-day survival after liver
transplantation.
METHODS: We prospectively analyzed patient survival in a multicentric observational cohort of adult liver transplantation through the
year of 2019 at the state of Paraná, Brazil. The receiver operating characteristic curve, the area under the curve, and the best cutoff
point (i.e., the Youden’s index) were estimated to analyze the prognostic value of each index.
RESULTS: In total, 252 liver transplants were included with an average model for end-stage liver disease score of 21.17 and a 30-day
survival of 79.76%. The donor risk index was the only prognostic variable with no relation to patients’ 30-day mortality model for
end-stage liver disease and donor model for end-stage liver disease have no prognostic value on receiver operating characteristic
curve, but preallocation survival outcomes following liver transplant, survival outcomes following liver transplant, and balance of risk
presented good relationship with this observation. The cutoff value was estimated in 11–12 points for balance of risk and 9–12 for
preallocation survival outcomes following liver transplant and survival outcomes following liver transplant. The 30-day survival for
the group of transplants with scores up to 12 points (n=172) in all the three indexes was 87.79%, and for those transplants with
scores higher than 12 it was 36.36%.
CONCLUSIONS: The 30-day survival is 79.76%, and balance of risk, survival outcomes following liver transplant, and preallocation
survival outcomes following liver transplant are the good prognostic indexes. The cutoff value of 12 points has clinical usefulness to
predict the post-liver transplantation results.
Overview
Endometrial carcinoma is the most frequent gynecologic cancer in the United States with over 50,000 new cases diagnosed per year. Over 80% have Type I cancers with the classic estrogen‐dependent endometrioid histology and a favorable prognosis. Type II cancers have a different molecular profile associated with more virulent disease and diminished survival and include uterine papillary serous carcinomas (UPSC) and clear cell carcinomas. The Cancer Genome Atlas (TCGA) has recently defined four molecular subtypes of endometrial cancer based on somatic mutations, copy number alterations, and microsatellite instability status. Over 75% of patients are present with irregular or postmenopausal bleeding. Surgical staging includes a total hysterectomy, bilateral salpingo‐oophorectomy, and pelvic and para‐aortic lymph node sampling, which can be performed via a laparotomy, laparoscopy, or robotic surgery. Surgery, where possible, constitutes the definitive primary treatment for most patients with endometrial carcinoma. Primary radiation therapy and primary hormonal therapy are alternatives for inoperable patients. Adjuvant therapy for stage I disease is determined by age, depth of myometrial invasion, lymphovascular space invasion, and tumor grade. For patients with advanced and recurrent disease, radiation therapy, chemotherapy, and hormonal therapy are utilized. Paclitaxel (T), carboplatin (C), cisplatin (P), and doxorubicin (A) are the most active single agents, with TC and TAP being the most effective combination of chemotherapy regimens. Hormonal therapy includes oral progestins, the progesterone‐containing intrauterine device, tamoxifen, gonadotropin‐releasing hormone analogs, and aromatase inhibitors. Emerging biologic agents with activity include bevacizumab and mTOR inhibitors. Tumor molecular profiling, minimal invasive surgery, sentinel lymph node assessment, and integration of novel biologic therapies will likely play a greater role in the future.
Endometrial cancer typically presents at an early stage, and surgery alone can be curative in many of these cases. Traditionally, surgery for early-stage disease has been carried out using an open approach; however, the use of minimally invasive surgery has rapidly grown in the field of gynecologic oncology. Multiple studies have demonstrated its feasibility, and oncologic outcomes continue to be validated.
Background:
This is an update of a previous Cochrane Review published in 2012, Issue 9.Surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last two decades there has been a steady increase of the use of laparoscopy for endometrial cancer. This review investigated the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.
Objectives:
To compare overall survival (OS) and disease free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer.
Search methods:
For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5) in the Cochrane Library, MEDLINE via Ovid (April 2012 to June 2018) and Embase via Ovid (April 2012 to June 2018). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. The trial registers included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol.
Selection criteria:
Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer.
Data collection and analysis:
We independently abstracted data and assessed risk of bias. We used hazard ratios (HRs) for OS and recurrence free survival (RFS), risk ratios (RR) for severe adverse events and mean differences (MD) for continuous outcomes in women who received laparoscopy or laparotomy with 9% confidence intervals (CI). These were pooled in random-effects meta-analyses.
