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Competing Interests: Competing interests: None declared.

Objectives: To report on a consensus survey of experts on a recently proposed simplified nomenclature of surgical anatomy of the female pelvis for radical hysterectomy. The aim was to standardize surgical reports in clinical practice and understanding of the techniques in future surgical literature., Methods: The anatomical definitions were included in 12 original images taken at the time of cadaver dissections. Denomination of the corresponding anatomical structures was based on the nomenclature recently proposed by the same team. A three step modified Delphi method was used to establish consensus. After a first round of online survey, the legends of the images were amended to respond to the comments of the experts. Second and third rounds were performed. Consensus was defined as a yes vote to each question regarding the images provided, and 75% was defined as the cut-off for agreement. Comments justifying the no votes were taken into account to amend the set of images and legends., Results: A group of 32 international experts from all continents was convened. Consensus exceeded 90% for all five images documenting the surgical spaces. Consensus ranged between 81.3% and 96.9% for the six images documenting the ligamentous structures surrounding the cervix. Finally, consensus was lowest (75%) for the most recently defined denomination of the broad ligament (lymphovascular parauterine tissue or upper lymphatic pathway)., Conclusion: Simplified anatomic nomenclature is a robust tool to describe the surgical spaces of the female pelvis. The simplified definition of ligamentous structures reached a high level of consensus, even if the terms paracervix (instead of lateral parametrium), uterosacral ligament (replaced by rectovaginal ligament), vesicovaginal ligament, and lymphovascular parauterine tissue remain matters of debate., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2023. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Objectives: Pelvic side wall infiltration by gynecological malignancies has been considered for a long time an absolute contraindication to curative resection. The development of the laterally extended endopelvic resection (LEER) has challenged this surgical paradigm. Although the LEER has been standardized in open surgery, only small studies have been published about its endoscopic feasibility. The objective of this study is to analyze the safety of LEER in patients with gynecological malignancies involving the pelvic side wall., Methods: We retrospectively evaluated a consecutive series of patients who underwent a laparoscopically modified LEER between July 2014 and November 2018. This indicated gynecological tumors involving the pelvic sidewall and surgeries were conducted in two Italian institutions. All patients underwent pre-operative CT scan or PET to evaluate for distant metastases. Patients without suspicioun of distant metastasis underwent pelvic MRI and examination under anesthesia to establish the resectability of the disease and concomitant diagnostic laparoscopy to exclude intraperitoneal dissemination. All women with disease-free interval <6 months, and/or performance status > 2 ECOG were excluded. Type of resection was defined based on the status of the pathologic margins: R0, microscopically negative (free margin < 5 mm); R1, microscopically positive; and R2, macroscopically (grossly) positive. Disease-free survival was calculated from the date of primary surgery to the time of recurrence. Overall survival was defined as the time from primary surgery to death., Results: Overall, 39 patients underwent a laparoscopic LEER and 18 (46.2%) patients were eligible for a laparoscopic approach. Laparoscopic LEER was performed as primary treatment for newly diagnosed tumors in eight patients (44.4%), and for recurrences in the other 10 patients (55.6%). No laparotomic conversions were registered. R0 resection was achieved with negative margins in all patients. The median operative time was 415 min (range, 285-615), median estimated blood loss was 285 mL (range, 100-600), and the median length of hospital stay was 10 days (range; 4-22). Only four patients (22.2%) needed blood intraoperative transfusion. In seven patients (38.9%), post-operative admission to intensive care unit was required. There were three (16.7%) intraoperative complications, all managed laparoscopically. In total there were six (33.3%) major postoperative complications: three patients (16.7%) experienced moderate hydronephrosis with normal renal function, which required temporary placement of nephrostomy; one patient (5.6%) had permanent urinary retention; and two patients (11.1%) had a reoperation, one for post-operative hemoperitoneum and another for complete vaginal cuff dehiscence., Discussion: Laparoscopic LEER can be safely performed by experienced laparoscopic surgeons, in carefully selected patients with gynecological malignancies involving the lateral pelvic side wall, even for those in which a bladder and rectum sparing surgery appears possible. Further larger prospective trials are needed to evaluate the oncological and the long-term functional outcomes., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The impact of immunosuppression on postoperative outcomes has primarily been studied in patients undergoing joint replacement surgery. We aimed to evaluate the impact of biologics and glucocorticoids on outcomes after other major surgeries., Methods: This retrospective cohort study used Medicare data 2006-2015 to identified adults with rheumatoid arthritis undergoing hip fracture repair, abdominopelvic surgery (cholecystectomy, hysterectomy, hernia, appendectomy, colectomy) or cardiac surgery (coronary artery bypass graft, mitral/aortic valve). Logistic regression with propensity-score-based inverse probability weighting compared 90-day mortality and 30-day readmission in patients receiving methotrexate (without a biologic or targeted synthetic disease-modifying antirheumatic drug (tsDMARD)), a tumour necrosis factor inhibitor (TNFi) or a non-TNFi biologic/tsDMARD <8 weeks before surgery. Similar analyses evaluated associations between glucocorticoids and outcomes., Results: We identified 10 777 eligible surgeries: 3585 hip fracture, 5025 abdominopelvic and 2167 cardiac surgeries. Compared with patients receiving methotrexate, there was no increase in the risk of 90-day mortality or 30-day readmission among patients receiving a TNFi (mortality adjusted OR (aOR) 0.83 (0.67 to 1.02), readmission aOR 0.86 (0.75 to 0.993)) or non-TNFi biologic/tsDMARD (mortality aOR 0.78 (0.49 to 1.22), readmission aOR 1.02 (0.78 to 1.33)). Analyses stratified by surgery category were similar. Risk of mortality and readmission was higher with 5-10 mg/day of glucocorticoids (mortality aOR 1.41 (1.08 to 1.82), readmission aOR 1.26 (1.05 to 1.52)) or >10 mg/day (mortality aOR 1.64 (1.02 to 2.64), readmission aOR 1.60 (1.15 to 2.24)) versus no glucocorticoids, although results varied when stratifying by surgery category., Conclusions: Recent biologic or tsDMARD use was not associated with a greater risk of mortality or readmission after hip fracture, abdominopelvic or cardiac surgery compared with methotrexate. Higher dose glucocorticoids were associated with greater risk., Competing Interests: Competing interests: MG has received a research grant from Bristol-Myers Squibb and the National Institutes of Health and consulting fees from AbbVie. JFB has received consulting fees from Bristol-Myers Squibb and Gilead. KLW has received research grants from Pfizer and Bristol-Myers Squibb, and consulting fees from Pfizer, AbbVie, UCB, Lilly, Galapagos, GSK, Roche, and Gilead. EA is an employee of Bristol-Myers Squibb. JRC has received research grants from the Patient Centered Outcomes Research Institute and research grants and consulting fees from Bristol-Myers Squibb, Amgen, AbbVie, Corrona, Janssen, Lilly, Myriad, Pfizer, UCB and Regeneron., (© Author(s) (or their employer(s)) 2020. No commercial re-use. See rights and permissions. Published by BMJ.)

