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Purpose: The aim of this review is to give an overview of the current status of molecular image-guided surgery in gynaecological malignancies, from both clinical and technological points of view., Methods: A narrative approach was taken to describe the relevant literature, focusing on clinical applications of molecular image-guided surgery in gynaecology, preoperative imaging as surgical roadmap, and intraoperative devices., Results: The most common clinical application in gynaecology is sentinel node biopsy (SNB). Other promising approaches are receptor-target modalities and occult lesion localisation. Preoperative SPECT/CT and PET/CT permit a roadmap for adequate surgical planning. Intraoperative detection modalities span from 1D probes to 2D portable cameras and 3D freehand imaging., Conclusion: After successful application of radio-guided SNB and SPECT, innovation is leaning towards hybrid modalities, such as hybrid tracer and fusion of imaging approaches including SPECT/CT and PET/CT. Robotic surgery, as well as augmented reality and virtual reality techniques, is leading to application of these innovative technologies to the clinical setting, guiding surgeons towards a precise, personalised, and minimally invasive approach., (© 2024. The Author(s).)

Competing Interests: Competing interests: NRA-R reports research funding from GRAIL paid to Memorial Sloan Kettering Cancer Center (MSK). MSK also has equity in GRAIL. AO is founder and managing director of SurgicalPerformance. ML reports consulting fees from Medtronic, speaker fees from Intuitive Surgical, and advisory board fees from J&J Ethicon and Immunogen.

Background: The anatomic descriptions and extents of radical hysterectomy often vary across the literature and operative reports worldwide. The same nomenclature is often used to describe varying procedures, and different nomenclature is often used to describe the same procedure despite the availability of guideline and classification systems. This makes it difficult to interpret retrospective surgical reports, analyze surgical databases, understand technique descriptions, and interpret the findings of surgical studies., Objective: In collaboration with international experts in gynecologic oncology, the purpose of this study was to establish a consensus in defining and interpreting the 2017 updated Querleu-Morrow classification of radical hysterectomies., Study Design: The anatomic templates of type A, B, and C radical hysterectomy were documented through a set of 13 images taken at the time of cadaver dissection. An online survey related to radical hysterectomy nomenclature and definitions or descriptions of the associated procedures was circulated among international experts in radical hysterectomy. A 3-step modified Delphi method was used to establish consensus. Image legends were amended according to the experts' responses and then redistributed as part of a second round of the survey. Consensus was defined by a yes response to a question concerning a specific image. Anyone who responded no to a question was welcome to comment and provide justification. A final set of images and legends were compiled to anatomically illustrate and define or describe a lateral, ventral, and dorsal excision of the tissues surrounding the cervix., Results: In total, there were 13 questions to review, and 29 experts completed the whole process. Final consensus exceeded 90% for all questions except 1 (86%). Questions with relatively lower consensus rates concerned the definitions of types A and B2 radical hysterectomy, which were the main innovations of the 2017 updated version of the 2008 Querleu-Morrow classification. Questions with the highest consensus rates concerned the definitions of types B1 and C, which are the most frequently performed radical hysterectomies., Conclusion: The 2017 version of the Querleu-Morrow classification proved to be a robust tool for defining and describing the extent of radical hysterectomies with a high level of consensus among international experts in gynecologic oncology. Knowledge and implementation of the exact definitions of hysterectomy radicality are imperative in clinical practice and clinical research., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the relationship between bowel preparation and surgical-site infection (SSI) incidence following colorectal resection during gynecologic oncology surgery., Methods: This post-hoc analysis used data from a randomized controlled trial of patients enrolled from 03/01/2016-08/20/2019 with presumed gynecologic malignancy investigating negative-pressure wound therapy among those requiring laparotomy. Patients were treated preoperatively without bowel preparation, oral antibiotic bowel preparation (OABP), or OABP plus mechanical bowel preparation (MBP) per surgeon preference. Univariate and multivariable analyses with stepwise model selection for SSI were performed for confirmed gynecologic malignancies requiring colorectal resection., Results: Of 161 cases, 15 (9%) had no preparation, 39 (24%) OABP only, and 107 (66%) OABP+MBP. The overall SSI rate was 19% (n = 31)-53% (n = 8/15) in the no preparation, 21% (n = 8/39) in the OABP alone, and 14% (n = 15/107) in the OABP+MBP groups (P = 0.003). The difference between OABP and OABP+MBP was non-significant (P = 0.44). The median length of stay was 9 (range, 6-12), 6 (range, 5-8), and 7 days (range, 6-10), respectively (P = 0.045). The overall complication rate (34%; n = 54) did not significantly vary by preparation type (P = 0.23). On univariate logistic regression analysis, OABP (OR, 0.23; 95% CI: 0.06-0.80) and OABP+MBP (OR, 0.14; 95% CI: 0.04-0.45) were associated with decreased SSI risk compared to no preparation (P = 0.004). On multivariate analysis, both methods of preparation retained a significant impact on SSI rates (P = 0.004)., Conclusion: Bowel preparation is associated with reduced SSI incidence and is beneficial for patients undergoing gynecologic oncology surgery with anticipated colorectal resection. Further investigation is needed to determine whether OABP alone is sufficient., Competing Interests: Declaration of Competing Interest Dr. Leitao reports personal fees from J&J/Ethicon and Takeda, and grants from KCI/Acelity. Dr. Chi reports personal fees from Apyx Medical, Verthermia Inc., Biom ‘Up, and AstraZeneca, as well as recent or current stock/options ownership of Apyx Medical, Verthemia, Intuitive Surgical, Inc., TransEnterix, Inc., Doximity, Moderna, and BioNTech SE. Dr. Abu-Rustum reports research funding paid to the institution by GRAIL. Dr. Jewel reports personal fees from Covidien/Medtronic. The other authors do not have potential conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Objective: To evaluate postoperative and oncologic outcomes associated with pelvic exenteration for non-ovarian gynecologic malignancies., Methods: This was a retrospective review of patients who underwent pelvic exenteration for non-ovarian gynecologic malignancies at our institution from 1/1/2010-12/31/2019. Palliative exenteration cases were excluded from survival analysis. Postoperative complications were early (≤30 days) or late (31-180 days). Complications were graded using a validated institutional scale. Major complications were considered grade ≥ 3. Categorical variables were compared using the chi-square test, and the Kaplan-Meier method was used for survival analysis., Results: Of 100 patients identified, 89 underwent pelvic exenteration for recurrent disease, 5 for palliation, 5 for primary disease, and 1 for persistent disease. Thirty percent had cervical, 27% vulvar, 24% uterine, and 19% vaginal cancer. Sixty-two percent underwent total, 30% anterior, and 8% posterior exenteration. No deaths occurred intraoperatively or within 30 days of surgery. Six patients died after 30 days. Ninety-seven experienced a perioperative complication-49 early, 1 late, and 47 both. Fifty experienced a major complication-22 (44%) early, 19 (38%) late, and 9 (18%) both. No variables were statistically associated with complication development. The 3-year progression-free survival rate was 61.0%; the 3-year overall survival rate was 61.6%. Of 58 surviving patients, 16 (28%) and 4 (7%) were alive after 5 and 10 years, respectively., Conclusion: The overall complication rate for pelvic exenteration remains high. No variables demonstrated association with complication development as the rate was nearly 100%. The low rate of perioperative mortality is likely due to improved perioperative care., Competing Interests: Declaration of Competing Interest Dr. Leitao is an ad hoc speaker for Intuitive Surgical, Inc.; outside the submitted work, he is on the Advisory Board of Ethicon/Johnson & Johnson and Takeda; and reports grants paid to the institution by KCI/Acelity. Dr. Abu-Rustum reports research funding paid to the institution by GRAIL; and Dr. Jewell reports personal fees from Covidien/Medtronic. The other authors do not have potential conflicts of interest to declare., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: The CovidSurg-Cancer Consortium aimed to explore the impact of COVID-19 in surgical patients and services for solid cancers at the start of the pandemic. The CovidSurg-Gynecologic Oncology Cancer subgroup was particularly concerned about the magnitude of adverse outcomes caused by the disrupted surgical gynecologic cancer care during the COVID-19 pandemic, which are currently unclear., Objective: This study aimed to evaluate the changes in care and short-term outcomes of surgical patients with gynecologic cancers during the COVID-19 pandemic. We hypothesized that the COVID-19 pandemic had led to a delay in surgical cancer care, especially in patients who required more extensive surgery, and such delay had an impact on cancer outcomes., Study Design: This was a multicenter, international, prospective cohort study. Consecutive patients with gynecologic cancers who were initially planned for nonpalliative surgery, were recruited from the date of first COVID-19-related admission in each participating center for 3 months. The follow-up period was 3 months from the time of the multidisciplinary tumor board decision to operate. The primary outcome of this analysis is the incidence of pandemic-related changes in care. The secondary outcomes included 30-day perioperative mortality and morbidity and a composite outcome of unresectable disease or disease progression, emergency surgery, and death., Results: We included 3973 patients (3784 operated and 189 nonoperated) from 227 centers in 52 countries and 7 world regions who were initially planned to have cancer surgery. In 20.7% (823/3973) of the patients, the standard of care was adjusted. A significant delay (>8 weeks) was observed in 11.2% (424/3784) of patients, particularly in those with ovarian cancer (213/1355; 15.7%; P<.0001). This delay was associated with a composite of adverse outcomes, including disease progression and death (95/424; 22.4% vs 601/3360; 17.9%; P=.024) compared with those who had operations within 8 weeks of tumor board decisions. One in 13 (189/2430; 7.9%) did not receive their planned operations, in whom 1 in 20 (5/189; 2.7%) died and 1 in 5 (34/189; 18%) experienced disease progression or death within 3 months of multidisciplinary team board decision for surgery. Only 22 of the 3778 surgical patients (0.6%) acquired perioperative SARS-CoV-2 infections; they had a longer postoperative stay (median 8.5 vs 4 days; P<.0001), higher predefined surgical morbidity (14/22; 63.6% vs 717/3762; 19.1%; P<.0001) and mortality (4/22; 18.2% vs 26/3762; 0.7%; P<.0001) rates than the uninfected cohort., Conclusion: One in 5 surgical patients with gynecologic cancer worldwide experienced management modifications during the COVID-19 pandemic. Significant adverse outcomes were observed in those with delayed or cancelled operations, and coordinated mitigating strategies are urgently needed., (Copyright © 2022 The Author(s). Published by Elsevier Inc. All rights reserved.)

