Search

After the publication of the Laparoscopic Approach to Cervical Cancer (LACC) trial, open surgery has become the standard approach for radical hysterectomy in early stage cervical cancer. Recent studies assessed the role of a non-radical approach in low risk cervical cancer and showed no survival difference compared with radical hysterectomy. However, there is a gap in knowledge regarding the oncologic outcomes of minimally invasive simple hysterectomy in low risk cervical cancer. This review offers an overview of the current evidence on the role of the minimally invasive approach in low risk cervical cancer and raises the need for a new clinical trial in this setting., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: This study aimed to evaluate the prevalence of concurrent endometrial cancer in patients pre-operatively diagnosed with atypical endometrial hyperplasia undergoing hysterectomy. Additionally, we assessed the occurrence of high to intermediate-risk and high-risk tumors according to the ESGO-ESTRO-ESP classification. The study also compared surgical outcomes and complications between patients undergoing simple hysterectomy and those undergoing hysterectomy with sentinel lymph node biopsy., Methods: In this multicenter retrospective study, patients with a pre-operative diagnosis of atypical endometrial hyperplasia were identified and divided into two groups: Group 1, which included patients treated with total hysterectomy with or without bilateral salpingo-oophorectomy, and Group 2, where sentinel lymph node biopsy was incorporated into the standard surgical treatment., Results: Among 460 patients with atypical endometrial hyperplasia, 192 received standard surgical management (Group 1) and 268 underwent sentinel lymph node biopsy (Group 2). A total of 47.2% (95% CI 42.6% to 51.7%) of patients were upgraded to endometrial cancer on final histopathological examination. High to intermediate-risk and high-risk tumors constituted 12.3% and 9.2% in Group 2 and 7.4% and 3.7% in Group 1. Lymph node metastases were identified in 7.6% of patients with concurrent endometrial cancer who underwent nodal assessment with at least unilateral mapping. Of the 12 sentinel lymph node metastases, 75.0% were micrometastases, 16.7% macrometastases, and 8.3% isolated tumor cells. No significant differences were found in estimated blood loss, operative time, and intra-operative and post-operative complications between the two groups. The rate of patients undergoing sentinel lymph node biopsy doubled every 2 years (OR 2.010, p<0.001), reaching 79.1% in the last 2 years., Conclusion: This study found a prevalence of concurrent endometrial cancer of 47.2%, and sentinel lymph node biopsy provided prognostic and therapeutic information in 60.8% of cases. It also allowed for the adjustment of adjuvant therapy in 12.3% of high to intermediate-risk patients without increasing operative time or complication rates., Competing Interests: Competing interests: None declared., (© IGCS and ESGO 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

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.)

Introduction: The primary aim of the present study was to assess the incidence of ovarian metastasis/recurrence and the survival of patients undergoing radical hysterectomy with ovarian conservation (CONSERV) versus oophorectomy (OOPHOR). Secondary aim was to assess the incidence and the characteristics of menopausal symptoms in both groups., Materials and Methods: Retrospective, multi-center, observational cohort study including patients <50 years with clinical FIGO 2009 stage IA1-IB1/IIA1 cervical carcinoma, treated by primary surgical treatment between 02/2007 and 07/2019. One-to-one case-control matching was used to adjust the baseline prognostic characteristics in survival analysis., Results: 419 patients were included. 264 in the OOPHOR (63.0%) and 155 (37.0%) in the CONSERV group. Ovarian transposition was performed in 28/155 (18.1%) patients. 1/264 (0.4%) patient had ovarian metastasis from endocervical adenocarcinoma. After propensity-matching, 310 patients were included in the survival analysis (155 per group). 5-year disease-free survival of patients undergoing CONSERV versus OOPHOR was 90.6% versus 82.2%, respectively (p = 0.028); 5-year overall survival was 94.3% versus 90.8%, respectively (p = 0.157). Two patients (1.3%) developed recurrence on the conserved ovary. CONSERV represented an independent protective factor of recurrence (HR:0.361, 95%CI 0.169-0.769; p = 0.008). 28 (20.6%) in the CONSERV group versus 116 (60.4%) in the OOPHOR group complained of menopausal symptoms during follow up (p < 0.001). HRT was prescribed to 12.0% of patients (median HRT time was 20 months)., Conclusion: CONSERV was associated with reduced risk of recurrence and menopausal symptoms in early-stage cervical cancer. As the risk of ovarian metastasis and ovarian recurrence is relatively low, CONSERV in pre-menopausal women has to be considered., Competing Interests: Declaration of competing interest The authors declare no conflict of interest., (Copyright © 2021 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Background: The aim of the present study was to assess the prognostic value of tumour-free distance (TFD), defined as the minimum distance of uninvolved stroma between the tumour and peri-cervical stromal ring, in early-stage cervical cancer., Methods: Patients with pathologic FIGO 2009 stage IA1-IIA2 cervical cancer, treated by primary radical surgical treatment between 01/2000 and 11/2019, were retrospectively included. Adjuvant treatment was administered according to the presence of previously established pathologic risk factors. TFD was measured histologically on the hysterectomy specimen. Pre-operative TFD measured at MRI-scan from a cohort of patients was reviewed and compared with pathology TFD., Results: 395 patients were included in the study. 93 (23.5%) patients had TFD ≤ 3.0 mm and 302 (76.5%) had TFD > 3.0 mm. TFD ≤ 3.0 mm together with lymph vascular space involvement represented the strongest predictor for lymph node metastasis at multivariate analysis. TFD ≤ 3.0 mm was associated with worse 5-year disease-free survival (DFS) and overall survival (OS), compared with TFD > 3.0 mm (p = 0.022 and p = 0.008, respectively). DFS difference was more evident in the subgroup of patients with low-risk factors who did not receive adjuvant treatment (p = 0.002). Cohen's kappa demonstrated an agreement between TFD measured at pre-operative MRI-scan and histology of 0.654., Conclusions: Pathologic TFD ≤ 3.0 mm represents a poor prognostic factor significantly associated with lymph node metastasis and it may be considered a novel marker to select candidates for adjuvant treatment. The possibility to obtain this parameter by radiological imaging makes it a potential easy-measurable pre-operative marker to predict the presence of high-risk pathologic factors in early-stage cervical cancer., (© 2021. The Author(s), under exclusive licence to Cancer Research UK.)