Main results:
We identified one new study in this update of the review. The review contains nine RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer.All nine studies met the inclusion criteria and assessed 4389 women at the end of the studies. Six studies assessing 3993 participants with early stage endometrial cancer found no significant difference in the risk of death between women who underwent laparoscopy and women who underwent laparotomy (HR 1.04, 95% 0.86 to 1.25; moderate-certainty evidence) and five studies assessing 3710 participants found no significant difference in the risk of recurrence between the laparoscopy and laparotomy groups (HR 1.14, 95% CI 0.90 to 1.43; moderate-certainty evidence). There was no significant difference in the rate of perioperative death; women requiring a blood transfusion; and bladder, ureteric, bowel and vascular injury. However, one meta-analysis of three studies found that women in the laparoscopy group lost significantly less blood than women in the laparotomy group (MD -106.82 mL, 95% CI -141.59 to -72.06; low-certainty evidence). A further meta-analysis of two studies, which assessed 3344 women and included one very large trial of over 2500 participants, found that there was no clinical difference in the risk of severe postoperative complications in women in the laparoscopy and laparotomy groups (RR 0.78, 95% CI 0.44 to 1.38). Most studies were at moderate risk of bias. All nine studies reported hospital stay and results showed that on average, laparoscopy was associated with a significantly shorter hospital stay.
Authors' conclusions:
This review found low to moderate-certainty evidence to support the role of laparoscopy for the management of early endometrial cancer. For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar OS and DFS. Furthermore, laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe postoperative morbidity between the two modalities.The certainty of evidence for OS and RFS was moderate and was downgraded for unclear risk of bias profiles and imprecision in effect estimates. However, most studies used adequate methods of sequence generation and concealment of allocation so studies were not prone to selection bias. Adverse event outcomes were downgraded for the same reasons and additionally for low event rates and low power thus these outcomes provided low-certainty evidence.
This chapter reviews the epidemiology, prevention, early detection, diagnosis, staging, treatment, and follow-up of uterine corpus cancers, with emphasis on endometrial carcinomas.
Hysterectomy is one of the most frequently performed gynaecological procedurein female. Objectives: The purpose of this study was to compare the outcome between totallaparoscopic hysterectomy and abdominal hysterectomy regarding blood loss during surgery,surgical time and postoperative hospital stay. Settings: Department of Gynecology & ObstetricsAllied Hospital, Faisalabad Medical University, Faisalabad. Period: 1st January 2016 - 31stDecember 2016 (1 Year). Study Design: Randomized control Study. Material & Methods: Theethical committee of Faisalabad Medical University, Faisalabad approved the study protocol. Thepatient demographical characteristics were similar in both groups. 112 patients were enrolled.Including 56 case of total laparoscopic hysterectomy and 56 cases of abdominal hysterectomywhich meets inclusion criteria. Result: Average blood loss in TLH was 83.09+10.74ml while itwas 387.88+59.54ml in TAH. When both groups were compared regarding operative time, itwas 76.73+20.2min in TLH while it was 84.7+19.9 in TAH. Postoperative stay in the hospitalwas 1.25+0.44 days in TLH while it was 5.72+0.83 in TAH. Conclusion: The laparoscopichysterectomy is a modern surgical method in current gynecological practice. With increasingexperience and good collaboration of surgical team, time duration can be shortened and bloodloss can be reduced to negligible.
Overview
Endometrial carcinoma is the most frequent gynecologic cancer in the United States with over 50,000 new cases diagnosed per year. Over 80% have Type I cancers with the classic estrogen‐dependent endometrioid histology and a favorable prognosis. Type II cancers have a different molecular profile associated with more virulent disease and diminished survival and include uterine serous papillary carcinomas (UPSC) and clear cell carcinomas. The Cancer Genome Atlas (TCGA) has recently defined four molecular subtypes of endometrial cancer based on somatic mutations, copy number alterations, and microsatellite instability status. Over 75% of patients are present with irregular or postmenopausal bleeding. Surgical staging includes a total hysterectomy, bilateral salpingo‐oophorectomy, and pelvic and para‐aortic lymph node sampling, which can be performed via a laparotomy, laparoscopy, or robotic surgery. Surgery, where possible, constitutes the definitive primary treatment for most patients with endometrial carcinoma. Primary radiation therapy and primary hormonal therapy are alternatives for inoperable patients. Adjuvant therapy for Stage I disease is determined by age, depth of myometrial invasion, lymphovascular space invasion, and tumor grade. For patients with advanced and recurrent disease, radiation therapy, chemotherapy, and hormonal therapy are utilized. Paclitaxel (T), carboplatin (C), cisplatin (P), and doxorubicin (A) are the most active single agents with TC and TAP being the most effective combination of chemotherapy regimens. Hormonal therapy includes oral progestins, the progesterone‐containing intrauterine device, tamoxifen, gonadotropin‐releasing hormone analogs, and aromatase inhibitors. Emerging biologic agents with activity include bevacizumab and mTOR inhibitors. Tumor molecular profiling, minimal invasive surgery, sentinel lymph node assessment, and integration of novel biologic therapies will likely play a greater role in the future.
Background: Hysteroscopy is a clinical procedure that allows a gynecologist to see inside the uterus through endoscopy. This can be done for diagnosis or treatment of intrauterine conditions and as a method of surgery.
Purpose: To establish the prevalence of uterine disease in a group of healthy patients who underwent hysteroscopy as part of their gynecological examination.