Since its founding in 1884, Memorial Sloan Kettering Cancer Center (MSK) has set standards of care in gynecologic oncology. Over time, the MSK treatment approach evolved into an effort of gynecologic oncology experts across disciplines. As the anatomic field of gynecologic oncology surgery expanded beyond the pelvis, experts in other fields of cancer care, including our hepatobiliary and thoracic colleagues, joined this interprofessional effort. Here, we describe recent, key contributions to surgical gynecologic oncology by the Gynecology Service at MSK., (© 2022 Wiley Periodicals LLC.)

Background: The cost of cancer care is high and rising. Evidence of increased patient cost burden is prevalent in the medical literature and has been defined as "financial toxicity," the financial hardship and financial concerns experienced by patients because of a disease and its related treatments. With targeted therapies and growing out-of-pocket costs, patient financial toxicity is a growing concern among patients with gynecologic cancer., Objective: This study aimed to determine the prevalence of financial toxicity and identify its risk factors in patients with gynecologic cancer treated at a large cancer center using objective data., Study Design: Using institutional databases, we identified patients with gynecologic cancer treated from January 2016 to December 2018. Patients with a preinvasive disease were excluded. Financial toxicity was defined according to institutionally derived metrics as the presence of ≥1 of the following: ≥2 bills sent to collections, application or granting of a payment plan, settlement, bankruptcy, financial assistance program enrollment, or a finance-related social work visit. Clinical characteristics were gathered using a 2-year look-back from the time of the first financial toxicity event or a randomly selected treatment date for those not experiencing toxicity. Risk factors were assessed using chi-squared tests. All significant variables on univariate analysis were included in the logistic regression model., Results: Of the 4655 patients included in the analysis, 1155 (25%) experienced financial toxicity. In the univariate analysis, cervical cancer (35%), stage 3 or 4 disease (24% and 30%, respectively), younger age (35% for age <30 years), nonpartnered marital status (31%), Black (45%) or Hispanic (37%) race and ethnicity, self-pay (48%) or commercial insurance (30%), clinical trial participation (31%), more imaging studies (39% for ≥9), ≥1 emergency department visit (36%), longer inpatient stays (36% for ≥20 days), and more outpatient clinician visits (41% for ≥20 visits) were significantly associated with financial toxicity (P<.01). In multivariate analysis, younger age, nonpartnered marital status, Black and Hispanic race and ethnicity, commercial insurance, more imaging studies, and more outpatient physician visits were significantly associated with financial toxicity., Conclusion: Financial toxicity is an increasing problem for patients with gynecologic cancer. Our analysis, using objective measures of financial toxicity, has suggested that demographic factors and healthcare utilization metrics may be used to proactively identify at-risk patients for financial toxicity., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Introduction: Financial toxicity is common and pervasive among cancer patients. Research suggests that gynecologic cancer patients experiencing financial toxicity are at increased risk for engaging in harmful cost-coping strategies, including delaying/skipping treatment because of costs, or forsaking basic needs to pay medical bills. However, little is known about patients' preferences for interventions to address financial toxicity., Methods: Cross-sectional surveys to assess financial toxicity [Comprehensive Score for Financial Toxicity (COST)], cost-coping strategies, and preferences for intervention were conducted in a gynecologic cancer clinic waiting room. Associations with cost-coping were determined using multivariate modeling. Unadjusted odds ratios (ORs) explored associations between financial toxicity and intervention preferences., Results: Among 89 respondents, median COST score was 31.9 (IQR: 21-38); 35% (N = 30) scored < 26, indicating they were experiencing financial toxicity. Financial toxicity was significantly associated with cost-coping (adjusted OR = 3.32 95% CI: 1.08, 14.34). Intervention preferences included access to transportation vouchers (38%), understanding treatment costs up-front (35%), minimizing wait times (33%), access to free food at appointments (25%), and assistance with minimizing/eliminating insurance deductibles (23%). In unadjusted analyses, respondents experiencing financial toxicity were more likely to select transportation assistance (OR = 2.67, 95% CI: 1.04, 6.90), assistance with co-pays (OR = 9.17, 95% CI: 2.60, 32.26), and assistance with deductibles (OR = 12.20, 95% CI: 3.47, 43.48), than respondents not experiencing financial toxicity., Conclusions: Our findings confirm the presence of financial toxicity in gynecologic cancer patients, describe how patients attempt to cope with financial hardship, and provide insight into patients' needs for targeted interventions to mitigate the harm of financial toxicity., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Purpose: To describe the development and implementation of a new digital health clinical tool (Gynecologic Survivorship Tool [GST]) for symptom management of women surgically treated for gynecologic cancer; to assess its feasibility; and to conduct a retrospective review of the data., Materials and Methods: The GST was developed on the basis of a comprehensive review of the literature, multidisciplinary expert opinion, and feedback from women with a history of gynecologic cancer. It is composed of 17 questions addressing six main categories-gynecologic health (abnormal bleeding/pain), lymphedema, vaginal/vulvar dryness, sexual health, menopause (hot flushes/sleep difficulties), and bowel/urinary issues. An electronic version using the Memorial Sloan Kettering Cancer Center Engage platform was piloted in two clinics for patients with endometrial or cervical cancer. Health information was generated into clinical summaries and identified concerns for actionable response. Associations of symptom and survey time point were assessed by longitudinal models using generalized estimating equations., Results: From January 1, 2019, to February 29, 2020, 3,357 GST assessments were assigned to 1,405 patients, with a 71% completion rate (90% within 5 minutes). Sixty-eight percent were performed at home via a patient portal, 32% at follow-ups using a clinic iPad. The most common symptoms were bowel problems, swelling/fluid, pain during examination, vaginal or vulvar dryness, and vaginal bleeding. Implementation challenges included improving patient compliance and ensuring that reports were reviewed by all clinical teams. We developed screening e-mails detailing patients whose assessments were due, planned training sessions for multidisciplinary teams, and incorporated feedback on methods for reviewing symptoms reports., Conclusion: The GST demonstrated feasibility, a high completion rate, and minimal time commitment. It was an effective electronic reporting mechanism for patients, enabling the medical team to develop specific strategies for alleviating bothersome symptoms during follow-up., Competing Interests: Nadeem R. Abu-RustumHonoraria: Prime OncologyResearch Funding: Stryker/Novadaq (Inst), GRAIL (Inst)Travel, Accommodations, Expenses: Prime Oncology Ling Y. ChenEmployment: Lyra Andrew J. VickersStock and Other Ownership Interests: OPKO HealthConsulting or Advisory Role: OPKO Diagnostics, Insightec, Steba BiotechPatents, Royalties, Other Intellectual Property: I am named on a patent for a statistical method to detect prostate cancer. This method has been commercialized by OPKO as the 4Kscore. I receive royalties from sales of the 4KscoreTravel, Accommodations, Expenses: OPKO Health Vance BroachOpen Payments Link: https://openpaymentsdata.cms.gov/physician/1162364 Dennis S. ChiLeadership: CSurgeriesStock and Other Ownership Interests: Bovie Medical, Verthermia, Intuitive Surgical, TransenterixHonoraria: Biom'UpConsulting or Advisory Role: Bovie Medical, Verthermia, Biom'upTravel, Accommodations, Expenses: Biom'Up Ginger J. GardnerHonoraria: BioAscentTravel, Accommodations, Expenses: BioAscent Elizabeth L. JewellHonoraria: SurvivornetConsulting or Advisory Role: Intuitive Surgical, Covidien/MedtronicResearch Funding: Summit Biomedical Mario M. Leitao JrHonoraria: Intuitive SurgicalConsulting or Advisory Role: Intuitive Surgical, Ethicon/Johnson & Johnson, Medtronic, TakedaResearch Funding: KCITravel, Accommodations, Expenses: Intuitive Surgical Yukio SonodaPatents, Royalties, Other Intellectual Property: Pending patent for a surgical instrument (uterine manipulator)No other potential conflicts of interest were reported.