Objective: To assess predictors of recurrence following laparoscopic radical hysterectomy (LRH) for apparent early stage cervical cancer (CC)., Methods: This is a retrospective multi-institutional study reviewing data of consecutive patients who underwent LRH for FIGO 2009 stage IA1 (with lymphovascular space invasion (LVSI)), IA2 and IB1(≤4 cm) CC, between January 2006 and December 2017. The following histotypes were included: squamous, adenosquamous, and adenocarcinoma. Multivariable models were used to estimate adjusted odds ratio (OR) and corresponding 95% CI. Factors influencing disease-free survival (DFS) and disease-specific survival (DSS) were also explored., Results: 428 patients were included in the analysis. With a median follow-up of 56 months (1-162) 54 patients recurred (12.6%). At multivariable analysis, tumor size (OR:1.04, 95%CI:1.01-1.09, p = .02), and presence of cervical residual tumor at final pathology (OR: 5.29, 95%CI:1.34-20.76, p = .02) were found as predictors of recurrence; conversely preoperative conization reduced the risk (OR:0.32, 95%CI:0.11-0.90, p = .03). These predictors remained significant also in the IB1 subgroup: tumor size: OR:1.05, 95%CI:1.01-1.09, p = .01; residual tumor at final pathology: OR: 6.26, 95%CI:1.58-24.83, p = .01; preoperative conization: OR:0.33, 95%CI:0.12-0.95, p = .04. Preoperative conization (HR: 0.29, 95%CI: 0.13-0.91; p = .03) and the presence of residual tumor on the cervix at the time of surgery (HR: 8.89; 95%CI: 1.39-17.23; p = .01) independently correlated with DFS. No independent factors were associated with DSS., Conclusions: In women with early stage CC the presence of high-volume disease at time of surgery represent an independent predictor of recurrence after LRH. Conversely, preoperative conization and the absence of residual disease at the time of surgery might play a protective role., Competing Interests: Declaration of Competing Interest All authors do not have any personal or financial conflict of interest to declare., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Objective: To analyze all published studies comparing minimally invasive surgery (MIS) with laparotomic one in the surgical treatment of high-risk endometrial cancer (EC) in term of operative, peri-operative and oncological outcomes., Data Sources: We conducted a systematic literature search in PubMed between January 1995-March 2019., Methods of Study Selection: Titles and abstracts were analyzed by two reviewers. A set of explicit criteria was used for selection of literature: 1) randomized controlled trials (RCT), prospective or retrospective cohort studies, given the rarity of this tumor and the concomitant lack of data in the form of large trials, all reviewed original report publications with an appropriate number of subjects were considered and included; 2) participants of interest being patients who have suffered from high risk EC 3) the outcome measures including overall survival (OS), disease-free survival (DFS) and recurrence, (4) English language, (5) abstract available., Results: Thirty relevant articles were selected for full reading. For final analysis 20 studies were selected. Then, as second step, the full articles were evaluated to determine whether full inclusion criteria were met. In total, 9 papers were identified and included., Conclusion: MIS appears to be safe in the management of high-risk EC patients, showing better perioperative and postoperative outcomes and comparable oncological outcomes than open surgery. Prospective randomized trial would be needed to confirm this data., Competing Interests: Declaration of competing interest Authors declare to have nothing to disclose., (Copyright © 2019 Elsevier Ltd, BASO ~ The Association for Cancer Surgery, and the European Society of Surgical Oncology. All rights reserved.)