Materials and methods: It was an observational study. 18 patients who attended a regular consultation provided by the clinical services of Gynecology and Obstetrics of the General Hospital Pemex Picacho were studied; a hysteroscopy was performed in 7 (38.8%) patients who only attended a usual gynecological examination, were asymptomatic and were without known gynecological pathology.
Results: When performing hysteroscopy, 6 (85.7%) patients with gynecological pathology not previously known were found. The disease most commonly found in this sample was the internal cervical stenosis (28.5%).
Conclusions: Hysteroscopy showed a high prevalence of detecting uterine pathologies that were never previously described in a population of healthy women in a common sample of patients attending the outpatient Hospital Pemex Picacho.
Der Vorteil der laparoskopischen Operationen liegt in der geringeren postoperativen Morbidität und schnelleren Rekonvaleszenz der Patientinnen. Seit dem Beginn der endoskopischen gynäkologischen Chirurgie konnten sich zunehmend mehr endoskopische Eingriffe als den offenen Techniken gleichwertig etablieren (◘Tab. 42.1).
Objective: Although laparoscopic surgery is widely utilized in the treatment of endometrial cancer, its efficacy in staging the cancer is not well established. The aim of this study was to compare staging endometrial cancer with laparoscopic and conventional open methods.
Materials and Methods: From January 2002 to June 2012, 151 patients (70 treated by laparoscopy and 81 by laparotomy) diagnosed with endometrial cancer were enrolled. This was a retrospective cohort review of endometrial cancer surgically staged using laparoscopy or laparotomy in the Department of Obstetrics and Gynecology, National Taiwan University Hospital, Taipei, Taiwan.
Results: The two groups did not significantly differ in patient age, body mass index, previous obstetrical history, or amount of previous abdominal surgery. No differences between the surgical cohorts were observed in relation to cancer status, including stage, grade, myometrial invasion, lymphovascular space invasion, lymph node involvement, and recurrence rate. The laparoscopic approach had less intraoperative blood loss, longer operative time, lower uterine weight, number of removed lymph nodes, and shorter hospital stay.
Conclusion: Our preliminary results showed that the laparoscopic method for staging endometrial cancer was technically feasible and efficient.
ABSTRACT
The laparoscopic surgery has taken a significant place in the concept of gynecological surgery for the last two decades. The thought including the application of the best surgical treatment modality to patients with minimal invasive procedure has been evolved new technological improvements and this idea has provided the application of robotics in the field of surgery. The robotics has integrated with virtual reality and the first step to the tele robotic surgery was started. The robotic assisted surgery is one of the latest innovations in the field of minimally invasive surgery. The da Vinci surgical system has been used in gynecological procedures including hysterectomy, myomectomy, urogynecology and cancer surgery. The advantages of the robotic surgery versus laparoscopy are the presence of 3-D visualization, direct view with optimal eye-hand alignment, instruments capable of making 7 different direction movements (df), improved dexterity and coordination, easy suturing, easy tying of knots, no tremor, decreased fatigue of surgeon during operation, short learning process, less convertion to laparotomy, ability to perform complex procedures , shorter operation time. The disadvantages of robotic surgery include lack of tactile feedback, the cost of system, the cost of limited use and disposable instrument, annual service fees, monopoly of one company providing the system, bulkiness of system requiring a larger operating room, long time needed for preparation to surgery, additional training of surgeon and operating room personel and learning process. The robotic surgery is not a surgical system in which the operations were performed by robotics on its own with artificial intelligence. Therefore, surgery with robot is best described as computer-assisted laparoscopic surgery. The aim of this article is to introduce the robotic surgery and to assess the application fields in gynecology.
Keywords: Robotics; video-assisted surgery; gynecology
The management and prognosis of isolated port-site metastases after laparoscopic surgery for endometrial cancer is poorly understood and rarely described in the literature. We report a series of cases treated with radiotherapy to better characterize outcomes in these patients.
We retrospectively reviewed medical records of patients with endometrial cancer who developed isolated port-site metastases and were treated with radiation therapy at MD Anderson Cancer Center from 1996 to 2013. Seven patients met these criteria for whom treatment and outcome data were collected.
The median interval from initial surgery to port-site recurrence was 15 months. Recurrent tumor size varied from 0.5 to 9 cm as measured on axial imaging. Six of the 7 patients underwent surgical resection of the recurrence. All received radiotherapy to a dose of 45 to 66 Gy. At a median follow-up of 2 years from the time of the port-site recurrence, the rate of disease-free survival at 1 and 2 years after the recurrence was 100% and 44%, respectively. The rate of local control and overall survival at 2 years was 100%.
Isolated port-site metastases in the setting of endometrial cancer are associated with high rates of local control when treated with multimodality therapy including radiotherapy. Long-term disease-free outcomes in some patients suggest the potential for cure and justify aggressive local therapy. The optimal integration of surgery, chemotherapy, and radiation is unknown.
This is the first report to determine the feasibility and safety of total laparoscopic modified radical hysterectomy (TLMRH) in the treatment of presumed stage I endometrial cancer.
