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Study objective To evaluate if extraperitoneal paraaortic lymphadenectomy using a robotic-assisted approach was associated with fewer complications when compared to all other approaches (conventional laparoscopic transperitoneal or extraperitoneal and robotic-assisted transperitoneal) without compromising lymph node yield, operative time or length of stay. Design Post-hoc analysis of the prospective randomized open-label multicenter trial (STELLA-2) SETTING: Three academic reference hospitals. Patients Two-hundred and three eligible patients from STELLA-2 trial were included. Interventions Patients were randomized to extraperitoneal or transperitoneal PALND using a minimally invasive approach (either laparoscopy or robotic-assisted) for surgical staging of endometrial or ovarian cancer. Minimally invasive approaches were not subjected to randomization. Measurements and main results Primary endpoint was evaluated through a composite variable which included at least one of the following events: bleeding during PALND ≥ 500 mL, any intraoperative complication related to PALND, severe postoperative complication (Dindo ≥ IIIA), impossibility to complete the procedure or conversion to laparotomy). Of the 203 patients analyzed, 68 patients were assigned to the extraperitoneal laparoscopic group (X-L), 62 to the transperitoneal laparoscopic group (T-L), 35 to the extraperitoneal robotic group (X-R), and 38 to the transperitoneal robotic group (T-R). A reduced trend in complications was observed in the extraperitoneal robotic-assisted arm when considering the primary endpoint (X-L: 25.0%, T-L:24.2%, X-R: 5.7%; T-R: 28.9%, p=0.073). In a multivariable analysis, age (OR: 1.05, 95% CI: 1.00-1.09), body mass index (OR: 1.09, 95% CI: 1.03-1.16), and waist-hip ratio (OR: 1.66, 95% CI: 1.12-2.47) were found to independently increase the risk of PALND complications, while extraperitoneal robotic approach (OR: 0.13, 95% CI 0.02-0.64) was an independent protective factor for complication occurrence. Conclusion Robotic-assisted extraperitoneal PALND is associated with fewer surgical complications, without compromising lymph node retrieval, operative time or length of stay. Robotic enhanced 3D visualization, surgeon's ergonomy or hemostatic precision could explain our results.

STUDY OBJECTIVE To analyze the effect that the introduction of minimally invasive procedures has had on surgical and oncologic outcomes when compared with conventional open radical hysterectomy (ORH) in a national reference cancer after 17 years of experience in radical hysterectomy. DESIGN A prospective controlled study (Canadian Task Force classification II-2). SETTING A university teaching hospital. PATIENTS All patients who underwent radical hysterectomy as primary treatment for cervical cancer in our institution between May 1999 and June 2016, with a total of 188 patients. INTERVENTIONS Patients underwent ORH or minimally invasive surgery (MIS) (i.e., laparoscopic or robotically assisted radical hysterectomy). MEASUREMENTS AND MAIN RESULTS Seventy-six patients underwent ORH, 90 laparoscopic radical hysterectomy, and 22 robotically assisted radical hysterectomy. Blood loss and hospital stay were inferior in the MIS group (p

Study Objective To show the feasibility and safety of nerve-preserving laparoscopic radical hysterectomy (type C1 Querleu-Morrow Classification [1] ) for the treatment of early cervical cancer. Design A surgical video article (Canadian Task Force classification III). Setting A university hospital (University Hospital of Barcelona, Barcelona, Spain). Patients Nerve-preserving radical hysterectomy is performed in a patient with Federation Internationale de Gynecologie et d'Obstetrique stage 1B1 cervical cancer with deep stromal invasion. Interventions Three steps are fundamental for the removal of the cervix with a safe oncologic margin and preservation of the pelvic autonomic nerves [2] . 1. Step 1: for the correct preservation of the pelvic splanchnic nerves (ventral roots from spinal nerves S2-S4) and the inferior hypogastric plexus during the section of the paracervix, it is essential to identify the deep uterine vein. This vein will correspond with the inferior limit of the dissection. 2. Step 2: during the dissection of the uterosacral ligament and after dissecting the Okabayashi space, the inferior hypogastric nerve is isolated. This nerve runs 2 cm parallel below the uterosacral ligament in the peritoneal leaf of the broad ligament. 3. Step 3: during the section of the vesicouterine ligament, the lateral side must be preserved because it includes the medial and inferior vesical veins that drain to the deep uterine vein. Conclusion Nerve-sparing laparoscopic radical hysterectomy is an attractive surgical approach for early-stage cervical cancer. Direct visualization of the pelvic autonomic nervous system (sympathetic and parasympathetic branches) innervating the bladder and rectum makes the nerve-sparing approach a safe and feasible procedure.