Objective: This multicentric prospective phase II study aimed to investigate the feasibility, safety, and efficacy of percutaneous-assisted laparoscopic hysterectomy in terms of perioperative outcomes, feasibility, VAS score, and cosmetic outcomes., Study Design: Between May 2015 and October 2017, 382 patients were considered eligible for minimally invasive percutaneous-assisted laparoscopic hysterectomy using Percuvance™, Percutaneous Surgical System - PSS, TELEFLEX ltd. Among them, 80 patients (20.9 %) met the inclusion criteria and were enrolled in the study. The coordinator center was the Division of Gynecologic Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy. Enrolled patients underwent total percutaneous-assisted laparoscopic hysterectomy ± bilateral salpingo-oophorectomy ± nodal assessment., Results: The median age was 52 (range, 32-80) years, and the median body mass index was 25 kg/m 2 (range, 16-37). Thirty-five patients (43.8 %) had previous surgery. A median operative time of 82.5 (range, 40-190) minutes and a median estimated blood loss of 50 (50-500) mL were registered. We observed 1 (1.3 %) intraoperative complication. The median time to discharge was 1 (range, 1-5) day. Patients were extremely satisfied with the scar evaluation and postoperative pain control. Five (6.25 %) complications were recorded within 30 days after surgery., Conclusion: Percutaneous-assisted technique for extrafascial hysterectomy achieved excellent results in terms of feasibility, safety, and efficacy, even in complex cases and advanced surgical procedures. Therefore, the technique appears to balance the limitations and advantages of minimal surgical invasiveness and standard approach efficacy., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Study Objective: The effect of the different types of vaginal cuff closures on posthysterectomy sexual function has not been investigated in depth. We evaluated if there is a difference between transvaginal versus a laparoscopic closure after total laparoscopic hysterectomy (TLH) on female sexual function, using a validated questionnaire., Design: Secondary analysis of a prospective randomized controlled trial., Setting: Three academic research centers., Patients: Women consenting to telephone interviews on their sexual life before and after undergoing TLH were included., Interventions: Patients were randomly assigned to a laparoscopic or transvaginal approach for vaginal cuff closure at the end of TLH for benign indications., Measurements and Main Results: A validated questionnaire (the Female Sexual Function Index [FSFI]) was used to explore sexuality before and after the operation. Of the 1408 patients enrolled in the primary study, 400 patients were asked to complete the questionnaire. Of them, 182 (41.4%) were eligible and accepted enrollment in the present analysis. No difference was found in terms of pre- and postoperative FSFI scores between groups. Patients with a low preoperative FSFI score (<26.55) had a significantly higher likelihood of having a postoperative sexual disorder (p <.001). Women who received bilateral adnexectomy before menopause and those with postoperative vaginal cuff hematoma had a significantly lower postoperative FSFI score (p = .001 and p = .04, respectively). After multivariable analysis, both variables maintained at least a tendency toward an association with a lower postoperative FSFI score (odds ratio, 2.696; 95% confidence interval, 1.010-7.194; p = 0.048 and p = 0.053; odds ratio, 13.2; 95% confidence interval, .966-180.5, respectively)., Conclusion: Transvaginal and laparoscopic cuff closures after TLH have similar sexual postoperative outcomes. A patient with sexual problems before TLH is more likely to have a low FSFI score postoperatively. Premenopausal patients undergoing bilateral ovariectomy and those with postoperative vaginal cuff hematoma have a worse postoperative sexual life. (Clinicaltrials.gov, protocol number NCT02453165, registration date May 25, 2015.)., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To reveal principles and the feasibility of a total laparoscopic hysterectomy (TLH) with uterine artery ligation at the origin., Design: Step-by-step demonstration and explanation of technique using videos from patients., Setting: Gynecologic oncology unit at a university hospital., Patient: A 54-year-old woman with uterine fibromatosis and metrorrhagia., Intervention: TLH has 7 common components. First, round ligaments are coagulated and cut to enter the retroperitoneum. The ureter is identified. Second, pararectal spaces are entered between the ureter and the internal iliac artery. This maneuver allows the identification of the uterine artery as it leaves its origin from the internal iliac artery. The uterine vessels are stapled with a vascular endoscopic stapler at their origin from the hypogastric vessels or sealed with a bipolar device. Third, adnexal structures are separated from the uterine corpus for subsequent preservation or removal. Fourth, the blood supply is dissected, occluded, and divided before extirpation of the uterine corpus. Fifth, the cardinal ligament complex is transected with colpotomy, and the cervix is amputated from the vaginal apex. Sixth, the specimen is removed. Finally, the vaginal cuff is closed [1]., Measurements and Main Results: Laparoscopic hysterectomy was first described by Reich et al. [2] in 1989 and has slowly gained popularity. Today, hysterectomy is the most common gynecologic procedure performed. TLH is where the entire operation (including suturing of the vaginal vault) is performed laparoscopically and there is no vaginal component except for the removal of the uterus. Currently, hysterectomies are performed by different approaches, and individual surgeons have different indications for the approach to hysterectomy based largely on their own array and patient characteristics. TLH requires the highest degree of laparoscopic surgical skills [3], and knowledge of pelvic anatomy defines a safe space for sharp entry into the retroperitoneum and safe identification of pelvic vasculature., Conclusion: We present an educational video with step-by-step explanation of the technique to highlight the anatomic landmarks that guides the procedure., (Copyright © 2019 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the feasibility of percutaneous approach, we prospectively compared our experience in percutaneous-assisted hysterectomy (PSS-H) with that in a series of laparoscopic hysterectomies (LPS-Hs)., Methods: In this multicentric cohort study, from May 2015 to October 2017, 160 patients affected by benign and malignant gynecological conditions were considered eligible for minimally invasive surgery (MIS): 80 patients received PSS-H and 80 LPS-H. In each group, 30 cases of low-/intermediate-risk endometrial cancer were enrolled. For both groups, we documented preoperative outcomes, postoperative pain, and cosmetic outcomes., Results: No statistically significant differences were noted in baseline characteristics or operative time. We observed significant differences in estimated blood loss: median of 50 cc (PSS-H) and 100 cc (LPS-H) (p = 0.0001). In LPS-H, we reported 4 (5.0%) intraoperative complications and 1 (1.3%) in PSS-H. Thirty-day complications were 4 (5%) in PSS-H and 11 (13.8%) in LPS-H (p = 0.058). No significative differences were found in visual analog scale score, despite a relevant disparity in cosmetic outcome (p = 0.0001). For oncological cases, the 2 techniques had comparable intra- and postoperative outcomes and oncological accuracy., Conclusions: In this study, we reported that PSS-H is comparable to LPS-H for intra- and perioperative outcomes and postoperative pain, while PSS-H seems to be superior in cosmetic outcomes and patient satisfaction. PSS-H may represent a valid alternative in ultra-MIS for benign gynecological conditions and low-/intermediate-risk endometrial cancer., (© 2020 S. Karger AG, Basel.)

Objective: To investigate the safety, feasibility and oncological adequacy of the Percutaneous Surgical System - PSS in a consecutive series of low-risk endometrial cancer staging., Study Design: From May 2015 to April 2017, we prospectively performed 30 consecutive percutaneous staging for low/intermediate risk endometrial cancer (FIGO stage IA G1-G2, IB G1-G2, IA G3). All patients were divided in two different groups on the basis of surgical procedure received: Group A included patients submitted to radical Class A hysterectomy and bilateral salpingo-oophorectomy; Group B concerned patients that received a lymph nodal assessment also., Results: The time needed to install percutaneous instruments and suprapubic trocar was 4 min. (range 2-10). The recorded median operative time (OT) was 80 min. (range 65-120) for Gr.A and 143 min. (range 107-190) for Gr.B, in which the median time of lymph nodal assessment was 55 min. (range 20-76). The median time for hysterectomy was 60 min. (range 40-110) in all cases. Lymph nodal assessment was performed in 14 (46.6%) cases: 7 sentinel node mapping, 7 pelvic lymphadenectomy. No intraoperative complications or LPS/LPT conversions were recorded. Median discharge time was 2 days (range 1-4), 5 patients were discharged in 3rd post-op day, and only 1 patient was discharged in 4th day for fever. All patients conveyed high satisfaction with the cosmetic results. A progressive overall reduction of pain perception was observed at 24 h after surgery. Median follow-up was of 14 months (range 12-36), no recurrences have been detected., Conclusions: PSS seems to be a feasible approach for endometrial cancer staging. Larger experiences and prospective comparative studies are important to assess our assumptions and further investigate the real benefits of percutaneous surgical system., (Copyright © 2019 Elsevier B.V. All rights reserved.)