This was a retrospective study of 132 consecutive patients who underwent surgery for early endometrial cancer. Thirty-nine patients underwent TLMRH and bilateral salpingo-oophorectomy (BSO), and 93 had a total abdominal extrafascial hysterectomy and BSO. Lymphadenectomy was performed in 87 patients. The groups were compared for epidemiological and clinical characteristics, surgical outcomes, hospital stay, lymph nodes harvested, and intraoperative and postoperative complications.
The patients in the TLMRH group had less blood loss (42.9 ± 76.3 vs 236.8 ± 186.6 mL, P < 0.0001), a similar number of lymph nodes removed (32.3 ± 13.1 vs 28.0 ± 11.9, P = 0.15), less need for analgesia and a shorter hospital stay (9.3 ± 2.5 vs 14.6 ± 12.6 days, P = 0.009) but longer operations (321.1 ± 65.9 vs 262.6 ± 75.0 min, P < 0.0001) than those treated by laparotomy. In our study, we had no conversions from laparoscopy to laparotomy. No major complications occurred in the TLMRH group. The patients who underwent TLMRH had less intense postoperative pain than patients treated by laparotomy. The median length of vaginal cuff removed was 12.0 ± 4.1 mm in the TLMRH group, and was 5.6 ± 6.6 mm in the laparotomy group (P < 0.0001). No patients demonstrated recurrence in either of the groups after a median follow-up of 48.5 months (range, 1-84).
TLMRH is a safe and reliable alternative to open surgery in the management of early endometrial carcinoma, with a significantly reduced hospital stay and complications.
In lifetesting, medical follow-up, and other fields the observation of the time of occurrence of the event of interest (called a death) may be prevented for some of the items of the sample by the previous occurrence of some other event (called a loss). Losses may be either accidental or controlled, the latter resulting from a decision to terminate certain observations. In either case it is usually assumed in this paper that the lifetime (age at death) is independent of the potential loss time; in practice this assumption deserves careful scrutiny. Despite the resulting incompleteness of the data, it is desired to estimate the proportion P(t) of items in the population whose lifetimes would exceed t (in the absence of such losses), without making any assumption about the form of the function P(t). The observation for each item of a suitable initial event, marking the beginning of its lifetime, is presupposed.
For random samples of size N the product-limit (PL) estimate can be defined as follows: List and label the N observed lifetimes (whether to death or loss) in order of increasing magnitude, so that one has \(0 \leqslant t_1^\prime \leqslant t_2^\prime \leqslant \cdots \leqslant t_N^\prime .\) Then \(\hat P\left( t \right) = \Pi r\left[ {\left( {N - r} \right)/\left( {N - r + 1} \right)} \right]\), where r assumes those values for which \(t_r^\prime \leqslant t\) and for which \(t_r^\prime\) measures the time to death. This estimate is the distribution, unrestricted as to form, which maximizes the likelihood of the observations.
Other estimates that are discussed are the actuarial estimates (which are also products, but with the number of factors usually reduced by grouping); and reduced-sample (RS) estimates, which require that losses not be accidental, so that the limits of observation (potential loss times) are known even for those items whose deaths are observed. When no losses occur at ages less than t the estimate of P(t) in all cases reduces to the usual binomial estimate, namely, the observed proportion of survivors.
Two postmenopausal patients with stage I adenocarcinoma of the endometrium who were managed with a combined laparoscopic and vaginal approach are presented. Surgical-pathologic staging was performed laparoscopically, with exploration of the abdomen and procurement of peritoneal cytology and pelvic and para-aortic lymph nodes. The adnexa were ligated and mobilized laparoscopically and removed with the vaginal hysterectomy. This approach offers decreased morbidity to the patient yet still obtains the same pathologic information and surgical goal as the traditional transabdominal approach.
Hysterectomy performed totally by laparoscopy has few advocates because separating the cervix from the vagina is difficult. This technical difficulty can be overcome by placing a wide-bore plastic tube in the vagina to expose the cervico-vaginal junction and stretch the vaginal fornices. The stretched vagina falls away from the cervix as diathermy cuts over the tube rim. The tube guides the incision, and the plastic protects any adjacent structures. The most convenient external diameter is between 4-5 cm. Made from smooth, electrically-inert plastic, the tube's opposite distal end has a valve that maintains the pneumoperitoneum. We have used it in 73 cases, and the only associated complication has been one vault pelvic hematoma.
A 58-year-old woman underwent abdominal hysterectomy and bilateral salpingo-oophorectomy for stage Ib, grade 2 endometrial adenocarcinoma followed by external pelvic irradiation. Five years later she presented with a 7 cm solitary infraumbilical incisional tumor recurrence that was resected. Histology of the tumor implant was similar to that of the primary cancer. The patient was then started on progestin therapy with no evidence of recurrence for four years. To our knowledge this is the fourth reported case of endometrial cancer implanting in an abdominal scar.