Competing Interests: Competing interests: None declared.

Competing Interests: Competing interests: None declared.

Aim: The primary objective of this review was to study and analyze techniques of nerve-sparing radical hysterectomy so as to be able to characterize and elucidate intricate steps for the dissection of each component of the pelvic autonomic nerve plexuses during nerve-sparing radical hysterectomy., Methods: This review was based on a five-step study design that included searching for relevant publications, selecting publications by applying inclusion and exclusion criteria, quality assessment of the identified studies, data extraction, and data synthesis., Results: There are numerous differences in the published literature concerning nerve-sparing radical hysterectomy including variations in techniques and surgical approaches. Techniques that claim to be nerve-sparing by staying above the dissection level of the hypogastric nerves do not highlight the pelvic splanchnic nerve, do not take into account the intra-operative patient position, nor the fact that the bladder branches leave the inferior hypogastric plexus in a ventrocranial direction, and the fact that inferior hypogastric plexus will be drawn cranially with the vaginal walls (if this is not recognized and isolated earlier) above the level of hypogastric nerves by drawing the uterus cranially during the operation., Conclusions: The optimal nerve-sparing radical hysterectomy technique has to be radical (type C1) and must describe surgical steps to highlight all three components of the pelvic autonomic nervous system (hypogastric nerves, pelvic splanchnic nerves, and the bladder branches of the inferior hypogastric plexus). Recognizing the pelvic splanchnic nerves in the caudal parametrium and the isolation of the bladder branches of the inferior hypogastic plexus requires meticulous preparation of the caudal part of the ventral parametrium., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: To determine the incidence of long term lymphadenectomy complications in primary surgery for endometrial cancer and to elucidate risk factors for these complications., Methods: A retrospective chart review was carried out for all patients with endometrial cancer managed at Parma University Hospital Unit of Gynecology and Obstetrics between 2010 and 2016. Inclusion criteria were surgical procedure including hysterectomy and lymphadenectomy (pelvic or pelvic and aortic). We identified patients with postoperative lymphocele and lower extremity lymphedema. Logistic regression analysis was used to identify predictive factors for postoperative complications., Results: Of the 249 patients tested, 198 underwent pelvic lymphadenectomy (79.5%), and 51 (20.5%) of those underwent both pelvic and para-aortic lymphadenectomy. Among the 249 patients, 92 (36.9 %) developed lymphedema while 43 (17.3%) developed lymphocele. Multivariate analysis showed that addition of para-artic lymphadenectomy was an independent predictor for both lymphedema (odds ratio (OR) 2.764, 95% confidence interval (CI) 1.023 to 7.470) and lymphocele (OR 5.066, 95% CI 1.605 to 15.989). Moreover, postoperative adjuvant radiotherapy (OR 2.733, 95% CI 1.149 to 6.505) and identification of any positive lymph node (OR 19.391, 95% CI 1.486 to 253.0) were significantly correlated with lymphedema, while removal of circumflex iliac nodes (OR 8.596, 95% CI 1.144 to 65.591) was associated with lymphoceles occurrence., Conclusion: Although sentinel lymph node navigation is a promising option, lymphadenectomy represents the primary treatment in many patients with endometrial cancer. However, comprehensive nodal dissection remains associated with a high rate of long term complications, such as lymphedema and lymphocele. Avoiding risk factors that are related to the development of these postoperative complications is often difficult and, therefore, the strategy to assess lymph nodal status in these women must be tailored to obtain the maximum results in terms of oncological and functional outcome., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Mini-invasive surgery has essentially replaced open laparotomy in surgery for endometrial and cervical carcinoma. Of the procedures needed for a complete staging, especially para-aortic lymphadenectomy (PALND) is challenging to perform. The present study was undertaken to investigate the technical and surgical outcomes of robotic-assisted PALND for gynecological cancers in the setting of a tertiary university hospital in Finland., Methods: This was a retrospective chart review of 283 robotic-assisted para-aortic lymphadenectomies using the single-docking transperitoneal technique performed at the Department of Obstetrics and Gynecology of Tampere University Hospital, in 2009-2016. The primary outcome measure was the extent of the operation in terms of the height, that is, how often the level cranial to the inferior mesenteric artery (IMA) was achieved. The secondary outcome measures included operation time and surgical outcome., Results: The majority of operations (n = 239 [84.4%]) were performed for endometrial carcinoma. The most common operation type was robotic-assisted hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy and PALND, which took a median of 3:38 hours or 218 minutes (range, 140-341 minutes) to perform. The high PALND (above the level of IMA) succeeded in 235 operations (83%). In the total cohort, the median number of para-aortic lymph nodes removed was 12 (range, 0-38), with a learning curve approximately more than 40 operations. Para-aortic lymph node metastases were found in 43 patients (15.2%). Seven conversions to laparotomy (2.5%) were done. The conversion and intraoperative complication rates were 2.5% and 3.5%, respectively, and postoperative complications was 18%, according to the classification of Clavien-Dindo. The median length of the postoperative hospital stay was 2 days (range, 1-8 days)., Conclusions: Using the transperitoneal technique for PALND, the area between IMA and the renal veins can be reached in more than 80% of the operations, with a very low or 2.5% conversion rate.

Objective: Radical hysterectomy with pelvic lymphadenectomy (RHL) is the preferred treatment for early-stage cervical cancer. Although oncological outcome is good with regard to recurrence and survival rates, it is well known that RHL might result in postoperative bladder impairments due to autonomic nerve disruption. The pelvic autonomic network has been extensively studied, but the anatomy of nerve fibers branching off the inferior hypogastric plexus to innervate the bladder is less known. Besides, the pathogenesis of bladder dysfunction after RHL is multifactorial but remains unclear. We studied the 3-dimensional anatomy and neuroanatomical composition of the vesical plexus and describe implications for RHL., Materials and Methods: Six female adult cadaveric pelvises were macroscopically dissected. Additionally, a series of 10 female fetal pelvises (embryonic age, 10-22 weeks) was studied. Paraffin-embedded blocks were transversely sliced in 8-μm sections. (Immuno) histological analysis was performed with hematoxylin and eosin, azan, and antibodies against S-100 (Schwann cells), tyrosine hydroxylase (postganglionic sympathetic fibers), and vasoactive intestinal peptide (postganglionic parasympathetic fibers). The results were 3-dimensionally visualized., Results: The vesical plexus formed a group of nerve fibers branching off the ventral part of the inferior hypogastric plexus to innervate the bladder. In all adult and fetal specimens, the vesical plexus was closely related to the distal ureter and located in both the superficial and deep layers of the vesicouterine ligament. Efferent nerve fibers belonging to the vesical plexus predominantly expressed tyrosine hydroxylase and little vasoactive intestinal peptide., Conclusions: The vesical plexus is located in both layers of the vesicouterine ligament and has a very close relationship with the distal ureter. Complete mobilization of the ureter in RHL might cause bladder dysfunction due to sympathetic and parasympathetic denervation. Hence, the distal ureter should be regarded as a risk zone in which the vesical plexus can be damaged.