We present the first reported case of a patient with a forgotten ureteral stent. A 68-year-old woman had undergone radical hysterectomy for cervical cancer in 1997, at which time bilateral ureteral stents were placed. She was admitted to our hospital with stranguria, dysuria, and lower back pain of 10 days duration. Preoperative radiologic evaluation revealed the presence of ureteral stents, which had been in place since 1997. With the patient under general anesthesia, the bilateral stents were removed by urethral cystoscopy. No stone formation was noted. The procedure was easy and fast, and no intraoperative complications occurred., (Copyright © 2018 American Association of Gynecologic Laparoscopists. Published by Elsevier Inc. All rights reserved.)

Background: Vaginal cuff dehiscence following hysterectomy is considered an infrequent but potentially devastating complication. Different possible techniques for cuff closure have been proposed to reduce this threatening adverse event., Objective: The aim of the present randomized study was to compare laparoscopic and transvaginal suture of the vaginal vault at the end of a total laparoscopic hysterectomy, in terms of incidence of vaginal dehiscence and vaginal cuff complications. Factors associated with vaginal dehiscence were also analyzed. This article presents the results of the interim analysis of the trial., Study Design: Patients undergoing total laparoscopic hysterectomy for benign indications were randomized at the time of colpotomy to receive vaginal closure through transvaginal vs laparoscopic approach using a 1:1 ratio. Allocation concealment was obtained using a password-protected randomization database. Monopolar energy for colpotomy was set at 60W. Vaginal closure was performed with a single-layer running braided and coated 0-polyglactin suture. In all cases an attempt was performed to include the posterior peritoneum in the suture. Laparoscopic knots were tied intracorporeally. All patients were scheduled for a postoperative follow-up visit 3 months after surgery, to detect possible vaginal cuff complications. Univariate and multivariable analyses were performed to identify independent predictors of vaginal cuff dehiscence after total laparoscopic hysterectomy., Results: After enrollment of 1408 patients, a prespecified interim analysis was conducted. Thirteen (0.9%) women did not undergo the postoperative assessment and were excluded. Baseline characteristics of the 1395 patients included (695 in the transvaginal group and 700 in the laparoscopic group) were similar between groups. Patients in the transvaginal group had a significantly higher incidence of vaginal dehiscence (2.7% vs 1%; odds ratio, 2.78; 95% confidence interval, 1.16-6.63; P = .01) and of any cuff complication (9.8% vs 4.7%; odds ratio, 2.19; 95% confidence interval, 1.43-3.37; P = .0003). Based on these findings, the data monitoring committee recommended that the trial be terminated early. After multivariable analysis, transvaginal closure of the vault was independently associated with a higher incidence of vaginal dehiscence and any vaginal complication; premenopausal status and smoking habit were independently associated with a higher risk of dehiscence., Conclusion: Laparoscopic closure of the vaginal cuff at the end of total laparoscopic hysterectomy is associated with a significant reduction of vaginal dehiscence, any cuff complication, vaginal bleeding, vaginal cuff hematoma, postoperative infection, need for vaginal resuture, and reintervention., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Introduction: The aim of this study was to identify, quantify and evaluate the use of robotic materials and operating theatre times in Telelap ALF-X robotic hysterectomy., Materials and Methods: Cost analysis was performed on 81 patients who underwent a Telelap ALF-X robotic hysterectomy. Data were collected during a phase II study trial conducted at the University Hospital A. Gemelli, Catholic University, Rome. According to micro-costing technique, surgical team costs, materials and operating theatre usage were recorded during each surgical intervention. Cost data were provided by the hospital's accounting office. Probabilistic sensitivity analysis was carried out in order to test the robustness of the results by assuming an Inv-norm random variable., Results: The base case analysis showed a cost/patient of €3391.82. The new robotic device requires a low consumption of robotic materials. Sensitivity analysis showed that the most sensitive cost driver was use of the operating theatre., Conclusion: This study shows that Telelap ALF-X robotic hysterectomy is feasible and safe and could offer specific advantages in terms of cost. Copyright © 2016 John Wiley & Sons, Ltd., (Copyright © 2016 John Wiley & Sons, Ltd.)