Radiation treatment planning for women with locally advanced cervical cancer (stages IB2-IVA) is often based on positron emission tomography (PET). PET, however, has poor sensitivity in detecting metastases in aortocaval nodes. We have initiated a study with the objective of determining whether pre-therapeutic laparoscopic surgical staging followed by tailored chemoradiation improves survival as compared with PET/computed tomography (CT) radiologic staging alone followed by chemoradiation. This international, multicenter phase III trial will enroll 600 women with stages IB2-IVA cervical cancer and PET/CT findings showing fluorodeoxyglucose-avid pelvic nodes and fluorodeoxyglucose-negative para-aortic nodes. Eligible patients will be randomized to undergo either pelvic radiotherapy with chemotherapy (standard-of-care arm) or surgical staging via a minimally invasive extraperitoneal approach followed by tailored radiotherapy with chemotherapy (experimental arm). The primary end point is overall survival. Secondary end points are disease-free survival, short- and long-term morbidity with pre-therapeutic surgical staging, and determination of anatomic locations of metastatic para-aortic nodes in relationship to the inferior mesenteric artery. We believe this study will show that tailored chemoradiation after pre-therapeutic surgical staging improves survival as compared with chemoradiation based on PET/CT in women with stages IB2-IVA cervical cancer.

Objective To demonstrate our experience with hysteroscopic assistance in the laparoscopic repair of an isthmocele. Design Surgical video article (Canadian Task Force classification III). Setting University hospital . Intervention A 42-year-old woman with a history of previous caesarean section presented as an emergency with a large, seriously infected isthmocele. Once the infection was cured with antibiotics, sonography revealed a 23 × 14-mm isthmocele with 1.4-mm residual myometrium thickness. She reported postmenstrual spotting and dysmenorrhea of several years duration, as well as previous dyspareunia that had worsened after her cesarean section. Given her symptomatic isthmocele with thin residual myometrium and desire for childbearing, laparoscopic repair was offered. First, the bladder was dissected to expose the isthmus. Uterine arteries were dissected. Hysteroscopic guidance and transillumination revealed the edges of the defect. The isthmocele and fibrotic tissue were excised with cold scissors, minimizing cauterization. A hysterometer was placed in the uterine cavity to respect the cervical canal and posterior uterine wall, and the myometrium was then closed in 2 layers. The total surgical time was 120 minutes. The postoperative period was uneventful. At 2 months after surgery, sonography confirmed restoration, with a myometrium thickness of 8.3 mm. The patient was asymptomatic, except for dyspareunia. At 6 months after surgery, hysteroscopic examination was normal. We recommended that the patient avoid attempting pregnancy for 9 months. Conclusion Hysteroscopic simultaneous assistance during laparoscopic isthmocele repair can be of great help in identifying the edges of the defect, especially in large cavities and in first cases, in which edges might not be clear otherwise. Resecting all of the fibrotic tissue while respecting healthy myometrium is essential. Excessive cauterization and ischemic suturing could prevent proper healing of the myometrium.

Objective To estimate the safety and feasibility of extraperitoneal laparoscopic approach for the diagnosis and treatment of paraaortic lymph node recurrence in gynecologic cancers. Material and Methods Between December 2002 and September 2009, 15 patients underwent extraperitoneal laparoscopic paraaortic lymphadenectomy for suspected isolated lymph node recurrence in the Gynecologic Oncology Unit of Hospital Vall d'Hebron. The suspected diagnosis of recurrence was performed with computed tomography scanning, 18F-fluorodeoxyglucose positron emission tomography scanning, or magnetic resonance imaging. Results The median age of patients was 63 years (range 42–75). The median body mass index was 28.5 Kg/m 2 (range 18–38). The median operative time was 157.5 minutes (range 120–240). The median blood loss was 70 mL (range 30–150). The mean nodal yield was 7.7 ± 5.3 (range 1–16). The median hospital stay was 2 days (range 2–13). There was 1 conversion to laparotomy. There was only 1 postoperative complication, a lymphorrhea that was resolved with drainage. Recurrence was confirmed in the pathologic study in 13 of the 15 patients. Conclusion The extraperitoneal laparoscopic surgical approach is a feasible and safe procedure for the diagnosis of paraaortic lymph node recurrences of gynecologic cancers. The previous abdominal surgeries or treatment with chemotherapy or radiotherapy and high body mass index are not a problem. The low complication rate, low blood loss and low hospitalization allow a rapid recovery of the patients, which in turn, allows the rapid onset of adjuvant therapy. Complete debulking of suspicious lymphadenopathy offers an exact diagnosis of malignancy, and it may have a therapeutic benefit in the case of being positive.

Laparoscopic radical hysterectomy is one surgical procedure currently performed to treat gynecologic cancer. The objective of this review was to update the current knowledge of laparoscopic radical hysterectomy in early invasive cervical cancer. Articles indexed in the MEDLINE database using the key words "Laparoscopic radical hysterectomy" and "Cancer of the cervix" were reviewed. Studies of laparoscopic radical hysterectomy for treatment of early cervical cancer with a minimum study population of 10 patients were selected. The laparoscopic approach was associated with less surgical morbidity (surgical bleeding) and with shorter length of hospital stay, although the duration of the operation may be longer. Laparoscopic radical hysterectomy with endoscopic pelvic lymphadenectomy, and paraaortic lymphadenectomy if needed, is a safe surgical option for treatment and staging of early invasive cervical cancer considering surgical risk, intraoperative bleeding, intraoperative and postoperative complications, and patient recovery. It is important to respect the learning curve. Surgical advances including new laparoscopic instrumentation and, in particular, use of robotics will contribute to reducing the duration of the operation and to facilitating learning and teaching of the procedure.