Objective: The primary aim is to evaluate the surgical and oncological outcome of robotic radical hysterectomy (RRH) plus pelvic lymphadenectomy in locally advanced cervical cancer (LACC) after neoadjuvant chemotherapy (NACT). The secondary aim is to compare the surgical and oncological results of RRH after NACT with a historical cohort of patients undergoing laparoscopic radical hysterectomy or abdominal radical hysterectomy plus pelvic lymphadenectomy for LACC after NACT., Methods: We enrolled a total of 41 patients in this study with LACC undergoing RRH, who achieved a clinical partial or complete response to NACT. The surgical and oncological outcomes of 2 historical groups were compared: the laparoscopic group (41 patients) with the laparotomic group (43 patients)., Results: The median estimated blood loss, operative time, and length of hospital stay were statistically significant and in favor of the robotic group. No conversion to laparotomy in the robotic group was necessary. There were no significant differences between the 3-year overall survival and disease-free survival rates in the minimally invasive groups; nevertheless, the robotic group showed the same recurrence rate of laparoscopic in a short-interval follow-up., Conclusions: The robotic approach could be considered a feasible and safe alternative to other surgical options. Multicenter randomized clinical trials with longer follow-ups are necessary to evaluate the overall oncologic outcomes of this procedure.

Objective: The aim of this study was to evaluate the incremental prognostic value of pelvic magnetic resonance imaging (MRI) and whole-body F-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT) findings compared with clinical-histopathologic factors in patients with newly diagnosed cervical cancer., Methods: The institutional review board approved this retrospective study of 114 patients (median age, 40.6 years) with International Federation of Gynecology and Obstetrics (FIGO) stage I-IVB cervical cancer who underwent pretreatment MRI and PET/CT. All scans were reviewed for locoregional tumor extent, pelvic or/and para-aortic lymphadenopathy, and distant metastases. Univariate Cox proportional hazard regression was performed to evaluate associations between clinical-histopathologic factors, imaging findings, and progression-free survival (PFS). Multivariate models were built using independent predictors for PFS. Harrell C was used to measure concordance (C index)., Results: Forty patients progressed within a median time of 10.4 months (range, 0.4-40.3 months). At univariate analysis, age, FIGO stage, tumor histology, tumor grade, and all MRI and PET/CT features were significantly associated with PFS (P < 0.0001 to P = 0.0474). A multivariate model including clinical and imaging parameters (parametrial invasion on MRI and para-aortic lymphadenopathy/distant metastases on PET/CT) had significantly higher concordance for predicting PFS than a model including clinical parameters only (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.68 [95% confidence interval, 0.59-0.78]; P < 0.001). The comparison of C indices for the combined clinical and imaging model approached significance when compared with a FIGO stage model (C index: 0.81 [95% confidence interval, 0.75-0.87] vs 0.75 [95% confidence interval, 0.69-0.82]; P = 0.058)., Conclusions: In patients with newly diagnosed cervical cancer, a prognostic model including combined MRI and PET/CT findings provides information that complements clinical and histopathologic factors., Competing Interests: None

This study describes a new technique for reconstructing the vagina and vestibule after radical extirpative surgery for urological and anorectal malignancy. The uterus is always excised when exenterative surgery is performed for gynecological cancer. The use of the uterus as a graft gives the gynecologic oncologist/reconstructive surgeon a role in the multidisciplinary team with urologists when the anterior vaginal wall and vestibule are excised and with the anorectal surgeons when the posterior vaginal wall and perineum are excised for nongynecological cancers. In some such cases, only the anterior or posterior wall of the vagina may be excised, leaving a healthy full-length, one-third, or half-circumference vaginal sleeve. A myoserosal flap is raised from the in situ uterus. The ectocervix is excised, and the adnexa are detached or excised. The uterus is opened to generate a hexagonal flap. The endometrium and endocervix are excised/ablated with electrocautery. The flap is advanced to the edge of the remaining anterior vestibule or reconstituted perineum. The serosal surface of the uterus forms the new wall of the vagina and undergoes metaplastic transformation to squamous epithelium within 3 months. The very satisfactory anatomical and functional outcome means that this technique merits further evaluation.

Objective: The objective of this study was to demonstrate that robotically assisted laparoscopy for aortic lymph node dissection was improved when double docking (DD) of the Da Vinci system is used for combined surgical procedures [defined by the combination of a pelvic procedure and a para-aortic lymphadenectomy (PAL)]., Methods: From February 2007 to February 2013, 41 patients underwent combined procedures including PAL up to the left renal vein in 2 cancer centers. We used 2 different approaches as follows: a single docking (SD) of the Da Vinci system (transperitoneal PAL and pelvic surgery) during the first period (22 patients) and a DD during the second period (19 patients). We recorded retrospectively the lymph node count (main criteria), operative time, estimated blood loss, hospital stay, and postoperative complications., Results: We observed a statistical difference between SD and DD concerning aortic lymph node count (5.86 vs 10.89, P < 0.005). Operative time is longer in the DD group (326.1 vs 239.4 minutes, P < 0.05). No difference was observed concerning estimated blood loss. Hospital stay was longer in the DD group (4.9 vs 3.2 days, P < 0.05). Only 1 conversion to open was described in the SD group., Conclusions: In our experience of robotically assisted laparoscopy, when PAL is combined to a pelvic procedure, the use of a DD seems to improve aortic lymph node count.Despite a longer operative time compared to SD, DD seems to be a good solution to combine the advantages of robotic assistance to our quality criteria of aortic dissection., Synopsis: We compare 2 techniques to realize robotic assisted para-aortic lymphadenectomy combined with pelvic procedure. Double docking seems to improve histological results compared to single docking.

Objective: The aim of this study was to report the incidence, severity, and factors associated with femoral nerve injury during gynecologic cancer surgery., Methods: All patients who underwent abdominal surgery for gynecologic cancer entered the study. A retrospective review of the medical records was carried out for patients operated on from 2003 to April 2011. After this analysis, the use of the Bookwalter retractor was modified and the data were prospectively recorded., Results: In the first period, femoral nerve injury was observed in 11 (2.7%) of 406 patients, occurring with a significantly higher frequency when the Bookwalter retractor was used (5.1% vs 0%, P < 0.01) and when pelvic lymphadenectomy was performed (5.1% vs 0.9%, P < 0.01). The analysis of the 212 patients (52.2%) in the Bookwalter group showed higher frequency of nerve injury in the patients undergoing pelvic lymphadenectomy (7.8% vs 2.0%, P = 0.05). In the second period, femoral nerve injury was observed in 1 (0.7%) of 132 patients operated on and in 1 (2.3%) of 43 patients (32.6%) in the Bookwalter group. When comparing the 2 periods, the lesser use of the Bookwalter retractor and the reduced time of maximal traction of the pelvic blades decreased the nerve injury rate from 2.7% to 0.7% and, in the Bookwalter group, from 5.1% to 2.3%. These results, although not statistically significant, are clinically relevant., Conclusions: Femoral nerve injury during gynecologic cancer surgery was associated with the Bookwalter retractor. The pelvic blades of the retractor may exert a compression on the nerve. The weakened muscles suggest that the nerve compression occurred intrapelvically over the iliacus muscle. Shortening the time of maximal traction of the pelvic blades reduced the incidence of femoral nerve injury. When performing gynecologic surgery with the use of the Bookwalter retractor, care must taken with the placement of the pelvic blades.