Background: To compare patterns and rates of early and late complications, and survival outcome in FIGO stage III cervical cancer patients underwent to radical hysterectomy after chemo-radiation (CT-RT) vs. chemo-radiation alone., Methods: Between May 1996 and April 2013 150 FIGO stage III cervical cancer patients were treated. We divide patients according to type of treatment: 77 were submitted to standard treatment (Group A), and 73 to completion hysterectomy after chemo-radiation (Group B)., Results: The baseline characteristics of the 2 groups were superimposable. We observed lower intra-operative and treatment-related early urinary and gastro-intestinal complications in Group B with respect to Group A (p < 0.001). Vascular complications were registered only in Group B (p < 0.001). We found a significantly higher rate of local recurrences in the Group A than in the Group B (p < 0.002). We registered 29 deaths in the Group A and 22 in the Group B (p = 0.021). The 3-years disease-free survival rate in the Group A and in the Group B was 62.9% and 68.3%, respectively (p = 0.686), and the 3-years overall survival rate in the Group A and in the Group B was 63.2% and 67.7%, respectively (p = 0.675)., Conclusions: This study confirms that radical hysterectomy after CT-RT is an effective therapeutic approach for advanced cervical cancer. Further prospective and randomized studies should be performed in order to solve the question about the standard approach, and how the different pattern of complication could impact on the quality of life., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Study Objective: To compare the feasibility and safety of the TELELAP ALF-X system and standard laparoscopy for total hysterectomy to treat patients with benign and early malignant gynecologic disease., Design: Single-institution retrospective case-control study (Canadian Task Force classification II-2)., Setting: Catholic University of the Sacred Heart, Rome, Italy., Patients: Between October 2013 and May 2015, 203 women underwent TELELAP-ALF X (group 1) or standard laparoscopic (group 2) total hysterectomy and were enrolled., Interventions: Total standard laparoscopy vs TELELAP ALF-X robot-assisted hysterectomy for benign and early malignant gynecologic disease., Measurements and Main Results: In group 1, the median age was 55 years (range, 40-79 years), median body mass index (BMI) was 25 kg/m(2) (range, 17-38 kg/m(2)), and 51 patients (58%) had undergone previous abdominal surgery. In the control group, the median age was 55 years (range, 34-90 years), median BMI was 25 kg/m(2) (range, 17-41 kg/m(2)), and 31 patients (27%) had previous abdominal surgery. The median operative time was 147 minutes (range, 58-320 minutes) in group 1 and 80 minutes (range, 22-300 minutes) in group 2 (p = .055). The median estimated blood loss was 57 mL (range, 0-600 mL) in group 1 and 99 mL (range, 0-400 mL) in group 2, with no significant differences between the 2 groups (p = .963). Procedures were successfully performed without conversion in 94.3% of cases in the group 1 and in all cases in group 2. Early postoperative pain was significantly lower in group 2., Conclusion: TELELAP ALF-X hysterectomy in patients with benign and early malignant gynecologic disease is feasible and safe, and can be considered a valid option for these patients., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

This randomized clinical trial (Canadian Task Force classification I) aimed to compare 2-dimension (2-D) versus 3-dimensional (3-D) laparoscopic hysterectomy and pelvic lymphadenectomy in endometrial and cervical cancer patients. Between December 2014 and March 2015, 90 patients were enrolled: 29 (32.2%) with early or locally advanced cervical cancer after neoadjuvant treatment and 61 (67.8%) with early-stage endometrial cancer. Patients were randomly assigned to undergo 2-D (Group A, n = 48 [53.3%]) or 3-D (Group B, n = 42 [46.7%)]) laparoscopy. Baseline characteristics were superimposable in the 2 groups. Median operative time was similar in the 2 groups. Median estimated blood loss during lymphadenectomy was significantly lower in Group B than in Group A (38 mL [range, 0-450] vs 65 mL [range, 0-200]; p = .033). In cervical cancer patients operative time of pelvic lymphadenectomy performed by "novice" surgeons (those with <10 procedures performed) was statistically significantly lower in Group B (p = .047). No differences in perioperative outcomes and postoperative complications were observed between the 2 groups. The 2-D and 3-D systems can be used safely in laparoscopic hysterectomy. However, the 3-D system could provide key benefits to intraoperative techniques and postoperative outcomes in reducing operative time for "expert" surgeons and in enhancing surgical precision for "novice" surgeons., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To compare the surgical and clinical outcomes of patients affected by early-stage endometrial cancer treated using the Telelap ALF-X platform versus conventional laparoscopic surgery., Design: Single institution retrospective cohort study (Canadian Task Force classification II-2)., Setting: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome, Italy., Patients: The study involved 89 patients affected by early-stage endometrial cancer who underwent elective surgical staging between October 2013 and September 2014. Among them, 43 (48.3%) underwent Telelap ALF-X staging (ALF-X group), and 46 (51.7%) underwent conventional laparoscopic staging (laparoscopic group)., Interventions: All selected patients underwent laparoscopic staging with radical hysterectomy (class A sec Querleu-Morrow), bilateral salpingo-oophorectomy, and pelvic lymphadenectomy if required. The 2 surgical groups were further divided into patients who did not require pelvic lymphadenectomy (subgroup 1) and those who underwent pelvic lymphadenectomy (subgroup 2)., Measurements and Main Results: In the ALF-X group, the median operative time was 128 minutes (range, 69-260 minutes) for subgroup 1 and 193 minutes (range, 129-290 minutes) for subgroup 2. In the laparoscopic group, the median operative time was 82 minutes (range, 25-180 minutes) in subgroup 1 and 104 minutes (range, 36-160 minutes) in subgroup 2. The difference in operative time between subgroups was statistically significant in both the ALF-X and laparoscopic groups (p = .000). In subgroup 1 of the ALF-X group, there was 1 conversion to standard laparoscopy (2.3%) and 2 conversions to laparotomy (4.7%) (p = .234). No conversions to laparotomy occurred in the laparoscopic group. Postoperative complications included 1 case of pelvic hematoma (2.3%) in subgroup 1 of the ALF-X group and 1 case of subocclusion and 1 case of pulmonary edema (4.3%) in subgroup 1 of the laparoscopic group., Conclusion: Based on operative outcomes and complication rates, our results suggest that the Telelap ALF-X approach is feasible and safe for endometrial cancer staging; however, further studies are needed to definitively assess the role of Telelap ALF-X early-stage endometrial cancer staging., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA)., Design: The basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany)., Background: Minilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery., Setting: Catholic University of the Sacred Hearth, Rome, Italy., Patient: A 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required., Intervention: The patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures., Main Results: The operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected., Conclusion: Percutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to maintain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To evaluate the impact of obesity on the outcomes of surgical treatment for endometrial cancer in general and also comparing laparoscopic and open abdominal approach., Design: Retrospective case-control study (Canadian Task Force classification II-1)., Setting: Obstetrics and Gynecology Department, University of Insubria, Varese, Catholic University of the Sacred Heart, Rome, International School of Surgical Anatomy, Sacred Heart Hospital, Negrar, and Sant'Orsola-Malpighi Hospital, Bologna, Italy., Patients: Data of consecutive patients who underwent surgery for endometrial cancer in 4 centers were reviewed. Univariate and multivariable analyses were performed. Adjustment for potential selection bias in surgical approach was made using propensity score (PS) matching., Interventions: Laparoscopic or open surgical treatment for endometrial cancer., Measurements and Main Results: A total of 1266 patients were included, including 764 in the laparoscopy group and 502 in the open surgery group. A total of 391 patients (30.9%) were obese, including 238 (18.8%) with class I obesity, 89 (7%) with class II obesity, and 64 (5.1%) with class III obesity. The total number of complications, risk of wound complications, and venous thromboembolic events were higher in obese women compared with nonobese women. Blood transfusions, incidence/severity of postoperative complications, and postoperative hospital stay were significantly higher in the open surgery group compared with the laparoscopy group, irrespective of obesity. These differences remained significant in both multivariable analysis and PS-matched analysis. The percentage of patients who received lymphadenectomy declined significantly in patients with BMI ≥40 in both the laparoscopy and open surgery groups. Conversions from the initially intended minimally invasive approach to open surgery were 1.1% to 2.2% for women with BMI <40, but increased in those with BMI ≥40 (8.6%; p = .05). PS analysis showed a lower complication rate, shorter hospital stay, and greater likelihood of receiving lymphadenectomy in obese women in the laparoscopic group., Conclusion: Laparoscopy for endometrial cancer retains its advantages over open surgery, even in obese patients. However, operating on obese patients can be challenging regardless of the surgical approach taken, especially in cases of morbid adiposity., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: The aim of this study was to evaluate the surgical and oncologic outcomes of robotic hysterectomy with or without or less pelvic and aortic lymphadenectomy in severely obese patients (body mass index [BMI] ≥ 40 kg/m(2)) with endometrial cancer., Material and Methods: Between August 2010 and November 2014, patients with histologically confirmed endometrial cancer and BMI ≥40 kg/m(2) were deemed eligible for the study and underwent RH with or without pelvic and aortic lymphadenectomy., Results: Seventy patients were divided into 3 groups according to their BMI: group A, BMI between 40 and 45 kg/m(2) (50 patients); group B, BMI between 45 and 50 kg/m(2) (10 patients); and group C, BMI above 50 kg/m(2) (10 patients). No significant statistical differences were found between the 3 groups in terms of operation time, blood loss, hospital stay, and oncologic results. Pelvic lymphadenectomy was performed in 42%, 30%, and 20% of patients in groups A, B, and C, respectively. An intraoperative complication occurred in 1 patient in group A, early postoperative complications in 4 patients in group A and in 1 patient in group C, and a late postoperative complication occurred in 1 patient in group A. No conversions to laparotomy were necessary; however, 3 patients underwent conversions to laparoscopy in group A and 1 patient in both groups B and C., Conclusion: Our study showed that robotic surgery in severely obese patients with endometrial cancer is safe and feasible. Moreover, it seems that an increase in BMI does not change the surgical and oncologic outcomes. However, randomized controlled trials are needed to confirm these results., (Copyright © 2016 AAGL. Published by Elsevier Inc. All rights reserved.)