Our objective was to compare the clinical outcomes and associated hospital charges between two methods of hysterectomy for patients with early-stage endometrial cancer.
Retrospective chart review of 320 patients with early-stage endometrial cancer treated by laparoscopic-assisted vaginal hysterectomy (LAVH) or total abdominal hysterectomy (TAH) was performed for the period of July 1, 1991, to September 30, 1996, at Memorial Sloan-Kettering Cancer Center.
Sixty-nine patients (22%) were treated by LAVH, and 251 (78%) were treated by TAH. The majority of the patients (80%) had Stage I disease. The mean age was similar for both groups: 60 years for the LAVH vs 61 years for TAH. The mean weight was significantly lower for the LAVH group, 71 kg (range 43-117 kg), than for the TAH group, 82 kg (range 38-200 kg), (P < 0.05). Overall complication rates were lower among patients treated by LAVH. Operating room time was longer for the LAVH group (214 min) than for the TAH group (144 min) (P < 0.05). The median length of stay was significantly shorter for patients treated by LAVH (2.0 days) compared to TAH (6.0 days) (P < 0.05). Room charges were significantly higher for the TAH patients ($6960) compared to the LAVH patients ($3130) (P < 0.05). Overall mean total charges were significantly less for the LAVH group ($11,826) than for the TAH group ($15,189) (P < 0.05). With a median follow-up of 30 months for the TAH group and 18 months for the LAVH group, there was no significant difference in disease recurrence (P = 0.91).
Patients treated by LAVH for early-stage endometrial cancer had significantly shorter hospitalization and fewer complications, resulting in less overall hospital charges when compared to patients treated by TAH. Long-term outcome was similar. Laparoscopic-assisted vaginal hysterectomy is an attractive alternative for selected patients with early-stage endometrial cancer.
Our goal was to evaluate the morbidity, recurrence, and survival of patients with clinical stage I endometrial cancer treated by laparoscopic lymphadenectomy with vaginal or laparoscopic hysterectomy and bilateral salpingo-oophorectomy. Study Design: This article is a retrospective review of records for 56 patients. The mean follow-up among those alive at last contact was 2.4 years (range, 32 days-5.2 years). Staging according to the International Federation of Gynecology and Obstetrics (1988) was as follows: I, 45 (80.4%); II, 3 (5.4%); III, 6 (10.7%); and IV, 2 (3.6%).
Intraoperative complications occurred in 4 patients (7.1%). Transformation to laparotomy was necessary in 7 patients. Postoperative complications were observed in 9 patients (16.1%). Pelvic irradiation was administered postoperatively to 11 patients (19.6%). Among the 45 patients with surgical stage I disease, the 3-year recurrence rate was 2.5% and the 3-year cause-specific survival was 96.0%.
Laparoscopic lymphadenectomy and vaginal or laparoscopic hysterectomy with bilateral salpingo-oophorectomy provided 3-year survival and recurrence rates similar to those of the traditional abdominal approach.
Women with endometrial carcinoma are being treated with laparoscopic surgery, but the risk of port-site recurrences remains undefined.
A 58-year-old woman underwent laparoscopically assisted vaginal hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic lymphadenectomy for endometrial cancer. Final surgical stage was IA, with grade 2 histology. Twenty-one months later, she developed a 5-cm recurrent tumor mass at a lateral laparoscopic port site. The mass was resected, and a restaging laparotomy performed, without evidence of other metastases. Radiation therapy was administered to the involved anterior abdominal wall. Two and one half years later, there is no evidence of recurrence.
An isolated laparoscopic port-site recurrence might be attributable to the initial laparoscopic management of an otherwise good-prognosis endometrial carcinoma.
We compared a laparoscopic-vaginal approach with the conventional abdominal approach for treatment of patients with endometrial cancer.
Between July 1995 and August 1999, 70 patients with endometrial cancer FIGO stage I-III were randomized to laparoscopic-assisted simple or radical vaginal hysterectomy or simple or radical abdominal hysterectomy with or without lymph node dissection.
Thirty-seven patients were treated in the laparoscopic versus 33 patients in the laparotomy group. Lymph node dissection was performed in 25 patients by laparoscopy and in 24 patients by laparotomy. Blood loss and transfusion rates were significantly lower in the laparoscopic group. Yield of pelvic and para-aortic lymph nodes, duration of surgery, and incidence of postoperative complications were similar for both groups. Overall and recurrence-free survival did not differ significantly for both groups.
The laparoscopic-vaginal approach for treatment of endometrial cancer is associated with lower perioperative morbidity compared with the conventional abdominal approach.
Laparoscopic management of endometrial cancer, although gaining in acceptance, has been associated with recurrent disease at trocar insertion sites in advanced disease. We report on a patient with a port site recurrence in early stage endometrial cancer. An 84-year-old patient with cancer of the endometrium underwent a laparoscopic surgical staging, vaginal hysterectomy, and adjunct radiation treatment. The final surgical pathology was grade 3, stage IC endometrioid adenocarcinoma. Seven months post-treatment, she presented with bilateral port site recurrences in the lower abdominal wall. Trocar port site recurrence in gynecologic cancer patients may be enhanced by laparoscopic management and are not limited only to patients with advanced disease.