Objectives: To explore pre-operative factors and their impact on overall survival (OS) in a modern cohort of patients who underwent pelvic exenteration (PE) for gynecologic malignancies., Methods: A retrospective review was performed for all patients who underwent a PE from 1/1/2010 through 12/31/2018 at our institution. Inclusion criteria were exenteration due to recurrent or progressive carcinoma of the uterus, cervix, vagina or vulva, with histologically confirmed complete surgical resection of the malignancy. Exclusion criteria included PE for palliation of symptoms without recurrence, and for ovarian or rare histologic malignancies. Univariable and multivariable analysis were performed to identify factors predicting prolonged survival., Results: Overall, 71 patients met the inclusion criteria. Median age at time of exenteration was 62 years (range, 28-86 years). Vulvar cancer was the most common primary diagnosis (32%); 30% had cervical cancer; 23%, uterine cancer; 15%, vaginal cancer. Median OS was 55.1 months (95% confidence interval (CI): 36-not estimable) with a median follow-up time of 40.8 months (95% CI: 1-116.1). On univariable analysis, age > 62 years (hazard ratio (HR) 2.71, 95% CI 1.27-5.79), American Society of Anesthesia (ASA) 3-4 (HR: 3.41 (95% CI 1.03-11.29), and vulvar cancer (HR 4.19 (95% CI 1.17-14.96) predicted worse OS. Tumor size and prior progression-free interval (PFI) did not meet statistical significance in OS analyses. On multivariable analysis, there were no significant factors associated with worse OS., Conclusions: PE performed with curative intent may be considered a treatment option in well-counseled, carefully selected patients, irrespective of tumor size and PFI before exenteration., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Mesonephric carcinoma of the cervix is a rare tumor derived from Wolffian remnants. Mesonephric-like carcinomas of the ovary and endometrium, while morphologically similar, do not have obvious Wolffian derivation. Here, we sought to characterize the repertoire of genetic alterations in primary mesonephric and mesonephric-like carcinomas, in the distinct histologic components of mixed cases, as well as in matched primary tumors and metastases. DNA from microdissected tumor and normal tissue from mesonephric carcinomas (cervix, n = 8) and mesonephric-like carcinomas (ovarian n = 15, endometrial n = 13) were subjected to sequencing targeting 468 cancer-related genes. The histologically distinct components of four cases with mixed histology and four primary tumors and their matched metastases were microdissected and analyzed separately. Mesonephric-like carcinomas were underpinned by somatic KRAS mutations (25/28, 89%) akin to mesonephric carcinomas (8/8, 100%), but also harbored genetic alterations more frequently reported in Müllerian tumors. Mesonephric-like carcinomas that lacked KRAS mutations harbored NRAS (n = 2, ovary) or BRAF (n = 1, endometrium) hotspot mutations. PIK3CA mutations were identified in both mesonephric-like (8/28, 28%) and mesonephric carcinomas (2/8, 25%). Only mesonephric-like tumors harbored CTNNB1 hotspot (4/28, 14%) and PTEN (3/13, 23%) mutations. Copy number analysis revealed frequent gains of chromosomes 1q and 10 in both mesonephric (87% 1q; 50% chromosome 10) and mesonephric-like tumors (89% 1q; 43% chromosome 10). Chromosome 12 gains were more frequent in ovarian mesonephric-like carcinomas, and losses of chromosome 9 were more frequent in mesonephric than in mesonephric-like carcinomas (both p = 0.01, Fisher's exact test). The histologically distinct components of four mixed cases were molecularly related and shared similar patterns of genetic alterations. The progression from primary to metastatic lesions involved the acquisition of additional mutations, and/or shifts from subclonal to clonal mutations. Our findings suggest that mesonephric-like carcinomas are derived from a Müllerian substrate with differentiation along Wolffian/mesonephric lines., (© 2021. The Author(s), under exclusive licence to United States & Canadian Academy of Pathology.)