Study Objective: To show the safety, feasibility, and perioperative outcomes of total TELELAP ALF-X hysterectomy (SOFAR S.p.A., ALF-X Surgical Robotics Department, Trezzano Rosa, Milan, Italy)., Design: Phase II study (Canadian Task Force II-2)., Setting: Catholic University of the Sacred Heart, Rome, Italy., Patients: From October 2013 to May 2014, 80 women underwent total TELELAP ALF-X hysterectomy. The study population was divided into 2 groups according to surgical procedures: total hysterectomy ± bilateral salpingo-oophorectomy (group 1) and endometrial cancer patients staged with pelvic lymphadenectomy (group 2)., Interventions: Total TELELAP ALF-X hysterectomy ± bilateral salpingo-oophorectomy with or without pelvic lymphadenectomy., Measurements and Main Results: The median age was 51 years (range, 48-79), and the median body mass index was 24 kg/m(2) (range, 17.3-34.2). Forty-five patients (56.2%) had previous surgery. The median operative time was 140 minutes (range, 58-320) in group 1 and 197 minutes (range, 129-290) in group 2 (p < .001). The median docking time was 8 minutes (range, 3-25). During the study period, a significant trend in operative time reduction was observed. Procedures were successfully performed without conversion in 93.7% of cases. We observed 2 (2.5%) intraoperative complications, 3 (3.7%) conversions to standard laparoscopy, and 2 (2.5%) to laparotomy. The median time to discharge was 2 days (range, 1-5). One patient (1.2%) was readmitted in the early postoperative period., Conclusion: As new technology evolves, critical appraisal of patient-related outcomes, use, cost, and access to minimally invasive hysterectomy must remain a priority. Despite the relative small number of our series, we showed the feasibility and safety of total TELELAP ALF-X hysterectomy for benign and malignant disease., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the feasibility of laparoscopic radical surgery in patients with locally advanced cervical cancer (LACC) who receive chemoradiation therapy (CT/RT)., Design: Prospective phase II study (Canadian Task Force classification II-1)., Intervention: Patients with LACC (FIGO stage IB2-III) were evaluated for accrual at the Gynecologic Oncology Unit of Catholic University, Rome/Campobasso. Neoadjuvant CT/RT included whole-pelvic irradiation (total dose, 45.0-50.4 Gy) combined with cisplatin and 5-fluorouracil. Objective response to treatment was evaluated according to Response Evaluation Criteria in Solid Tumors criteria. Laparoscopic radical hysterectomy (RH) plus pelvic and/or aortic lymphadenectomy was attempted within 6 to 8 weeks after CT/RT. The feasibility of laparoscopic RH, as well as the rate, pattern, and severity of early and late postoperative complications, were analyzed., Results: Between January 2010 and October 2013, a total of 58 patients were enrolled into the study. After CT/RT, 23 patients (39.6%) underwent type B2 RH, 31 (53.4%) underwent type C1 RH, and 4 (6.9%) underwent type C2 RH. Pelvic lymphadenectomy was performed in all cases. Laparoscopic RH was feasible in 55 of 58 cases (feasibility rate, 94.8%). No intraoperative complications were recorded. During the observation period (median, 22 months; range, 5-50 months), there were 28 complications, of which only 21.4% were grade 2 complications and 14.3% were grade 3 complications. As of January 2015, disease recurrence was documented in 4 cases (6.9%)., Conclusion: Total laparoscopic radical surgery is feasible in patients with LACC receiving preoperative CT/RT, providing perioperative outcomes comparable to those registered in early-stage disease., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the role of bladder training during postoperative hospital stay in patients submitted to nerve-sparing radical hysterectomy, and to identify any clinical or surgical factor associated with postoperative bladder dysfunction., Design, Setting, and Participants: Parallel group randomized single institution trial, on gynaecologic malignancies patients conducted in Catholic University of Sacred Heart Rome, between April 2009 and November 2011. Randomization was on 1:1, using a block randomized computer-generated list., Interventions: Patients underwent Querleu-Morrow type B2 or C1 radical hysterectomy. After 2 days from surgery, patients were randomized to perform or not bladder training (scheduled clamping and unclamping of the trans-urethral catheter every three hours). Main outcome measures Necessity and duration of clean intermittent self catheterization., Results: Randomized participants were 111 women (bladder training arm n = 55; control arm n = 56). A total of 22 women (19.8%) required clean intermittent self catheterization, equally distributed in the two arms. At univariate analysis, only the type of radical hysterectomy was significantly associated with need of clean intermittent self catheterization (type C1 vs. type B2; p = 0.013). At univariate analysis, duration of clean intermittent self-catheterization was not associated with age, BMI, type of hysterectomy and of neo-adjuvant treatment., Conclusions: Functional bladder disfunctions are the most common long-term complications following radical hysterectomy. Systematic postoperative bladder training following nerve-sparing radical hysterectomy does not influence the rate of urinary retention or re-admission for bladder catheterization.