Laparoscopically assisted vaginal hysterectomy (LAVH) has evolved into an alternative form of surgical management in the treatment of low-risk endometrial cancer. The purpose of this study was to determine whether low-risk endometrial cancer patients are subject to a higher incidence of positive peritoneal cytology when treated with LAVH compared to total abdominal hysterectomy (TAH).
We retrospectively reviewed the medical records of patients with low-risk endometrial cancer (grade 1--2 endometrioid type with no evidence of extrauterine spread or grade 3 with <50% myometrial invasion (MI), no cervical or adnexal involvement, and negative lymph nodes when sampled) treated at Memorial Sloan-Kettering Cancer Center from January 1993 to September 1999. We compared 131 patients treated with LAVH to 246 controls who underwent TAH. The two groups were compared for known prognostic factors including grade, MI, vascular space involvement, and lower uterine segment extension.
The mean age of patients who underwent LAVH (61 years) was similar to that of the controls (62 years). Fourteen (10.3%) of the patients treated with LAVH had positive peritoneal cytology compared to only 7 (2.8%) of the control population. Factors including FIGO grade, myometrial invasion, and preoperative hysteroscopy did not influence the final results. When stratifying for these factors, the odds ratios of having positive peritoneal washings in those patients treated by LAVH were 5.2, 5.2, and 3.7, respectively.
Treatment of low-risk endometrial cancer by LAVH is associated with a significantly higher incidence of positive peritoneal cytology. This may be due to the retrograde dissemination of cancer cells into the peritoneal cavity during uterine manipulation. The clinical significance of these findings is yet to be determined.
To evaluate clinical outcome and tissue trauma after laparoscopic and abdominal hysterectomy.
Fifty women scheduled for abdominal hysterectomy were randomized to undergo either laparoscopic (n = 25) or abdominal (n = 25) hysterectomy. Surgical characteristics, hospital stay, convalescence and complications were analyzed. Blood samples for assay of markers of tissue trauma (interleukin-6, C-reactive protein, tumor-associated trypsin inhibitor and tumor-associated antigen CA 125) were taken preoperatively, on the first, second and seventh postoperative day and at the follow-up visit four weeks after surgery.
In uncomplicated hysterectomies (n = 18) the operating time (85.3 min versus 57.5 min, p < 0.00001) was longer for laparoscopic group but the hospital stay (2.1 days versus 3.4 days, p < 0.00001) and sick leave (21.4 days versus 38.5 days, p < 0.00001) were shorter in the laparoscopic group. Postoperative increases in all markers were significant in both groups. The interleukin-6 concentration was highest on the first postoperative day in both groups, that of C-reactive protein on the second postoperative day in both groups, tumor-associated trypsin inhibitor on the seventh postoperative day in the laparoscopic group and on the second postoperative day in the abdominal group and tumor-associated antigen CA 125 on the seventh postoperative day in both groups. Both interleukin-6 and C-reactive protein levels were lower in the laparoscopic group on the first (p = 0.01 and p = 0.03, respectively) and on the second postoperative day (p = 0.02 and p < 0.001, respectively) compared with the abdominal group. No differences were seen in tumor-associated trypsin inhibitor and tumor-associated antigen CA 125 levels between the groups.
Laparoscopic hysterectomy should replace abdominal hysterectomy whenever possible because of a more favorable clinical outcome and less tissue trauma.
To give insight into the utility of laparoscopic staging of endometrial cancer in the elderly population by reviewing the surgical management of clinically stage I endometrial cancer patients.
A retrospective analysis evaluating patients that were > or =65 years old and had planned laparoscopic staging, traditional staging via a laparotomy, or a transvaginal hysterectomy as management of their early endometrial cancer. The laparoscopic group had complete staging with bilateral pelvic and paraaortic lymph node dissections and was compared to the group who had staging performed via laparotomy. Patients were identified by our institution's database and data were collected by review of their medical records. Data were collected on demographics, pathology, and procedural information including completion rates, operating room (OR) time, estimated blood loss (EBL), transfusions, lymph node count, complications, and length of stay. Associations between variables were analyzed by Student's t tests and chi(2) testing using Excel v. 9.0.