Objectives: The aims of this study were to predict pelvic lymph node metastasis in uterine cervical cancer before surgery and to evaluate the potential efficacy of omitting pelvic lymphadenectomy., Materials and Methods: A total of 163 patients with invasive uterine cervical cancer in FIGO stage IA2 to IIB, all of whom underwent primary radical hysterectomy with pelvic lymphadenectomy, participated in this study., Results: The incidences of pelvic lymph node metastasis in stage IA2, stage IB1, stage IB2, stage IIA, and stage IIB cervical cancer were 0% (0/12), 17% (13/76), 22% (6/27), 33% (8/24), and 63% (15/24), respectively. A significant difference was observed in overall survival with nodal metastasis status (P < 0.0001). Univariate analysis revealed that parametrial invasion (P < 0.0001), tumor markers (P = 0.0006), tumor size greater than 2 cm (P < 0.0001), tumor size less than 3 cm (P = 0.0009), and tumor size greater than 4 cm (P = 0.0024) were correlated with pelvic lymph node metastasis. However, multivariate analysis revealed that parametrial invasion (P = 0.01; odds ratio, 3.37; 95% confidence interval, 1.31-9.0) and tumor size greater than 2 cm (P = 0.005; odds ratio, 4.93; 95% confidence interval, 1.54-22.01) were independently associated with nodal metastasis., Conclusions: Pelvic lymphadenectomy may be avoided in patients with negative parametrial invasion and a tumor size less than 2 cm, thereby minimizing postoperative complications.

Objective: In this study, we aimed to describe the value of pelvic lymph node dissection (LND) after sentinel lymph node (SN) biopsy in early-stage cervical cancer., Methods: We performed a retrospective multicenter cohort study in 8 gynecological oncology departments. In total, 645 women with International Federation of Gynecology and Obstetrics stage IA to IIB cervical cancer of squamous, adeno, or adenosquamous histologic type who underwent SN biopsy followed by pelvic LND were enrolled in this study. Radioisotope tracers and blue dye were used to localize the sentinel node, and pathologic ultrastaging was performed., Results: Among the patients with low-volume disease (micrometastases and isolated tumor cells) in the sentinel node, the overall survival was significantly better (P = 0.046) if more than 16 non-SNs were removed. No such significant difference in survival was detected in patients with negative or macrometastatic sentinel nodes., Conclusions: Our findings indicate that in patients with negative or macrometastatic disease in the sentinel nodes, an additional LND did not alter survival. Conversely, our data suggest that the survival of patients with low-volume disease is improved when more than 16 additional lymph nodes are removed. If in a prospective trial our data are confirmed, we would suggest a 2-stage operation.

Objective: Individualized treatment of pregnant patients with cervical cancer is mandatory; hence, information on nodal status is pivotal to allow a waiting strategy in early-stage disease.We aimed to verify the oncological safety and surgical reproducibility of a standardized laparoscopic pelvic lymphadenectomy in pregnant patients with cervical cancer., Methods: We standardized laparoscopic pelvic lymphadenectomy during the first and second term of gestation in 32 patients with cervical cancer since 1999. According to gestational week (GW) of less than 16 GWs or more than 16 GWs, 2 different techniques were used., Results: The International Federation of Gynecology and Obstetrics stages were IA in 10 patients, IB1 in 17 patients, IB2 in 4 patients, and IIA in 1 patient. Mean (SD) GW was 17.5 (5.1) weeks. Mean (SD) operative time was 105.4 (29) minutes. Mean (SD) blood loss was 5.3 (10.2) mL. There were no conversion to laparotomy and no intraoperative complications. A median number of 14 pelvic lymph nodes (range, 8-57) were harvested. Median hospital stay was 6 days. Median follow-up is 42.5 months (range, 17-164). Four patients had lymph node metastases. Five patients interrupted their pregnancy. Fourteen patients were given neoadjuvant platin-based systemic therapy. All patients are alive and disease free. All children born through cesarean delivery at a mean (SD) 34 (1.9) GWs are well and show normal clinical neurological development., Conclusions: To the best of our knowledge, this is the largest series so far reported on laparoscopic pelvic lymphadenectomy during pregnancy. This procedure is safe and associated with good oncological and obstetrical outcomes.

Objective: To evaluate our short-term clinical outcomes of robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy., Methods: Between March 2011 and June 2012, we observed prospectively 28 consecutive patients who underwent robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy, including the superior and inferior gluteal, presacral (subaortic), common iliac, and lower para-aortic nodes., Results: The predominant International Federation of Gynecology and Obstetrics stage was IB1 (15 patients), followed by IB2 (5 patients), IA2 (3 patients), IIA1 (3 patients), and IIA2 (2 patients). The mean ± SD total operating time was 308.8 ± 54.9 minutes, and the mean ± SD console time was 280.0 ± 46.0 minutes. The mean ± SD blood loss was 102.7 ± 153.8 mL. The mean ± SD acquired pelvic lymph node was 27.1 ± 9.3, the mean ± SD extended lymph node was 19.2 ± 9.6, and the mean ± SD total lymph node was 46.3 ± 14.5. A total of 10 patients (35.7%) had nodal metastasis; among them, 6 patients (21.4%) had single pelvic nodal metastasis, 3 patients (10.7%) had concurrent pelvic and extended nodal metastasis, and one patient (3.6%) had single extended nodal metastasis. No intraoperative complications that required treatment occurred; however, ureterovaginal fistula was identified in 4 patients (14.3%) and ureter stricture in 4 patients (14.3%) after radiotherapy. After a median follow-up of 10 months (range, 1-16 months), there was no pelvic recurrence; however, one patient had recurrence at transposition site of ovary., Conclusions: With the advantage of delicate movement of robot instrument, robot-assisted systematic extended lymphadenectomy with total preservation of pelvic autonomic nerves did not compromise the radicality, and its surgical technique was feasible and safe. By using this approach, we could harvest more lymph nodes and have a high rate of metastatic nodes without disturbing voiding function; however, there was increased rate of urological complications. Moreover, long-term survival benefit after an extended systematic lymphadenectomy must be evaluated.