Objective: To assess the feasibility and perioperative outcomes of laparoendoscopic single-site (LESS) hysterectomy in obese and nonobese women., Design: A multicentric retrospective case-control study (Canadian Task Force II-2)., Setting: Catholic University of the Sacred Heart and National Cancer Institute "Regina Elena" (Rome, Italy), Massachusetts General Hospital (Boston, MD), and Johns Hopkins Hospital (Baltimore, MD)., Patients: From July 2009 to April 2013, 120 women underwent LESS hysterectomy. Five women (8%) were excluded from the analysis. The remaining 115 women were divided into 2 groups: obese (n = 43, body mass index [BMI] ≥30 kg/m(2)) and nonobese (n = 72, BMI <30 kg/m(2))., Interventions: Total LESS hysterectomies for malignant and premalignant uterine disease or at least for prophylactic intent were performed., Measurements and Main Results: No statistical differences regarding perioperative outcomes were observed between the 2 groups. Conversion to standard laparoscopy occurred in 2 obese (5%) and 2 (5%) nonobese women (p = .62). Conversion to laparotomy occurred in 1 obese (2.3%) and 3 (4.2%) nonobese women (p = .212). The median operative time was 115 minutes (range, 48-300 minutes) in obese and 114 minutes (range, 55-342 minutes) in nonobese women (p = .787). The intraoperative complication rate was 11.6% and 9.6% in obese and nonobese women, respectively (p = .712). The early postoperative complication rate was 6.9% in obese and 4.1% in nonobese women (p = .516)., Conclusion: Despite the fact that the present analysis was performed in a relatively small group of patients, this study suggests that obesity (BMI ≥30) does not preclude successful completion of total LESS hysterectomy. Further prospective studies are required to confirm these preliminary data and to clarify potential advantages and disadvantages of LESS in obese women., (Copyright © 2015 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: The aim of this study was to verify possible differences in terms of perioperative outcomes and complications between mini-laparoscopic radical hysterectomy with lymphadenectomy (mLRH) and robotic radical hysterectomy with lymphadenectomy (RRH) in patients with early cervical cancer (ECC)., Material and Methods: In this retrospective study, thirty women with early stage cervical cancer who underwent mini-laparoscopic radical hysterectomy plus lymphadenectomy (mLRH) were compared with a cohort of thirty women who underwent robotic multiport radical hysterectomy (RRH). The study involved patients, between August 2010 and December 2012, from three Italian institutions: National Cancer Institute of Rome, University of Insubria, Varese, and the Catholic University of the Sacred Heart of Rome., Results: No significant differences between groups were observed in terms of age, BMI, previous abdominal surgery or FIGO stage. Operative time, blood loss, need of blood transfusion, risk of intra- and post-operative complications, and lymph nodes yield were similar between mLRH and RRH in patients with ECC. The median length of hospital stay was 2 days in the mLRH group and 3 days in the RRH group (p < 0.05)., Conclusions: The few differences we registered do not seem clinically relevant, thus making the two procedures comparable. The decision on how to gain best access for radical hysterectomy considers the surgeon's skill and experience with the different possible approaches. Further randomized trials are needed to determine whether mini-laparoscopic techniques truly offer any advantages., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