From February 25, 1994, through December 21, 2000, 125 elderly patients were identified. Sixty-seven patients had planned laparoscopic staging (Group 1), 45 patients had staging via planned laparotomy (Group 2), and 13 patients had a transvaginal hysterectomy (Group 3). Group 1 and Group 2 were compared regarding surgical and postoperative data. Age was not different between these groups (75.9 vs 74.7 years, P = NS). Quetelet index was also similar (29.4 vs 29.9, P = NS) 32.8% of Group 1 had > or =1 previous laparotomy compared to 51.1% in Group 2 (P = NS). In Group 1, 53/67 (79.1%) had stage I or II disease compared to 29/45 (64.4%) in Group 2 (P = NS). Laparoscopy was completed in 52/67 (77.6%) attempted procedures. The reasons for conversion to laparotomy were obesity 7/67 (10.4%), bleeding 4/67 (6.0%), intraperitoneal cancer 3/67 (4.5%), and adhesions 1/67 (1.5%). OR time was significantly longer in successful Group 1 patients compared to Group 2 patients (236 vs 148 min, p = 0.0001). EBL was similar between these groups (298 vs 336 ml, P = NS). Ten of 52 (19.2%) of successful Group 1 patients received a blood transfusion compared to 1/45 (2.2%) of Group 2 patients (P < 0.0001). Pelvic, common iliac, and paraaortic lymph node counts were similar between successful Group 1 patients and those in Group 2 combined with those that received a laparotomy in Group 1 (17.8, 5.2, 6.6 vs 19.1, 5.1, 5.2, P = NS). Length of stay (LOS) was significantly shorter in Group 1 versus Group 2 (3.0 vs 5.8 days, P < 0.0001). There were less fevers (6.0 vs 15.6%, P = 0.01), less postoperative ileus's (0 vs 15.6%, P < 0.001), and less wound complications (6.0 vs 26.7%, P = 0.002) in Group 1 compared to Group 2. Group 3 average age was 77.5 years. Concurrent medical comorbidities were the main reason for the transvaginal approach. OR time averaged 104.5 min. The average length of stay was 2.1 days with no procedural or postoperative complications.
The favorable results from this retrospective study refute the bias that age is a relative contraindication to laparoscopic surgery. Laparoscopic staging was associated with an increased OR time and an increased rate of transfusion but equivalent blood loss and lymph node counts. Possible advantages are decreased length of stay, less postoperative ileus, and less infections complications. Transvaginal hysterectomy still remains a proven option for women with serious comorbid medical problems with short OR times, minimal complications, and short lengths of stay.
Every year the American Cancer Society estimates the number of new cancer cases and deaths expected in the United States in the current year and compiles the most recent data on cancer incidence, mortality, and survival, using National Cancer Institute (NCI) incidence and National Center for Health Statistics (NCHS) mortality data. Incidence and death rates are age adjusted to the 1970 US standard population. It is estimated that 1,284,900 new cases of cancer will be diagnosed and 555,500 people will die from cancer in the United States in the year 2002. From 1992 to 1998, cancer death rates declined in males and females, while cancer incidence rates decreased among males and increased slightly among females. Most notably, African-American men showed the largest decline for both incidence and mortality. Nevertheless, African Americans still carry the highest burden of cancer with later-stage cancer diagnosis and poorer survival compared with whites. Despite the continued decline in cancer death rates, the total number of recorded cancer deaths in the United States continues to increase slightly due to the aging and expanding population.
To assess hysterectomy rates, type of hysterectomy, and other factors associated within the United States from 1990-1997.
A descriptive statistical analysis of national discharge data was undertaken. Data from the nationwide Inpatient Sample of the Healthcare Cost and Utilization Project (from which national estimates are generated based on a 20% stratified sample of US community hospitals) were used for the years 1990-1997. All women who underwent hysterectomy were identified using International Classification of Diseases, 9th Revision, Clinical Modification, procedure codes. Outcome measures included rate, type of hysterectomy, age of patients, length of stay, total hospital charges, and diagnostic categories.
Rates of hysterectomy have not changed significantly over the years from 1990-1997. Rates for hysterectomy in 1990 were 5.5 per 1000 women and increased slightly by 1997 to 5.6 per 1000 women. The type of hysterectomy has changed, with laparoscopic hysterectomy accounting for 9.9% of cases by 1997, with a concomitant decline in abdominal hysterectomy but no substantial change in vaginal hysterectomy rates. Length of stay decreased and total charges increased for all types of hysterectomy. Vaginal hysterectomy and laparoscopic hysterectomy are associated with shorter length of stay than abdominal hysterectomy. Abdominal hysterectomy is the most common procedure (63.0% in 1997).
The majority of hysterectomies are abdominal, and the most common indication is uterine fibroids. The introduction of alternative techniques for controlling abnormal uterine bleeding such as endometrial ablation has not had an impact on hysterectomy rates, and there has only been a limited uptake of laparoscopic approaches.
To compare total laparoscopic hysterectomy (TLH) with open hysterectomy in the management of endometrial carcinoma.
Retrospective chart review (Canadian Task Force classification II-3).
Gynecologic cancer center.
All women with endometrial carcinoma managed between January 1, 1993, and June 30, 1999.
Of 403 patients reviewed, in 161 (40%) the surgical intention was laparoscopic management, in 230 (57%) the intention was open management, and in 12 (3%) it was vaginal hysterectomy. Total laparoscopic hysterectomy was successfully completed in 153 (95%) of the laparoscopic group.