Objective: The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases., Methods: Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH., Results: Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases., Conclusions: During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.

Objective: Lymphoceles are among the most common postoperative complications of pelvic lymphadenectomy (PL), with a reported incidence of 1% to 50%. Symptoms are pelvic pain, leg edema, gastrointestinal obstruction, obstructive uropathy, and deep vein thrombosis, and severe complications such as sepsis and lymphatic fistula formation. After laparoscopic PL, we tested the prevention of lymphoceles using collagen patch coated with the human coagulation factors (TachoSil, Nycomed International Management GmbH, Zurich, Switzerland) on 55 patients with endometrial cancer stages IB to II who had undergone laparoscopy., Materials and Methods: The authors divided the patients into 2 laparoscopy groups: PL plus TachoSil (group 1: 26 patients) and PL without TachoSil in a control group (group 2: 29 patients), as historical cohort of patients who underwent PL between 2010 and 2012. We collected surgical parameters, and the patients underwent ultrasound examination on postoperative days 7, 14, and 28. The main outcome measures were the development of symptomatic or asymptomatic lymphoceles, the need for further surgical intervention, as adverse effect of surgery, and the drainage volume and duration., Results: The same number of lymph nodes in both groups was removed; group 1 showed a lower drainage volume. Lymphoceles developed in 5 patients in group 1 and in 15 patients in group 2; of these, only 2 patients were symptomatic in group 1 and 5 patients were symptomatic in group 2, without statistical difference and no percutaneous drainage request., Conclusions: In this preliminary investigation, the intraoperative laparoscopy application of TachoSil seems to reduce the rate of postoperative lymphoceles after PL, providing a useful additional treatment option for reducing drainage volume and preventing lymphocele development after PL.

Objective: This study aimed to determine the number of lymph nodes (LNs) removed in patients who underwent abdominal complete systematic pelvic and para-aortic lymphadenectomy and to identify factors that contribute to disparity in the number of LNs removed., Methods: We retrospectively reviewed 260 patients with endometrial cancer and ovarian cancer between 1997 and 2011. All pelvic and para-aortic LNs were submitted as 25 separate packets. The correlations of the number of LNs with age, year of surgery, the operating surgeon, pathologist, body mass index (BMI), histology, clinical stage, operating time, blood loss, and lymph node metastasis were investigated., Results: The median number of LNs removed was 45 pelvic (17-92) and 25 para-aortic (6-69) LNs. Among pelvic LNs, the common iliac nodes were the most frequently removed followed by the obturator nodes. The median number of the left upper para-aortic LNs between the left renal vein and the inferior mesenteric artery was highest among para-aortic LNs. There were significant correlations between the total number of LNs removed and age (P = 0.036), histology (clear vs serous; P = 0.015), and BMI (P < 0.0001) in ovarian cancer. Features associated with higher LN count on multivariate linear regression analysis included younger patients (P = 0.038) and higher BMI (P = 0.012)., Conclusions: Age and BMI are independently associated with higher LN counts during LN dissection in ovarian cancer. The present study results may be important when using LN counts as a surrogate for adequate lymphadenectomy.

Objective: To investigate the feasibility and surgical outcomes of laparoscopic nerve-sparing radical parametrectomy (LNSRP) and lymphadenectomy for treatment of occult early-stage invasive cervical cancer after simple hysterectomy., Methods: From 2006 to 2010, 28 patients who were discovered to have occult early-stage invasive cervical cancer after a simple hysterectomy underwent LNSRP, upper vaginal resection, and pelvic lymphadenectomy. A retrospective analysis of these cases was performed., Results: All patients underwent successful LNSRP. There was no conversion to laparotomy. The mean ± SD operation time was 173.30 ± 56.20 minutes. The mean ± SD estimated blood loss was 230.00 ± 109.55 mL. Two intraoperative complications were recorded. The median number of extracted pelvic and para-aortic lymph nodes was 23 (range, 12-36) and 7 (range, 3-15), respectively. The mean ± SD time before Foley catheter removal was 5.6 ± 2.74 days (range, 3-14 days ), and bladder voiding function recovery to grade 0 to grade 1 was observed in 26 patients (92.9%). Of the 28 patients, 3 patients received further adjuvant therapy. The median follow-up period was 38 (range, 4-62) months for all patients. No recurrence case was found in this series., Conclusion: Laparoscopic nerve-sparing radical parametrectomy is a therapeutic option for occult early-stage invasive cervical cancer discovered after hysterectomy. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function.

Objective: Pathologic evaluation of aortocaval nodes in patients with locally advanced cervical cancer in an effort to better tailor radiotherapy has gained popularity. We sought to determine which aortocaval nodes should be sampled during surgical staging procedures., Methods: From 2004 to 2011, 246 patients with locally advanced cervical cancer underwent positron emission tomography (PET) before definitive chemoradiation. We reviewed the imaging studies to determine the location of PET-positive aortocaval nodes in relationship to the inferior mesenteric artery (IMA)., Results: Forty-two patients (17%) had PET images suggesting aortocaval metastasis. Ten patients had stage IB, 1 had stage IIA, 13 had stage IIB, 13 had stage IIIB, and 5 had stage IV disease. Of these 42 patients, 39 (93%) had FDG-avid pelvic nodes, 1 (2%) had PET-negative pelvic nodes but FDG-avid common iliac nodes, and 2 (5%) had direct spread to the aortocaval nodes. Three patients (7%) had FDG-avid aortocaval nodes above the IMA without FDG-avid nodes between the aortic bifurcation and IMA. All 3 of these patients also had FDG-avid nodes in the pelvis. Nineteen patients (45%) had FDG-avid nodes above and below the IMA, and 20 (48%) had FDG-avid nodes below the IMA only., Conclusions: This hypothesis-generating study revealed that a small number of patients have PET-positive aortocaval nodes above the IMA only. For patients undergoing surgical staging for locally advanced cervical cancer, dissection to the renal vessels may be necessary. A future international, randomized study will prospectively evaluate the locations of pathologically positive aortocaval lymph nodes.

Objective: The aim of the present study was to evaluate the incidence of lymphedema and cancer recurrence rate in patients with cervical cancer who undergo sentinel lymph node (SLN) biopsy alone in the absence of SLN metastases., Patients and Methods: The study included 35 consecutive patients with cervical cancer scheduled for radical hysterectomy at Tohoku University Hospital between May 2006 and July 2009. All patients had International Federation of Gynecology and Obstetrics stages IA1 to IIA1 disease. Patients in whom SLNs were detected unilaterally or not detected and/or whose lymph nodes were diagnosed intraoperatively as positive metastasis underwent systemic pelvic lymphadenectomy. Patients who were found negative for SLN metastasis did not undergo further pelvic lymphadenectomy., Results: The mean number of detected SLNs was 4.1 (range, 1-11). True lymph node metastasis could be detected in 11 (31%) of the 35 cases. Intraoperative frozen section identified correctly in 8 of 11 metastatic patients. Twenty-three patients underwent SLN biopsy alone without systematic pelvic lymphadenectomy. None of the 23 patients diagnosed with negative SLNs have experienced a lymph node recurrence in the pelvic cavity. New symptomatic lower extremity lymphedema was identified in 2 (8.7%) of the 23 patients who underwent SLN biopsy alone and in 5 (42%) of 12 patients who underwent systematic lymphadenectomy., Conclusion: Radical hysterectomy with SLN biopsy alone seems to be a safe and effective strategy for detection of lymph node metastasis and for reducing the number of patients with lower extremity lymphedema, but a more convenient and sensitive procedure for intraoperative diagnosis needs to be established.