Objective: To evaluate the feasibility of an electronic symptom-tracking platform for patients recovering from ambulatory surgery., Method: We assessed user response to an electronic system designed to self-report symptoms. Endpoints included compliance, postoperative symptoms, patient satisfaction. An 8-item symptom inventory (pain, nausea, vomiting, shortness of breath, fever, swelling, discharge, redness) was developed and made available on postoperative days (POD) 2-6. Responses exceeding defined thresholds of severity triggered alerts to healthcare providers. Symptoms, alerts, actions taken, urgent care center (UCC) visits, hospital admissions were tracked until POD 30. Patient satisfaction was evaluated on POD 7. A patient was defined as "responder" if at least 5/8 items on at least 3 PODs were completed. The assessment method was deemed successful if 64/100 patients responded., Results: 97/102 patients were evaluable; 65 met "responder" criteria (67% responder rate; 95% CI 57-76%). 321 surveys were completed (median 4/patient), 248 (77%) in ≤2 min. Involving caregivers and allowing additional symptom-reporting improved the responder rate to 72% (95% CI 58-84%). Most commonly-reported moderate, severe, very severe symptoms were pain, nausea, swelling; 71% reported moderate to very severe pain on POD 2. Phone calls and adjustment of medications adequately addressed most symptoms. Two patients (2%) presented at UCC before, 6 (6%) after, POD 6; 1 (1%) was admitted. Most agreed or strongly agreed that electronic symptom-tracking was helpful, easy to use, and would recommend it to others., Conclusion: Electronic symptom-tracking is feasible for patients undergoing ambulatory gynecologic cancer surgery. Symptom burden is high in the early postoperative period. Addressing patient-reported symptoms in a timely, automated manner may prevent severe downstream adverse events, reduce UCC visits and admission rates, and improve outcomes., Competing Interests: Declaration of Competing Interest None declared., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objectives: Reducing anastomotic leak rates after rectosigmoid resection and anastomosis is a priority in patients undergoing gynecologic oncology surgery. Therefore, we investigated the implications of performing near-infrared angiography (NIR) via proctoscopy to assess anastomotic perfusion at the time of rectosigmoid resection and anastomosis., Methods: We identified all patients who underwent rectosigmoid resection and anastomosis for a gynecologic malignancy between January 1, 2013 and December 31, 2018. NIR proctoscopy was assessed via the PINPOINT Endoscopic Imaging System (Stryker)., Results: A total of 410 patients were identified, among whom NIR was utilized in 133 (32.4%). There were no statistically significant differences in age, race, BMI, type of malignancy, surgery, histology, FIGO stage, hypertension, diabetes, or preoperative chemotherapy between NIR and non-NIR groups. All cases of rectosigmoid resection underwent stapled anastomosis. The anastomotic leak rate was 2/133 (1.5%) in the NIR cohort compared with 13/277 (4.7%) in the non-NIR cohort (p = 0.16). Diverting ostomy was performed in 9/133 (6.8%) NIR and 53/277 (19.9%) non-NIR patients (p < 0.001). Postoperative abscesses occurred in 8/133 (6.0%) NIR and 44/277 (15.9%) non-NIR patients (p = 0.004). The NIR cohort had significantly fewer post-operative interventional procedures (12/133, 9.0% NIR vs. 55/277, 19.9% non-NIR, p = 0.006) and significantly fewer 30-day readmissions (14/133, 10.5% NIR vs. 61/277, 22% non-NIR, p = 0.004)., Conclusions: NIR proctoscopy is a safe tool for assessing anastomotic rectal perfusion after rectosigmoid resection and anastomosis, with a low anastomotic leak rate of 1.5%. Its potential usefulness should be evaluated in randomized trials in patients undergoing gynecologic cancer surgery., Competing Interests: Declaration of competing interest Dr. Iasonos reports personal fees from Mylan, outside the submitted work. Dr. Abu-Rustum reports grants from Stryker/Novadaq, grants from Olympus, grants from GRAIL, outside the submitted work. Dr. Leitao is a consultant for Intuitive Surgical Inc., outside the submitted work. Dr. Chi reports personal fees from Bovie Medical Co., personal fees from Verthermia Inc. (now Apyx Medical Corp.), personal fees from C Surgeries, other from Intuitive Surgical, Inc., other from TransEnterix, Inc., personal fees from Biom ‘Up, outside the submitted work. Dr. Long Roche reports other* from Intuitive Surgical Inc., outside the submitted work. (*Airfare to a survivorship conference, where she spoke)., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Competing Interests: Competing interests: None declared.

Background: Narrow band imaging (NBI) is an optic filtration enhancement for endoscopy that uses two wavelengths of light (415 and 540 nm) to highlight superficial microvascular patterns. It has been successfully utilized to improve identification of lesions with abnormal vasculature, which is associated with endometriosis and endometrial cancer. Case studies suggest it may also facilitate surgical staging of gynecologic cancer, which is critical in determining appropriate adjuvant therapies. A technology that enhances the ability to identify metastatic disease during minimally invasive surgery (MIS) could make an important difference in patient outcomes., Methods: A prospective comparative study was conducted to evaluate patients with clinical indication for diagnostic or operative laparoscopy. All received white light imaging followed by NBI during the same procedure. Suspicious lesions were examined and photographed, using both modalities, before excision. The two techniques were compared. Positive predictive value, negative predictive value, and diagnostic accuracy in identifying histologically confirmed metastatic lesions were assessed, using appropriate statistical methods., Results: Of 124 patients enrolled in the study, 94 were evaluable; 30 did not undergo MIS and were therefore excluded. A significantly higher number of peritoneal abnormalities were identified with NBI versus white light imaging (P = 0.0239). However, no statistically significant difference (P = 0.18, patient level) was observed in identification of histologically confirmed metastatic disease., Conclusions: NBI imaging provides a unique contrast between peritoneal surface and microvascular patterns. However, the results of this study suggest that NBI-enhanced laparoscopy does not provide superior detection of peritoneal surface malignancy compared with standard white light high-definition laparoscopy.

Historically, cancer treatment has emphasized measures for the "cure" regardless of the long-term consequences. Advances in cancer detection and treatment have resulted in improved outcomes bringing to the fore various quality of life considerations including future fertility. For many young cancer patients, fertility preservation is now an integral component of clinical decision-making and treatment design. Optimal fertility-sparing options for young patients with gynecologic cancer are influenced by patient age, primary cancer, treatment regimens, and patient preferences. Possible approaches include embryo or oocyte cryopreservation, ovarian transposition, conservative surgery, and conservative medical treatment to delay radical surgery. These may be used alone or in combination to maximize fertility preservation. Awareness of the various fertility-sparing options, eligibility criteria, and the central role of magnetic resonance imaging in the proper selection of patients will enable radiologists to produce complete clinically relevant imaging reports and serve as effective consultants to referring clinicians. Knowledge of the potential imaging pitfalls is essential to avoid misinterpretation and guide appropriate management.

Objective: Surgical site infections (SSIs) can lead to substantial morbidity, prolonged hospitalization, increased costs, and death in patients undergoing colorectal procedures. We sought to investigate the effect of using an SSI reduction bundle on the rate of SSIs in gynecologic cancer patients undergoing colon surgery., Methods: We identified all gynecologic cancer patients who underwent colon resection at our institution from 2014 to 2016, during which time a service-wide SSI reduction bundle was introduced. The intervention included preoperative oral antibiotics with optional mechanical bowel preparation, skin preparation with antibacterial solution, and the use of a separate surgical closing tray. SSI rates were assessed within 30days post-surgery., Results: Of 233 identified patients, 115 had undergone colon surgery prior to (PRE) and 118 after (POST) the implementation of the intervention. A low anterior resection was the most common colon surgery in both cohorts. The incidence of SSI within 30days of surgery was 43/115 (37%) in the PRE and 14/118 (12%) in the POST cohorts (p≤0.001). Wound dehiscence was noted in 30/115 (26%) and 2/118 (2%) patients, respectively (p≤0.001). In patients whose operation took longer than 360min, 30-day SSI rates were 37% (28/76) and 12% (8/67), respectively (p≤0.001). In patients with an estimated blood loss >500cm 3 , SSI rates were 44% (27/62) and 15% (10/67), respectively (p≤0.001)., Conclusions: The implementation of an SSI reduction bundle was associated with a significant reduction in 30-day SSIs in these patients. The intervention remained effective in patients undergoing longer operations and in those with increased blood loss., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Purpose: To assess sexual/vaginal health issues and educational intervention preferences in women with a history of breast or gynecologic cancer., Methods: Patients/survivors completed a cross-sectional survey at their outpatient visits. Main outcome measures were sexual dysfunction prevalence, type of sexual/vaginal issues, awareness of treatments, and preferred intervention modalities. Descriptive frequencies were performed, and results were dichotomized by age, treatment status, and disease site., Results: Of 218 eligible participants, 109 (50%) had a history of gynecologic and 109 (50%) a history of breast cancer. Median age was 49 years (range 21-75); 61% were married/cohabitating. Seventy percent (n = 153) were somewhat-to-very concerned about sexual function/vaginal health, 55% (n = 120) reported vaginal dryness, 39% (n = 84) vaginal pain, and 51% (n = 112) libido loss. Many had heard of vaginal lubricants, moisturizers, and pelvic floor exercises (97, 72, and 57%, respectively). Seventy-four percent (n = 161) had used lubricants, 28% moisturizers (n = 61), and 28% pelvic floor exercises (n = 60). Seventy percent (n = 152) preferred the topic to be raised by the medical team; 48% (n = 105) raised the topic themselves. Most preferred written educational material followed by expert discussion (66%, n = 144/218). Compared to women ≥50 years old (41%, n = 43/105), younger women (54%, n = 61/113) preferred to discuss their concerns face-to-face (p = 0.054). Older women were less interested in online interventions (52%, p < 0.001), despite 94% having computer access., Conclusion: Female cancer patients/survivors have unmet sexual/vaginal health needs. Preferences for receiving sexual health information vary by age. Improved physician-patient communication, awareness, and educational resources using proven sexual health promotion strategies can help women cope with treatment side effects.