Study Objective To estimate the feasibility and results of sentinel lymph node identification and radical hysterectomy with pelvic lymphadenectomy entirely completed by laparoscopy versus laparotomy in early stage cervical cancer. Design Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting Acute care, teaching hospital. Patients From September 2000 through January 2005, 50 consecutive patients with International Federation of Gynecology and Obstetrics stage IA 2 , IB 1 , and IIA disease less than 4 cm underwent radical hysterectomy and lymphadenectomy with intraoperative sentinel lymph node biopsy. Interventions The operation was performed entirely by laparoscopy in 20 patients and using the conventional abdominal approach in 30. Feasibility of sentinel lymph node identification, surgical morbidity, overall survival, and recurrence rate–free survival in both groups were compared. Measurements and Main Results The overall detection rate of the sentinel lymph node was 100% (false negative 0%). A mean of 2.50 sentinel nodes/patient was detected in the laparotomy group compared with a mean of 2.55 nodes in the laparoscopic group (p = .874). Bifurcation of the right common iliac artery was the most frequent nodal location. Blood loss and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The median follow-up was 35 months (range 5–57) in the laparotomy group and 22.5 (range 2–52) in the laparoscopic group. Differences in overall survival and disease-free survival were not observed. Conclusion Sentinel lymph node identification and radical hysterectomy in the initial treatment of early stage cervical cancer can be performed safely by laparoscopy with lower morbidity and overall survival and recurrence-free survival similar to standard laparotomy.

Study objective To assess potential differences in perioperative features and survival between laparoscopic-assisted vaginal hysterectomy and conventional transabdominal hysterectomy in stage I endometrial cancer. Design Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting Acute-care, teaching hospital. Patients A total of 370 patients undergoing hysterectomy and bilateral salpingo-oophorectomy with surgical staging for primary treatment for clinical stage I endometrial cancer from January 1995 through June 2001. Intervention Clinical outcomes and survival in patients treated with laparoscopic-assisted vaginal hysterectomy (n = 55) and hysterectomy using the conventional abdominal approach (n = 315) were compared. Measurements and main results Baseline characteristics and histopathologic variables were similar in both groups. A total of 91.4% of patients underwent pelvic lymphadenectomy and 49.7% paraaortic lymphadenectomy. The median follow-up was 38.1 months. Blood loss, blood transfusions required, and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The mean number of pelvic and aortic nodes recovered was higher in the laparoscopic group (p Conclusion Surgical staging of early-stage endometrial cancer by laparoscopic-assisted vaginal hysterectomy is feasible, with lower perioperative morbidity and shorter hospital stay compared with transabdominal hysterectomy. Prognosis and survival were not affected by the laparoscopic vaginal approach to hysterectomy.

A 60-year-old patient had undergone a subtotal hysterectomy through a standard laparotomy approach due to multiple uterine myomas 6 years before. She had a 1-month history of postmenopausal uterine bleeding. An endocervical polyp was found and excised. The histopathologic examination showed a poorly differentiated adenocarcinoma. Magnetic resonance imaging of the abdomen and pelvis revealed the mass (4x2x2.5 cm) without parametrial involvement previously identified on vaginal examination. There was no retroperitoneal adenopathy. The patient was successfully treated with total laparoscopic radical trachelectomy in association with laparoscopic intraoperative detection of the sentinel lymph node.

Study objective To describe the feasibility and outcome of total laparoscopic radical hysterectomy with pelvic lymphadenectomy in early cervical cancer. Design Retrospective, nonrandomized study (Canadian Task Force classification II-2). Setting Acute-care, teaching hospital. Patients Twenty-seven nonconsecutive patients with International Federation of Gynecology and Obstetrics (FIGO) stage IA2 (n = 4) or IB1 (n = 23) cancer of the cervix. Intervention Laparoscopic type II (n = 9) or type III (n = 18) hysterectomy with systematic bilateral pelvic lymphadenectomy. Monopolar coagulation, vascular clips, and harmonic scalpel were used. Resection of the cardinal and uterosacral ligaments was performed with Endo GIA stapling and the harmonic scalpel. Measurements and main results Histopathologically, there were 20 cases of squamous carcinoma, 6 adenocarcinomas, and 1 adenosquamous carcinoma. The operation was performed entirely by laparoscopy in 26 patients. One patient underwent laparotomy because of equipment failure. The patients’ mean age was 45.1 years (95% CI 41.7–48.4), with a median body mass index of 26.0 kg/m2. The mean number of resected pelvic nodes was 19.1 (95% CI 17.02–21.2). Three patients had microscopic metastatic nodal disease. The surgical margins were free of disease in all cases. The median blood loss was 400 mL (range 250–700 mL). The median length of stay was 5 days. Major intraoperative complications did not occur. All patients are free of disease after a median follow-up of 32 months (range 4–52 months). Conclusion Radical hysterectomy can be successfully completed by laparoscopy in patients with early cervical cancer. This procedure may reduce the morbidity associated with abdominal or transvaginal radical hysterectomy.