Background: The use of radical vaginal hysterectomy in the treatment of cervical cancer is associated with lower morbidity and a similar cure rate when compared with the abdominal approach. The present study reports a case series of radical vaginal hysterectomy followed by extraperitoneal (Mitra) or video-laparoscopic (VLP) lymphadenectomy, with comparison of the 2 techniques., Methods: Twenty-five patients with cervical carcinoma (stages IA1 to IIA) were submitted to radical vaginal hysterectomy and extraperitoneal or laparoscopic lymphadenectomy., Results: The Mitra technique was used in 17 cases, and VLP was used in 8. Seventeen patients presented minor postoperative complications. The number of resected lymph nodes was similar with both techniques (median of 14 with VLP vs. 21 with Mitra) (P = 0.215). The duration of surgery in the VLP group (mean, 339 minutes) was shorter than that of the Mitra group (mean, 421 minutes) (P = 0.015)., Conclusions: The results obtained with both techniques are similar to those reported in the literature. The duration of extraperitoneal lymphadenectomy was longer than that of VLP lymphadenectomy. There were no differences between the 2 techniques concerning the number of resected lymph nodes and hospital stay.

Objective: To evaluate the therapeutic role of pelvic and aortic lymphadenectomy in patients with epithelial ovarian cancer (EOC) and positive nodes (stages IIIC and IV)., Methods: Retrospective chart review. Data from all consecutive patients with EOC and positive retroperitoneal lymph nodes (stage IIIC and IV) in Mayo Clinic from 1996 to 2000 were included. To evaluate the impact of nodal metastases, the extent of lymphadenectomy was compared according to the number of nodes removed and positive nodes resected. Multivariable Cox regression and Kaplan-Meier survival curves were used for analysis., Results: The median number of nodes removed was 31 (pelvic, 21.5, and aortic, 10), and the median number of positive nodes was 5. The 5-year overall survival was 44.8%. On multivariate analysis, only the extent of peritoneal metastases before surgery was a significant factor for survival (P = 0.001 for stage IIIC and P = 0.004 for stage IV). Analysis of 83 patients with advanced peritoneal disease more than 2 cm demonstrated before debulking, removal of more than 40 lymph nodes was a significant prognostic factor for overall survival (hazard ratio, 0.52; P = 0.032; 95% confidence interval, 0.29-0.35). In 29 patients with advanced peritoneal disease and no residual disease after debulking, removal of more than 10 positive was a factor for survival., Conclusions: There was a survival benefit in patients with EOC with advanced peritoneal disease more than 2 cm before debulking when more than 40 lymph nodes were removed. There was an additional survival benefit in those patients with no residual disease after debulking when more than 10 positive nodes were removed.

Objectives: Extensive perineal resections often require autologous tissue reconstruction, especially in wide oncological resections. Local and regional pedicled flaps from the lower extremity and abdominal sites have been described. Defects of the pelvis and perineum rarely require free-tissue transfer. The vertical rectus abdominis myocutaneous (VRAM) flap, traditionally delivered to the perineum through an intraperitoneal transpelvic route, is a workhorse flap for combined pelvic and perineal defects because of its ability to provide substantial coverage of the perineum, reliable vascular supply, and larger volume to obliterate dead space. We propose and describe an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion., Methods: A 54-year-old woman with a prior history of anal squamous cell carcinoma underwent neoadjuvant chemoradiotherapy followed by abdominoperineal resection, total abdominal hysterectomy, and bilateral salpingo-oophorectomy. Three years later, she developed vulvar squamous cell carcinoma with vascular and lymphatic invasion and underwent radical vulvectomy and distal urethrectomy. The resection defect was 10 × 15 cm, including the distal 1 cm of the urethra, distal vaginal orifice, and wide exposure of the pubic bone. An extrapelvic extended VRAM flap was used for reconstruction., Results: The flap was harvested and transposed into the defect via a wide suprapubic subcutaneous tunnel. A neovaginal and urethral orifice was created in the flap by splitting the muscle in the direction of its fibers, taking care to protect the vascular pedicle, and inset to the vaginal orifice. There were no postoperative complications. She has maintained urinary continence with follow-up of 38 months., Conclusions: Introduction of a rectus abdominis flap to the perineum through an extrapelvic route is preferred if laparotomy is not used for the resection. We successfully report and advocate the use of an extended VRAM flap for vulvar reconstruction delivered to the perineum in an extrapelvic fashion.

Objective: The purpose of this study was to compare surgical outcomes of robotic radical hysterectomy (RRH) using 3 robotic arms with those of abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer., Methods: Thirty-two patients with stage IA2-IIB cervical carcinoma according to the International Federation of Gynecology and Obstetrics underwent RRH between June 2006 and February 2009. Patient outcomes were compared with those of a historic cohort of 32 patients who underwent ARH, who were matched for age, stage according to the International Federation of Gynecology and Obstetrics, and type of radical surgery., Results: All RRHs were completed robotically with no conversions to laparotomy. Robotic radical hysterectomy showed favorable outcomes over ARH in terms of the mean length of hospital stay (11.6 vs 16.9 days, P < 0.001) and the mean estimated blood loss (220 vs 531 mL, P = 0.002). The mean operating time and the number of lymph node retrievals were comparable. There were no significant differences in the incidence of postoperative complications between the 2 groups. The mean follow-up time was 15.3 months, and 2 patients in the RRH group had recurrences., Conclusions: Robotic radical hysterectomy and pelvic lymphadenectomy using 3 robotic arms is feasible and preferable over ARH for the treatment of cervical cancer patients. Prospective randomized trials should be completed to confirm the potential benefits associated with RRH.