Purpose: We previously reported on the feasibility of a Web-based system to capture patient-reported outcomes (PROs) in the immediate postoperative period. The purpose of this study was to update the experience of these patients and assess patient and provider satisfaction and feedback regarding the system., Methods: This is a prospective cohort study of patients scheduled to undergo laparotomy for presumed gynecologic malignancy. Patients completed a Web-based Symptom Tracking and Reporting (STAR) questionnaire preoperatively and weekly during a 6-week postoperative period. Email alerts were sent to study nurses when concerning patient responses were entered. The patient and the nurse assessments of STAR's usefulness were measured via an exit survey., Results: The study enrolled 96 eligible patients. Of these, 71 patients (74%) completed at least four of seven total sessions. Of the patients who completed the exit satisfaction survey, 98% found STAR easy to use; 84% found it useful; and 82% would recommend it to other patients. Despite positive feedback from patients, clinical personnel found that the STAR system increased their current workload without enhancing patient care., Conclusions: Application of an electronic program for PROs in those recovering from major gynecologic cancer surgery is feasible, and acceptable to most patients. While most clinicians did not find STAR clinically helpful, the majority of patients reported a positive experience with the system and would recommend its use. The program helped many patients feel more empowered in their postoperative recovery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Objective: The purpose was to determine the potential impact of IMRT on the rate of bowel obstruction (BO), in patients with gynecologic malignancies undergoing postoperative pelvic RT., Methods: We performed a retrospective review of all patients with endometrial or cervical cancer who received postoperative pelvic RT at our institution from 2000 to 2012. Patients who received definitive or palliative RT, or those with BO due to disease progression, were excluded. Standard two-sided statistical tests were used to evaluate for associated risk factors. Kaplan-Meier, Log rank and Cox proportional hazards regression analysis tests were performed for actuarial analysis., Results: A total of 224 patients were identified, 120 (54%) received postoperative pelvic IMRT and 104 (46%) 3-dimentional (3-D) RT. Median follow-up time was 67months. BO was grade 1 (asymptomatic) in 2/228 (0.9%), grade 2 (conservative management) in 4 (1.8%), and grade 3≥ in 4 (1.8%). Overall, the 5-year actuarial rate of BO was 4.8%. The 5-year rate of BO in the IMRT group was 0.9% compared to 9.3% for 3-D RT (p=0.006). Patients with BMI≥30kg/m(2) were less likely to develop BO (2.6% vs. 8.3; p=0.03). On multivariate analysis, only IMRT retained its significance as an independent predictor of less BO (p=0.022)., Conclusions: The use of postoperative IMRT for cervical and endometrial cancer was associated with significant reduction in the rate of bowel obstruction. This difference maintained its statistical significance on multivariate analysis. Such finding if confirmed by others will help further solidify the benefit of IMRT in gynecologic cancers., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Purpose: To determine if second-opinion review of gynaecologic oncologic (GynOnc) magnetic resonance imaging (MRI) by sub-specialized radiologists impacts patient care., Methods: 469 second-opinion MRI interpretations rendered by GynOnc radiologists were retrospectively compared to the initial outside reports. Two gynaecologic surgeons, blinded to the reports' origins, reviewed all cases with discrepancies between initial and second-opinion MRI reports and recorded whether these discrepancies would have led to a change in patient management defined as a change in treatment approach, counselling, or referral. Histopathology or minimum 6-month imaging follow-up were used to establish the diagnosis., Results: Second-opinion review of GynOnc MRIs would theoretically have affected management in 94/469 (20 %) and 101/469 (21.5 %) patients for surgeons 1 and 2, respectively. Specifically, second-opinion review would have theoretically altered treatment approach in 71/469 (15.1 %) and 60/469 (12.8 %) patients for surgeons 1 and 2, respectively. According to surgeons 1 and 2, these treatment changes would have prevented unnecessary surgery in 35 (7.5 %) and 31 (6.6 %) patients, respectively, and changed surgical procedure type/extent in 19 (4.1 %) and 12 (2.5 %) patients, respectively. Second-opinion interpretations were correct in 103 (83 %) of 124 cases with clinically relevant discrepancies between initial and second-opinion reports., Conclusions: Expert second-opinion review of GynOnc MRI influences patient care., Key Points: • Outside gynaecologic oncologic MRI examinations are often submitted for a second-opinion review. • One-fifth of MRIs had important discrepancies between initial and second-opinion interpretations. • Second-opinion review of gynaecologic oncologic MRI is a valuable clinical service.

Objective: It is well documented that recurrence after pelvic exenteration remains high (up to 50%), and patients may require a prolonged period of recuperation following this aggressive surgery. We conducted a retrospective review to evaluate the feasibility of administering adjuvant chemotherapy after pelvic exenteration for gynecologic malignancies., Methods: We reviewed the medical records of patients with any gynecologic cancer who underwent exenterative surgery between January 2005 and February 2011 at our institution. Patients were referred for postexenteration adjuvant chemotherapy based on surgeon's discretion and/or presence of high-risk features: positive margins, positive lymph nodes, and/or lymphovascular space invasion. Suitability for chemotherapy was assessed by a gynecologic medical oncologist. Regimens consisted of 4 to 6 cycles of platinum-based doublet chemotherapy. Chemotherapy-related toxicities were assessed using the Common Terminology Criteria for Adverse Events version 4., Results: We identified 42 patients who underwent pelvic exenteration during the study period. Eleven (26%) were referred for adjuvant chemotherapy. Three (27%) of the 11 patients did not receive chemotherapy because of delayed postoperative recovery or physician choice. Seven (88%) of the remaining 8 patients completed all scheduled chemotherapy. Grade 2 toxicities or greater were documented in 6 patients (75%), the most common being neutropenia, neuropathy, and fatigue. Median follow-up time was 25 months (range, 6-56 months). The 3-year progression-free and overall survival rates of the 8 patients who received chemotherapy were 58% (95% confidence interval, 18%-84%) and 54% (95% confidence interval, 13%- 83%), respectively., Conclusions: The administration of adjuvant chemotherapy is feasible for a select group of patients after pelvic exenteration for gynecologic malignancies. Our results need to be interpreted with caution because of the small and heterogeneous cohort of patients included.