Mean weight of women in the laparoscopic group (80.1 kg) was greater than that in the open group (73.3 kg, p = 0.002), and included 27 patients weighing over 100 kg (maximum individual weight 170 kg). Mean operating times were 138 minutes for laparoscopy and 121 minutes for the open procedure (p = 0.002). Complications differed, with significantly more occurring in the open group (43%, 100) than in the laparoscopic group (17%, 27, p <0.00001). Mean postoperative hospital stay was significantly shorter for the laparoscopic group (4.3 days) than for the open group (8.5 days, p = 0.0001). Conclusion. TLH combined with laparoscopic surgical staging has many advantages over the open approach, especially in obese women.
Surgical treatment of endometrial cancer was traditionally done by laparotomy, however the laparoscopic approach has gained wider acceptance by gynecologic surgeons. The primary aim of the study was to report the perioperative and postoperative outcomes of laparoscopic surgery in a major group of patients with endometrial cancer. The second aim was to study the long-term results of laparoscopic surgery in patients with endometrial cancer.
A prospective multicentric study was conducted at three oncolaparoscopic centres; 221 women who had undergone laparoscopic (177 women) or abdominal (44 women) hysterectomy with bilateral salpingo-oophorectomy and lymphadenectomy were included in the study. Women with stage IA, grade I did not undergo lymphadenectomy unless they had a high risk histologic tumor type. Lymph node dissection was performed in 145 women with disease greater than IA or grades other than 1.
The mean age and weight were similar in the compared laparoscopic and open groups. Perioperative blood loss was comparable in both groups (211.2 ml vs 245.7 ml, respectively) without any significant consecutive changes in serum hemoglobin values. Although the length of operating time for the laparoscopic surgery was significantly longer than the time for the laparotomy procedure (163.3 min vs 114.7 min, p < 0.0001), the laparoscopic patients were discharged from hospital much earlier at 3.9 days (range 2-16) after the laparoscopic procedure compared with 7.3 days (range 5-16) after the abdominal procedure (p < 0.0001). The difference in surgical complications between groups was statistically insignificant (p = 0.58). Similar long-term results were noted in both groups. With a median follow-up of 33.6 months for the laparoscopy group and 45.2 months for the open group, there were no significant differences in tumor recurrence (p = 0.99] or recurrence-free survival (p = 0.86) between the two groups.
The study illustrates that laparoscopically assisted surgical staging of endometrial cancer is safe as an open procedure. The laparoscopic approach may also be considered for endometrial malignancy which typically occurs in obese and elderly, high-risk women. Our analysis showed no difference with respect to recurrence or survival between the compared laparoscopic and the open group.
The effect of the laparoscopic surgical approach on the survival of women with endometrial carcinoma remains unclear. The objectives of the current study were to assess the effect of laparoscopic surgery on the survival of women with early-stage endometrial carcinoma and to analyze the factors that affect such survival.
A retrospective review of women presenting with clinical stage I endometrial carcinoma (according to the 1988 International Federation of Gynecology and Obstetrics Staging System) was performed. Women treated with laparoscopy were compared with those treated with laparotomy with regard to their characteristics, surgical procedure, treatment, surgical stage, histology, tumor grade, and recurrence-free and overall survival. Factors affecting survival (surgical approach, histology, grade, and surgical stage) were evaluated using multivariate analysis and survival curves were constructed using Kaplan-Meier analyses.
One hundred women underwent laparoscopy and 86 underwent laparotomy. Both groups were similar with regard to age, parity, menopausal status, lymphadenectomy, surgical stage, tumor grade, histology, and postoperative radiation therapy. Women who underwent laparoscopy and those who underwent laparotomy had similar 2-year and 5-year estimated recurrence-free survival rates (93% vs. 94% and 90% vs. 92%, respectively), as well as similar 2-year and 5-year overall survival rates (98% vs. 96% and 92% vs. 92%, respectively). There was no apparent difference with regard to the sites of recurrence between both groups. In univariate and multivariate analyses, surgical stage, tumor grade, and histology (but not the surgical approach) were found to have a significant effect on survival.
Although longer follow-up is needed, the survival of women with early-stage endometrial carcinoma does not appear to be worsened by laparoscopy. Surgical stage, tumor histology, and tumor grade were found to significantly affect survival regardless of the surgical approach used.
Laparoscopic-assisted vaginal hysterectomy (LAVH) has been suggested as an alternative to total abdominal hysterectomy (TAH) for the treatment of early endometrial cancer. Although studies have reported good results with equivalent rates of recurrence and survival, the need for use of intrauterine manipulators during the LAVH raises the concern for operative dissemination of tumor cells.
We report three patients with stage I, noninvasive or superficially invasive endometrial cancer with vaginal cuff recurrence within 9 months of treatment by LAVH.
While LAVH may be a technically acceptable alternative to TAH for the management of early-stage endometrial cancer, its routine use should be undertaken with caution, as the long-term risks for recurrence and survival have yet to be defined in a randomized, controlled fashion.
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