Background and Objectives: Innovations in minimally invasive surgery have allowed surgeons to perform increasingly complex surgeries through smaller incisions. We describe the feasibility and the technique of single-port laparoscopic pelvic and para-aortic lymph node sampling or lymphadenectomy in gynecologic malignancies., Methods: The study was approved by the institutional review board at the Cleveland Clinic (Cleveland, Ohio). Inclusion criterion was patients with apparent early-stage gynecologic malignancies who required pelvic and/or para-aortic lymph node sampling or lymphadenectomy and were candidates for single-port laparoscopy. Procedures were performed through a single 2.0- to 3.0-cm umbilical incision using a single-port device, deflecting-tip laparoscope, and multifunctional instrumentation., Results: Twenty-one patients underwent single-port surgery/staging performed during the study period. The median patient age was 58 years (range, 17-80 years), and the median patient body mass index was 30 mg/kg² (range, 19-46 mg/kg²). Median overall operating time was 120 minutes (range, 60-185 minutes). Median pelvic and para-aortic node counts were 14 (range, 7-19) and 6 (range, 2-14), respectively., Conclusions: In this preliminary report, the technique was feasible, and no morbidity was noted. Further studies are needed to better define the ideal gynecologic oncology procedures for single-site surgery and to assess the relative benefits of this new technique compared with more conventional minimally invasive approaches.

Radical hysterectomy with pelvic lymphadenectomy is considered to be the cornerstone in the treatment of early-stage cervical cancer. Although survival in early-stage cervical cancer is up to 95%, long-term morbidity with regard to bladder, bowel, and sexual function is considerable. Damage to the pelvic autonomic nerves may be the cause of these long-term complications following radical hysterectomy. Some authors have presented surgical techniques to preserve the autonomic nerves (ie, the hypogastric nerves and the splanchnic nerves) without compromising radicality. Safety, efficacy, and the surgical techniques of nerve-sparing radical hysterectomy are presented, and data confirm that whenever the decision is made to perform a radical hysterectomy, nerve-sparing techniques should be considered.

Objectives: To determine the clinical effect of nonperitonization and laparoscopic lymphadenectomy using bipolar electrocautery after radical hysterectomy for cervical cancer compared with peritonization and open lymphadenectomy using monopolar electrocautery., Materials and Methods: This was a retrospective study of 180 patients who underwent a radical hysterectomy and pelvic lymph node dissection (PLND) for cervical cancer from August 1998 to August 2007. The patients were composed of the Peritonization + Laparotomy group (group A; n = 98, 196 PLND) and the Nonperitonization + Laparoscopy group (group B; n = 82, 164 PLND). Group B left the peritoneum in front of the PLND open. Two closed-suction drains were placed at each side of the PLND., Results: Group B statistically showed a lesser total amount of lymphatic drainage (P = 0.001), shorter duration of inserted drains (P < 0.001), and shorter length of hospital stay (P < 0.001), compared with group A. The formation of lymphocysts occurred in 30 patients (41 lymphocysts) of group A and 5 patients (5 lymphocysts) of group B. Lymphocyst formation of group B had a statistically lower incidence than that of group A (P < 0.001). Lymphocyst formation was associated with an increase in the total amount of lymphatic drainage in group A (P = 0.090) and group B (P = 0.041) and a pathologic type of adenocarcinoma in group B (P = 0.016). Surgical experiences were not correlated with lymphocyst formation., Conclusions: The omission of peritonization and laparoscopic lymphadenectomy using bipolar electrocautery in early-stage cervical cancer were more effective than peritonization and open lymphadenectomy using monopolar electrocautery in minimizing the incidence of lymphocyst formation.

Background: Radical hysterectomy is a common and effective treatment of early cervical cancer. Modern advances include the use of robotic assistance to perform equivalent minimally invasive procedures. The purpose was to compare surgical and short-term outcomes, as well as margins, between robotic-assisted laparoscopic radical hysterectomy and open radical hysterectomy., Methods: The first 30 cases of robotically assisted type III radical hysterectomy for cervical cancer were compared with the 30 previous cases of open type III radical hysterectomy. Body mass index, length of operation, nodal yield, margins, estimated blood loss, hospital stay, and complications were all documented and compared., Results: The 30 patients undergoing robotically assisted laparoscopic radical hysterectomy were similar in body mass index to the women undergoing open radical hysterectomy (34 kg/m robotic, 32 kg/m open, P = 0.22). The mean operating time was 154 minutes compared with 166 minutes in the open arm (P = 0.36). The mean blood loss was 165 mL compared with 323 mL in the open arm (P = 0.001). The mean pelvic nodal yield was 25 nodes compared with 26 nodes in the open group (P = 0.45). The mean parametrial margin size was not significantly different between groups. The mean postoperative length of stay was 1.4 days compared with 2.8 days for the open cases (P < 0.001). Urinary retention was significantly more common in the robotic arm., Conclusions: Radical surgery for cervical cancer can be accomplished using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, Calif) with acceptable blood loss, operating time, parametrial margins, and nodal yield. Future studies need to address long-term outcomes.

We investigated the survival and the failure pattern of 288 patients with endometrial cancer treated with extensive surgery including systematic pelvic and para-aortic lymphadenectomy followed by cisplatin-based chemotherapy from 1982 to 2002. We correlated the failure pattern with various clinicopathologic factors to find the predictors of recurrence sites. The 5-year overall survival rates were 97.5% for stage I, 87.5% for stage II, 85.2% for stage III, and 12.5% for stage IV. Notably, the 5-year survival rate was 76.5% for patients with stage IIIC disease. Among patients with a low risk (n = 92) for recurrence who received no adjuvant chemotherapy, 2 (2.2%) showed recurrent disease. Among those with intermediate (n = 98) and high (n = 98) risks for recurrence who received adjuvant chemotherapy, 9 (9.2%) and 20 (20.4%) showed recurrent disease, respectively. The recurrence sites were described as follows: distant (n = 12), vaginal (n = 8), peritoneal (n = 7), pelvic (n = 2), and lymphatic (n = 2). Lymphatic failure was found beyond the area of lymphadenectomy. Architectural and nuclear grades; myometrial, lymph-vascular space, and cervical invasions; and lymph node metastasis were predictors of distant failure. Cervical invasion and lymph node metastasis were predictors of vaginal failure. For patients with stage I/II cancer, the architectural and nuclear grades were related to distant failure. Seven (63.6%) of 11 patients with a low or intermediate risk survived after relapse, whereas only 1 (4.8%) of 21 patients with a high risk survived after a recurrence. We conclude that we need to further test the efficacy of systemic adjuvant therapy using new chemotherapeutic regimens to prevent distant failure and to improve the survival of patients with endometrial cancer.