Objective: Little prospective data exist on quality of life (QOL) after pelvic exenteration (PE). This ongoing study prospectively examines the QOL changes following this radical procedure using a comprehensive battery of psychological instruments., Methods: Since 2005, enrolled patients were interviewed (EORTC QLQ-C30, EORTC QLQ-CR38, EORTC QLQ-BLM30, BFI, BPI-SF, IADL, CES-D, IES-R) preoperatively and at 3, 6, and 12 months after PE for physical/psychological symptoms. Data were examined using repeated measure ANOVA., Results: Sixteen women (3 anterior, 1 posterior, and 12 total PEs), with more than 1 year of follow-up, completed all scheduled interviews. Median age was 58 years (range, 28-76 years). Overall QOL (F = 6.3, p < 0.02), ability to perform instrumental daily activities (F = 6.8, p < 0.02), body image (F = 11.9, p < 0.00), and sexual function (F = 8.0, p < 0.01) all declined at 3 months but were near baseline by 12 months after PE. Although, overall, physical function followed a similar trend (F = 14.8, p < 0.00), it did not return to baseline. At the 12-month interview, patients reported increased gastrointestinal symptoms (F = 8.9, p < 0.01) but significantly less stress-related ideation (F = 6.1, p < 0.03) compared to baseline. Pain levels did not change significantly during the study period (F = 0.4, p < 0.74)., Conclusions: Although patients report lingering gastrointestinal symptoms and some persistent decline in physical function after PE, most adjust well, returning to almost baseline functioning within a year. Providers can counsel patients that many, though not all, symptoms in the first 3 months following exenteration are likely to improve as they adapt to their changed health status. These preliminary results await confirmation of a larger analysis., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Purpose: The purposes of this study are to evaluate the feasibility of capturing patient-reported outcomes (PROs) electronically and to identify the most common distressing symptoms in women recovering from major gynecologic cancer surgery., Methods: This was a prospective, single-arm pilot study. Eligible participants included those scheduled for a laparotomy for presumed or known gynecologic malignancy. Patients completed a Web-based "STAR" (Symptom Tracking and Reporting for Patients) questionnaire once preoperatively and weekly during the 6-week postoperative period. The questionnaire consisted of the patient adaptation of the NCI CTCAE 3.0 and EORTC QLQ-C30 3.0. When a patient submitted a response that was concerning, an automated email alert was sent to the clinician. The patient's assessment of STAR's usefulness was measured via an exit survey., Results: Forty-nine patients completed the study. The procedures included the following: hysterectomy±staging (67%), resection of tumor (22%), salpingo-oophorectomy (6%), and other (4%). Most patients (82%) completed at least 4 sessions in STAR. The CTC generated 43 alerts. These alerts resulted in 25 telephone contacts with patients, 2 ER referrals, one new appointment, and one pharmaceutical prescription. The 3 most common patient-reported symptoms generating an alert were as follows: poor performance status (19%), nausea (18%), and fatigue (17%). Most patients found STAR useful (80%) and would recommend it to others (85%)., Conclusion: Application of a Web-based, electronic STAR system is feasible in the postoperative period, highly accepted by patients, and warrants further study. Poor performance status, nausea, and fatigue were the most common distressing patient-reported symptoms., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Goals: Gynecologic cancers represent a significant proportion of malignancies affecting women. Historically, cancer treatment focused primarily on eradicating disease, irrespective of the impact on fertility. The implementation of early detection protocols and advanced treatment regimens has resulted in improved prognosis for gynecologic cancer patients. With this improvement, more attention is now paid to quality-of-life issues. Fertility preservation (FP) has become an integral component in the selection and execution of gynecological cancer management. In this report we address gynecologic malignancies as they relate to future fertility potential., Methods: We review reproductive principles such as ovarian reserve, uterine function, cervical competence, and early obstetrical management, as well as available FP methods. In addition, we discuss the potential damage that cancer and cancer treatments can impart on the female reproductive system. We offer general recommendations regarding baseline screening tests useful in assessing the feasibility of FP. Lastly, cancer-specific FP methods are presented., Results: Oocyte quantity and quality naturally decline with advancing age. In most patients, the slope of decline steepens significantly after the age of 35. Reliable ovarian reserve measures exist and should be utilized to assess and triage potential candidates for FP. Advancements in FP, particularly in oocyte cryopreservation (OC), have improved the success rates associated with the techniques available to cancer patients. Currently, where successfully available, OC appears to be the preferred method for single women diagnosed with a gynecologic malignancy as it affords reproductive autonomy, whereas embryo cryopreservation using a donor gamete remains an alternative., Conclusions: In gynecologic oncology, effective treatments to achieve cancer survival can compromise the ability to subsequently conceive and/or carry a child. Therefore, as the field of oncofertility continues to expand, a discussion regarding FP should be initiated when tailoring a cancer treatment protocol., (Copyright © 2010 Elsevier Inc. All rights reserved.)

Introduction: To empirically assess and describe the emotional, sexual, and physical impact of cancer-related infertility on gynecologic cancer survivors., Methods: The study was composed of 88 survivors of cervical, endometrial/uterine, ovarian cancer, and gestational trophoblastic disease who experienced impaired or loss of fertility as a result of treatment. Patient age ranged from 21 to 49 years. Participants completed a 1-time self-report survey, including medical and demographic information and empirical measures of mood (Center for Epidemiologic Studies Depression Scale), distress (Impact of Event Scale), sexual function (Female Sexual Function Index), and menopause (Menopausal Symptom Checklist)., Results: Eighty-four (96%) of the 88 enrolled patients had undergone a surgical intervention as part of their cancer treatment. Sixty-three patients (77%) reported clinically significant levels of distress in relation to loss of fertility or impaired fertility. Survivors' levels of distress (P < 0.0001) and depression (P < 0.0001) were associated with the severity and number of menopausal symptoms reported. Patients who retained functioning ovaries (partial fertility) (41%, n = 36) reported being less bothered by menopausal symptoms (P = 0.01) and having higher sexual functioning than those with ovarian failure (P < 0.0001)., Conclusions: The emotional and physical impact of impaired or loss of fertility can be complex and long lasting, with women experiencing high levels of distress, menopausal symptoms, and changes in sexual function persisting into survivorship. Future research should focus on the development of strategies to identify, monitor, and address, in a clinical care setting, the issues these cancer survivors face. Alternate family-building strategies should also be explored before treatment and/or upon treatment completion when feasible.

The treatment of gynecologic malignancies can include surgery, systemic therapy, and radiation. Depending on the primary site of disease and the extent of the disease, these treatment strategies are applied alone or in combination. Trends over the past few decades have concentrated on performing more comprehensive staging procedures for a large percentage of patients with gynecologic malignancies. The surgical techniques available for comprehensive staging have facilitated a greater understanding of stage and prognosis overall, and better tailoring of postsurgical treatment. One such technique is regional lymphadenectomy. Although the role of regional lymphadenectomy as a therapeutic procedure in some gynecologic cancers is debated and challenged (regional lymphadenectomy and multimodality therapy increases adverse side effects and long-term sequelae without proven survival benefit), there is no controversy regarding the staging and prognostic benefit of the evaluation of regional lymph nodes. The sentinel lymph node (SLN) concept was successfully introduced in melanoma. It has since become the standard of care in breast cancer and has had a significant impact on postoperative morbidity for a large percentage of breast cancer patients. Interest in using SLN techniques in gynecologic cancers was thus a natural progression. In light of the growing body of evidence in the literature opposing the therapeutic benefit of systematic lymphadenectomy, the SLN concept will continue to play an important role in the treatment of gynecologic malignancies. This technique can provide accurate staging information in some gynecologic cancers. Increased use of this technique could potentially impact the quality of life of gynecologic cancer survivors while still providing important staging information without compromising oncologic safety. In this review, we examine the body of literature related to gynecologic cancer malignancies and SLN biopsy.

Objective: To determine the effect of perioperative patient-controlled epidural analgesia (PCEA) compared to postoperative intravenous (IV) patient-controlled analgesia (PCA) on postoperative recovery parameters after major open gynecologic surgery., Methods: A randomized controlled clinical trial included women undergoing laparotomy for a gynecologic disorder. Patients were randomized to postoperative IV morphine PCA (control arm) or to postoperative morphine-bupivacaine PCEA (treatment arm). Postoperative outcomes such as pain, and length of hospital stay were compared with an intention-to-treat analysis. The primary endpoint was postoperative pain at rest and when coughing--assessed by a 10-point visual analog scale (VAS)., Results: Between 9/04 and 6/07, 153 patients were randomized and 135 were evaluable (PCEA=67; PCA=68). Over 75% of the women in this study had gynecologic cancer. Patients in the PCEA arm had significantly less postoperative pain at rest on Day 1 and during the first 3 postoperative days when coughing compared to the PCA arm (P<0.05). The mean pain score at rest on Day 1 was 3.3 for the PCEA group compared to 4.3 for the PCA group (P=0.01). Overall, postoperative pain at rest and while coughing in the first 6 days was less in women treated with PCEA compared to PCA (P<0.003)., Conclusions: PCEA offers superior postoperative pain control after laparotomy for gynecologic surgery compared to traditional IV PCA. Women requiring major open surgery for gynecologic cancer should be offered PCEA for postoperative pain management if there are no contraindications.

Background: The aim was to describe the rate of laparoscopic trocar-related subcutaneous tumor implants in women with underlying malignant disease., Methods: An analysis of a prospective database of all patients undergoing transperitoneal laparoscopic procedures for malignant conditions performed by the gynecologic oncology service., Results: Between July 1991 and April 2007, laparoscopic procedures were performed in 1694 patients with a malignant intraabdominal condition and in 505 breast cancer patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures without intraabdominal disease. Port-site metastases were documented in 20 of 1694 patients (1.18%) who underwent laparoscopic procedures for a malignant intraabdominal condition. Of these, 15 patients had a diagnosis of epithelial ovarian or fallopian tube carcinoma, 2 had breast cancer, 2 had cervical cancer, and 1 had uterine cancer. Nineteen of 20 patients (95%) had simultaneous carcinomatosis or metastases to other sites at the time of port-site metastasis. Patients who developed port-site metastases within 7 months from the laparoscopic procedure had a median survival of 12 months whereas patients who developed port-site metastasis >7 months had a median survival of 37 months (P=0.004). No port-site recurrence was documented in patients undergoing risk-reducing, diagnostic or therapeutic laparoscopic procedures for breast cancer without intraabdominal disease., Conclusion: The rate of port-site tumor implantation after laparoscopic procedures in women with malignant disease is low and almost always occurs in the setting of synchronous, advanced intraabdominal or distant metastatic disease. The presence of port-site implantation is a surrogate for advanced disease and should not be used as an argument against laparoscopic surgery in gynecologic malignancies.

Pelvic and paraaortic lymph nodes are common sites of metastases from gynecologic malignancies and may act as a sanctuary of chemoresistant tumor cells in some patients. There is no doubt that the evaluation of the regional lymph nodes provides important prognostic information for patients with gynecologic malignancies. The rationale is a more accurate assessment of the extent of disease, allowing for better individualization of adjuvant therapy. Nonetheless, the therapeutic role of systematic lymphadenectomy in patients with gynecologic malignancies is still under debate. The retroperitoneal lymph node dissection (RPLND) has been shown to prolong survival for patients with chemorefractory ovarian immature teratoma. Furthermore, RPLND is an important aspect of post-chemotherapy debulking surgery for nonseminomatous germ cell tumors, which is the counterpart of the ovarian immature teratoma. Therefore, the ability to perform an extensive RPLND is an important skill in the surgical armamentarium of the gynecologic oncologist. In the following article we outline the surgical anatomy and describe the essential steps of the RPLND.

Minimally invasive surgery has been performed since the early 1990s, and gynecologic oncology surgeons continue to improve their skills for this procedure. Advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Laparoscopy has significant benefits in selected oncologic patients and may be a more useful technique than the abdominal approach. The benefits of laparoscopy include less postoperative pain, less blood loss, shorter length of hospital stay, and a shorter recovery period with no significant increase in complications or morbidity. With emerging data, it appears that the risk of cancer recurrence does not increase with a minimally invasive approach. The incorporation of laparoscopic pelvic and para-aortic lymphadenectomy has expanded the types of procedures performed for the management of certain gynecologic malignancies. New techniques, including hand-assisted laparoscopic procedures and extraperitoneal lymph node dissections, are expanding the role of laparoscopy in the treatment of all gynecologic malignancies.

Clinicians, researchers, and survivorship communities are beginning to recognize the late effects of cancer treatment, such as infertility, and the negative impact this can have on cancer survivorship. Reproductive concerns that emerge within cancer experiences have been shown to be negatively associated with quality of life. Gynecologic cancer can present before childbearing has been started or completed, during pregnancy, or can even arise out of pregnancy, as is the case with gestational trophoblastic disease. Parenthood has been cited as an important aspect of cancer survivorship. As a result, interest concerning fertility preservation, reproductive concerns, and family-building options in cancer survivorship has increased, in addition to awareness of the emotional ramifications of cancer-related infertility. Education and support are clearly an essential component of cancer survivorship. Furthermore, more attention and investigation is still needed about the reproductive issues of gynecologic cancer survivors in the future.

The role of minimally invasive surgery in the management of gynecologic cancers continues to expand. Radical vaginal trachelectomy with laparoscopic pelvic lymphadenectomy has emerged as a safe, reasonable option for women with early-stage cervical cancer desiring fertility preservation. Similarly, laparoscopically assisted radical vaginal hysterectomy has been systematically described, is feasible, and can be offered to women with early-stage cervical cancer who do not desire future childbearing. In the treatment of early-stage endometrial cancer, the surgical approach of laparoscopic hysterectomy, peritoneal washings, and pelvic and para-aortic lymph node dissection, with or without an omentectomy, is being compared with the same surgery performed via laparotomy in the cooperative Gynecologic Oncology Group LAP 2 study, which has completed accrual, and appears to be a reasonable surgical option. In ovarian cancer, minimally invasive surgery has been incorporated to manage early-stage, advanced-stage, and recurrent disease, as well as second-look procedures. Hand-assisted laparoscopy has also recently been described in managing larger volume primary and recurrent gynecologic cancers. Extraperitoneal laparoscopy for para-aortic and pelvic lymph node dissections has been shown to yield adequate nodal counts and to be safe and feasible in the management of gynecologic cancers.

Objectives: To determine the incidence and prognostic implications of positive mesorectal lymph nodes in patients undergoing total pelvic exenteration for recurrent gynecologic malignancies., Methods: We performed a retrospective chart review of all patients who had undergone total pelvic exenteration for a gynecologic malignancy between July 1992 and December 2003. Patient charts were reviewed for information regarding demographics, site of cancer, histology, pathology report, and time to recurrence., Results: Fifty-eight women had undergone total pelvic exenteration for recurrent gynecologic malignancies during the study period and 57 were available for analysis. Primary cancer site was as follows: cervix, 37 (65%); vagina, 8 (14%); vulva, 5 (9%); and uterine corpus, 7 (12%). In 30 patients (53%), the mesorectal lymph node status was pathologically evaluated. Of these 30 patients, 3 (10%) had positive mesorectal lymph nodes at the time of total pelvic exenteration. All 3 patients had rectal wall involvement (rectal submucosa, 2; rectal mucosa, 1), and all 3 patients recurred within 4 months of pelvic exenteration. The median time to recurrence after surgery was 2.4 months in those patients with positive mesorectal lymph nodes compared with 7.3 months in those with negative mesorectal lymph nodes (P = 0.005). When individually adjusted for other prognostic variables, such as margin status, tumor grade, lymphovascular space involvement, primary cancer site, and histologic type, a finding of positive mesorectal lymph nodes was associated with a shorter time to recurrence of disease (all P < 0.05)., Conclusions: Mesorectal lymph node involvement is a common finding at total pelvic exenteration, particularly in patients with rectal wall involvement. Patients with positive mesorectal lymph nodes appear to have a worse outcome with a shorter time to recurrence of disease.