Objective: Diagnosis of lymph node metastasis is a critical issue in the treatment of cervical cancer. Many studies describing sentinel node navigation surgery (SNNS) for examination of node status have been reported in the past decade. In this study, the feasibility of node status diagnosis by SNNS, including intraoperative frozen section diagnosis, in patients with early and advanced cervical cancer was evaluated., Patients and Methods: Fifty-eight cervical cancer patients with early and advanced stage disease were enrolled. All patients were treated with backup pelvic lymphadenectomy after SNNS. To detect sentinel lymph nodes (SLNs), radioactive material and/or blue dye were used as tracers. Lymph nodes confirmed as SLNs were immediately sent to pathologists and diagnosed by frozen section intraoperatively., Results: A total of 118 and 16 SLNs were pathologically investigated in early and advanced stage cervical cancer, respectively. The detection rate of SLNs in the early and advanced stages was 94.7% and 66.7%, respectively, whereas the detection rate using 1 or 2 tracers was 62.5% and 90%, respectively. The false-negative rate and negative predictive value was 0% and 100% for all stages. Pathological diagnosis by frozen section was completed within 30 minutes in all cases., Conclusions: Our data demonstrate that SNNS in cervical cancer is a promising procedure for patients with early stage (up to Ib1) disease, especially patients with small tumor diameter (<2.0 cm). However, SNNS raises several points for discussion before it can be established as a practical clinical procedure or as part of a subsequent radical hysterectomy.

Ureteroarterial fistulas (UAF) are a rare but potentially life-threatening complication of intra-abdominal malignancy, typically occurring after vascular or pelvic surgery. Patients with a history of radical pelvic surgery, chronic indwelling ureteral stents, and prior pelvic radiation appear to be at increased risk. The predisposing risk factors suggest that gynecological oncologists are the likely specialty to face this problem and should be familiar with the clinical presentation and etiology of UAF. We present two such cases to illustrate these salient points of clinical diagnosis and management.

Recently, we experienced a case of port-site and liver metastases after 75 cases of laparoscopic transperitoneal pelvic lymph node dissection (PLND) and para-aortic lymph node dissection (PALND) for surgical staging of locally advanced cervical cancer. A 45-year-old-woman with stage IIB cervical adenocarcinoma underwent laparoscopic PLND and PALND for surgical staging. There was no intraperitoneal disease and cervical tumor was not manipulated at the time of laparoscopic surgery. Pathologic examination revealed only one micrometastasis in left internal iliac lymph node (LN), measuring 1 mm, of the 60 pelvic and para-aortic LNs removed. She received concurrent chemoradiation therapy and pelvic mass disappeared completely. One month after the completion of therapy, both lateral and umbilical port-site and liver metastases were detected. We conclude that although cases of port-site metastasis have mostly occurred after extensive disease, the possibility of such complication should be kept in mind at laparoscopy of early cancer and laparoscopy which does not manipulate primary tumor.

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29-78 years). The mean pelvic lymph node count was 31 (range, 10-61) in the TLRH group versus 21.8 (range, 8-42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100-600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200-464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2-11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.

We performed unilateral or bilateral nerve-sparing (UNS or BNS) radical hysterectomies combined with a parametrial excision in patients with locally advanced cervical cancer. The parametrial excision technique is characterized by a meticulous sharp dissection of the avascular plane outside the visceral fascia of the uterus and vagina under direct vision, providing an en bloc parametria and ensuring that all regional spread of the disease is contained within negative surgical margins. The aim of this study was to describe this surgical technique and to retrospectively evaluate the feasibility and the impact on early bladder function. From February 2005 to November 2006, 32 patients with FIGO stage IB-IIB cervical cancer, who had the tumor of more than 20 mm in diameter, underwent the UNS surgery or BNS surgery. A parametrial excision was performed in all the patients. The surgical procedure was safely completed in all the patients. Though 14 patients had tumor invasion to the parametria, none of the patients had a positive surgical margin in the parametrium. The bladder function of patients in the UNS group immediately after surgery was more damaged than that in the BNS group. However, all the patients in both groups recovered spontaneous voiding with no need of self-catheterization during the perioperative periods. This preliminary study showed that the surgical technique is feasible and safe. For confirmation of the efficacy of this technique, further large prospective studies are needed.

Two hundred and eight patients with a clinical stage I endometrial carcinoma were studied (164 fulfilled the inclusion criteria). High risk was defined as nonendometrioid, or endometrioid tumors grade 3 (G3), or G2 with any or G1 with deep (>1/2) myometrial infiltration. The low-risk group consisted of the remaining patients. Surgical staging in the high-risk group included pelvic lymphadenectomy with para-aortic lymphadenectomy in selected cases. Twelve percent of the high-risk patients had nodal metastasis. Patients with low-risk (group A, n = 85) and high-risk disease confined to the uterus (group B, n = 57) did not receive adjuvant radiotherapy. Patients with nodal metastases (group C, n = 10) received postoperative irradiation. The total recurrence rate of the entire population was 12.5%, and the actuarial overall survival, disease-specific survival, and disease-free survival were 90%, 94%, and 88%, respectively. All patients with only vaginal relapse (n = 9) were cured locally with salvage radiotherapy until the date of analysis. The pelvic relapse rate was low as only one patient of group B recurred in the pelvis. In conclusion, lymphadenectomy remains indicated to better select patients at high risk of pelvic recurrence that may benefit from postoperative radiotherapy.

The aim of this study was to investigate the feasibility and safety of laparoscopic radical parametrectomy and pelvic and para-aortic lymphadenectomy after previous supracervical or extrafascial hysterectomy. This is a prospective study of six patients with vaginal or cervical stump carcinoma after previous supracervical or extrafascial hysterectomy. The technique of radical parametrectomy with pelvic and para-aortic lymphadenectomy as used for open surgical cases for years was performed laparoscopically. The average operating time was 180 min, the estimated average blood loss was 220 mL, and the duration of hospitalization was 11.8 days. There was no intraoperative or postoperative complication. Laparoscopic radical parametrectomy with pelvic and para-aortic lymphadenectomy for cervical or vaginal stump carcinoma can be successfully and safely accomplished.

Surgery is still the procedure of choice in treatment of advanced vulvar cancer. Radical vulvar surgery is often associated with severe vulvar and inguinal skin and fat-tissue deficits resulting from wide "butterfly" shape resection. Primary closure of large vulvar and inguinal defects is hampered by lack of tissue. The study presents the case of using prolene mesh in filling up the tissue defects over femoral vein and artery after radical excision of enlarged inguinal superficial, femoral, and pelvic nodes to prevent vessels in hiatus saphenus. It is the first report describing the use of prolene mesh in such a procedure.

This is a report of a case of gynecological hemorrhage after a posterior pelvic exenteration in patients with vulvar cancer treated by temporary pelvic packing at the Department of Gynecology of the Medical University in Gdańsk. The packing was successful and the sponges were removed after 24 h. Twenty-eight days after the operation, the patient was transferred to the Department of Radiotherapy for supplementary treatment. In patients with severe intraoperative hemorrhage, intra-abdominal packing has been successful as a mode of treatment.

A new surgical method was introduced for the treatment of Ib lymph node positive and IIb cervical cancer patients. The lateral resection plane corresponds to the true pelvic side wall, the plane represented by the internal obturator muscle, the linea arcuata, and the piriformis muscle with the convergent branches of the sacral plexus. The LEP procedure overcomes the limitations of the standard class III-IV radical hysterectomy, which leaves in situ the gluteal superior, inferior and pudendal nodes, thus improving local control and survival.