Laparoscopy, a minimally invasive surgery, may benefit select patients more than traditional abdominal approaches. The benefits of this procedure include low morbidity, shorter length of hospital stay, less blood loss, no significant increase in complications, and a shorter postoperative recovery period; this allows patients to begin adjuvant therapy more quickly. Laparoscopy has been used in gynecologic oncology since the early 1990s and has continued to grow and develop. Complex gynecologic oncology procedures can be performed with a low rate of complication and a low rate of conversion to laparotomy. The literature supports the fact that laparoscopy can be performed with short-term benefit with no increase in morbidity. Although the data are limited and emerging, the risk of cancer recurrence does not appear to increase because of this minimal access approach. Currently, advanced laparoscopic techniques are used to evaluate and treat cervical, endometrial, and ovarian malignancies. Specifically, transperitoneal laparoscopic lymphadenectomy including pelvic and paraaortic nodes is a feasible and efficacious procedure in the management of certain gynecologic malignancies.

Objective: The objective of this study was to empirically assess the emotional and sexual impact of cancer-related infertility in women with a history of gynecologic cancer., Method: Women with a history of gynecologic cancer were approached during their gynecologic oncology clinic appointment; they were provided a description of the study and asked to participate. All participants completed a one-time self-report survey. We present data acquired via the following methods: Center for Epidemiologic Studies-Depression Scale (CES-D), Impact of Events Scale (IES), Modified Inventory of Traumatic Grief (M-ITG), Female Sexual Function Index (FSFI), and the Menopausal Symptom Checklist., Results: The study sample consisted of 20 women, ages 27 to 49 years (mean, approximately 40 years), who had undergone treatment for cervical (40%), ovarian (20%), or uterine (40%) cancer. Forty percent of the sample reported depressive symptoms as measured by the CES-D, with 35% of the women experiencing moderate to severe levels of distress as measured by the IES. The women in this sample experienced dissatisfaction with their overall sex lives (67%), pain during vaginal penetration (62%), and low levels of sexual desire (56%)., Conclusions: The preliminary findings of this study indicated that feelings of depression, grief, stress, and sexual dysfunction are being experienced by women with a history of gynecologic cancer who have lost their fertility as a result of their cancer treatment.

Objective: The purpose of this study was to analyze our initial 10-year experience with laparoscopy and to determine risk factors for complications and conversions to laparotomy for technical difficulty., Study Design: We reviewed the charts of all laparoscopic procedures from January 1991 through December 2000 and divided the procedures into 4 levels on the basis of the degree of difficulty: level I, diagnostic; level II, procedures on the uterus and/or adnexa; level III, second look operations for malignancy; and level IV, lymphadenectomies/other complex procedures. Complications were graded from 1 (mild) to 5 (death). Standard univariate and multivariate analyses were performed., Results: We identified 1451 evaluable procedures. The number of complications was as follows: grades 1 to 5, 129 complications (9%); grades 3 to 5, 36 complications (2.5%). On multivariate analysis, older age ( P = .03), previous radiation ( P = .03), and malignancy ( P = .006) were associated with an increased risk of complications grades 3 to 5. Complication rates for grades 3 to 5 for patients with malignancy versus benign disease was 4% versus 1%, respectively. Technical difficulty led to conversion to laparotomy in 105 cases (7%). Previous abdominal surgery ( P < .001) significantly increased the rate of conversion to laparotomy; more complex, higher procedure levels were associated with a significant decrease in conversions ( P = .005)., Conclusion: Both simple and complex laparoscopic procedures can be performed by a gynecologic oncology service with a low rate of complications and conversions to laparotomy. Older age, malignancy, previous radiation therapy, and previous abdominal surgery were identified as significant risk factors for complications and/or conversion and should be taken into account in patient selection, preoperative counseling, and surgical planning.

Objective: To describe the incidence of clinically detected laparoscopy-related subcutaneous tumor implantation in women with malignant disease who were treated by a gynecologic oncology service., Methods: We reviewed all cases of primary or metastatic malignancy who underwent a transperitoneal laparoscopy. Open laparoscopy technique was used in all cases with the Hasson trocar, usually placed near the umbilicus. A carbon dioxide pneumoperitoneum was used in all cases, with maximum intraabdominal pressure set at 15 mm Hg. All trocar sites more than 5 mm were closed at the fascia level. Identifying subcutaneous implantation was performed by a detailed review of all available medical records and by review of a prospectively maintained comprehensive complications database., Results: In a 12-year period (July 1991 to July 2003), 2,593 laparoscopic procedures were performed, including 1,335 transperitoneal laparoscopies in 1,288 women with malignant disease. Malignant disease sites included adnexa/peritoneum (584), uterine corpus (355), uterine cervix (100), and other (249). There were no "isolated" trocar-related subcutaneous tumor implantations during the study period. Subcutaneous tumor implantations (n = 13, 0.97%) usually occurred with carcinomatosis, with synchronous metastases to other sites, and in the setting where the preceding laparoscopy was performed in the presence of advanced or recurrent abdominopelvic disease., Conclusion: Laparoscopy-related subcutaneous tumor implantation is rare (0.97%) in women undergoing transperitoneal laparoscopy with malignant disease. Subcutaneous implantation appears to occur in patients with known metastatic disease and is detected in the setting of synchronous advanced intraabdominal or pelvic metastasis and progression of carcinomatosis. The risk of subcutaneous tumor implantation should not be used as an argument against laparoscopy in the majority of women with gynecologic malignancies managed by gynecologic oncologists., Level of Evidence: II-2

This clinical needs assessment retrospectively identified 11 women with a history of gynecologic cancer who had undergone pelvic exenteration within the last 4 years, of whom six were available for interview. All patients agreed to telephone interviews, which lasted approximately 45-60 min and addressed their surgical experience. Seven themes emerged from the interviews: concerns about recovery, complications, ostomies, social support, sexuality, disclosure, and fear. The findings of our needs assessment concur with the existing literature noting decreased sexual interest/activity and difficulties with body image. An improvement in mood and an increase in activities over time postoperatively were noted. We also found reluctance by participants to disclose information about their exenterative procedure., (Copyright 2003 John Wiley & Sons, Ltd.)

Objective: The objective was to describe the results, technique, and complications of transperitoneal laparoscopic (LSC) pelvic and aortic lymph node dissection (LND) using the argon-beam coagulator (ABC) and monopolar electrosurgical instruments in women with gynecologic malignancies., Methods: A retrospective chart review of 114 patients who underwent LSC pelvic and/or aortic LND in addition to other LSC procedures between 1/1994 and 12/2001 was conducted. All intraoperative complications and complications that occurred within the first 30 postoperative days were included. Complications were graded according to an institutional surgical secondary events reference. During the same time period, 89 patients underwent LSC followed immediately by laparotomy that included LND, resulting in a total of 203 cases. These 203 total cases are used as a denominator to determine the etiology of cases converted from LSC to laparotomy. Monopolar electrosurgical instruments or the 10-mm ABC (Conmed) set at 70 W with argon flow of 3-4 L/m min were used for laparoscopic nodal dissection., Results: Sixty-one of 114 (53%) patients underwent pelvic LND, 35 (31%) underwent both pelvic and aortic LND, and 18 (16%) underwent aortic LND only. Mean patient age and body mass index were 53.3 years (range, 16 to 87 years) and 25 (range, 16 to 40), respectively. In addition, the mean number of pelvic and aortic lymph nodes removed was 10.7 (range, 1 to 39) and 5.7 (range, 0 to 21), respectively. The mean estimated blood loss was 151 mL (range, 25 to 600 ml) and the mean hospital stay was 2.8 days (range, 0 to 35 days). Overall, complications occurred in eight (7%) cases. There were no fatal complications, and no patient required conversion to laparotomy due to uncontrollable bleeding from the laparoscopic nodal dissection. Only 17 of 203 (8%) patients required conversion to laparotomy secondary to adhesions and unsatisfactory exposure., Conclusion: Laparoscopic pelvic and aortic LND for gynecologic malignancies can be satisfactorily performed in the majority of patients, with only 8% of patients requiring conversion to laparotomy due to adhesions or unsatisfactory exposure. The overall complication rate was 7% and was limited to grade 3 or less.