Study Objective: To compare the perioperative outcomes of laparoendoscopic single-site radical hysterectomy (LESS-RH) and minilaparoscopic radical hysterectomy (mLPS-RH)., Design: Retrospective study (Canadian Task Force classification II-2)., Setting: Seven institutions in Italy., Patients: Forty-six patents with early cervical cancer (FIGO stage IA2-IB1/IIA1) were included in the study. Nineteen patients (41.3%) underwent LESS-RH, and 27 (58.7%) underwent mLPS-RH. Pelvic lymph node dissection was performed in all patients., Interventions: In the LESS-RH group, all surgical procedures were performed through a single umbilical multichannel port. In the mLPS-RH group, the procedure was completed using a 5-mm umbilical optical trocar and 3 additional 3-mm ancillary trocars, placed suprapubically and in the left and right lower abdominal regions., Measurements and Main Results: There was no difference in clinicopathologic characteristics at the time of diagnosis between the LESS-RH and mLPS-RH groups. Median operative time was 270 minutes (range, 149-380 minutes) for LESS-RH, and was 180 minutes (range, 90-240 minutes) for mLPS-RH (p = .001). No further differences were detected between the 2 groups insofar as type of radical hysterectomy, number of lymph nodes removed, or perioperative outcomes. In the LESS-RH group, conversion to laparotomy was necessary in 1 patient (5.3%) because of external iliac vein injury, and in another patient, conversion to standard laparoscopy was required because of truncal obesity. In the mLPS-RH group, no conversions were observed; however, a repeat operation was performed to repair a ureteral injury. The percentage of patients discharged 1 day after surgery was significantly higher in the LESS-RH group (57.9%) compared with the mLPS-RH group (25.0%) (p = .03). After a median follow-up of 27 months (range, 9-73 months), only 1 patient, who had undergone mLPS-RH, experienced pelvic recurrence and died of the disease., Conclusions: Both LESS-RH and mLPS-RH are feasible ultra-minimally invasive approaches for performance of radical hysterectomy plus pelvic lymph node dissection. Further technical improvements are required to enable wider use of these techniques for more complex procedures., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Purpose of Review: The goal was to evaluate the safety, feasibility, and reproducibility of total and radical single-site hysterectomy., Recent Findings: Minimally invasive surgery represents the gold standard for benign and malignant gynecological disease. Laparoendoscopic single-site surgery has emerged as a new technical concept to decrease parietal trauma and improve body image. Laparoendoscopic single-site surgery is not a new essay, but recent developments in surgical technology have resulted in an exponential enlargement of indications. Recently published data showed feasibility, safety, and reproducibility of single-port hysterectomy for benign and malignant gynecological diseases., Summary: Laparoendoscopic single-site surgery represents a new challenge in minimally invasive surgery and appears to be feasible and safe to perform in a variety of gynecologic diseases. The aim of this review is to critically analyze the recent literature about single-site hysterectomy.

Background: We provided a comprehensive analysis of rate, pattern, and severity of early and late postoperative complications in a very large, single-institution series of locally advanced cervical cancer (LACC) patients administered CT/RT plus radical surgery (RS)., Methods: A total of 362 consecutive LACC (FIGO stage IB2-IVA) patients were submitted to RS after CT/RT at the Gynecologic Oncology Unit of the Catholic University (Rome/Campobasso). At 4 weeks after CT/RT, patients were evaluated for objective response and triaged to radical hysterectomy and pelvic ± aortic lymphadenectomy. Surgical morbidity was classified according to the Chassagne's grading system., Results: Most cases underwent type III-IV radical hysterectomy (N = 313, 86.5 %); pelvic lymphadenectomy was performed in all patients, while 116 patients (32.1 %) were also submitted to aortic lymphadenectomy. A total of 93 patients (25.7 %) experienced any grade postoperative complications, and 60 (16.6 %) had ≥grade 2 complications; grade 3-4 complications occurred in 21 patients (5.8 %). Of all early postoperative complications (N = 100), 31 (31.0 %) were urinary, 9 (9.0 %) were gastrointestinal, and 45 (45.0 %) were vascular. Of all late complications (N = 31), 20 (64.5 %) were urinary, 7 (22.6 %) gastrointestinal, and 2 (6.4 %) were vascular. Multivariate analysis showed that not complete clinical response to treatment retained an independent, unfavorable association with risk of development of postoperative morbidity, while advanced stage, and aortic lymphadenectomy showed only a borderline value., Conclusions: Failure to achieve clinical complete response to treatment and, to a lesser extent, more advanced stage, and aortic lymphadenectomy, were associated with a higher risk of developing any grade as well as ≥grade 2 complications.

Study Objective: To compare operative time with use of THUNDERBEAT (TB) vs standard electrosurgery (SES) during laparoscopic radical hysterectomy and pelvic lymphadenectomy to treat gynecologic tumors., Design: Evidence obtained from a properly designed, randomized, controlled trial (Canadian Task Force classification I)., Setting: Gynecologic Oncology Unit of the Catholic University of the Sacred Heart in Rome, Italy., Patients: Fifty patients with early cervical cancer (FIGO stages IA2, IB1, IIA <2 cm) or locally advanced cervical cancer (FIGO stages IB2, IIA >2cm, IIB) who received neoadjuvant treatment (chemotherapy or radiochemotherapy) and demonstrated a complete or partial clinical response and early stage endometrioid endometrial cancer (FIGO stages IB, II) were randomly assigned to undergo TB (arm A) or SES (arm B)., Intervention: Laparoscopic radical hysterectomy with bilateral pelvic lymphadenectomy, using an easily reproducible technique was performed., Measurements and Main Results: Fifty patients were available for analysis, with 25 women randomly assigned to TB (arm A) and 25 to SES (arm B). The median operative time was 85 minutes for TB vs 115 minutes for SES (p = .001). At multivariate analysis, endometrial cancer (p = .001) and TB (p = .001) were independently associated with shorter operating time. No differences in perioperative outcomes and postoperative complications were observed between the 2 arms. Patients who underwent TB reported less postoperative pain, both at rest (p = .005) and after the Valsalva maneuver (p = .008), with less additional analgesic therapy other than standard therapy required in patients who underwent SES (p = .02)., Conclusion: TB is associated with shorter operative time and less postoperative pain than is the standard technique (SES) in patients with uterine cancer., (Copyright © 2014 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the preliminary experience of three gynecologic oncology services with minilaparoscopic radical hysterectomy (mLRH) for the treatment of cervical cancer and to compare perioperative outcomes with those of conventional laparoscopic surgery (LRH)., Methods: Prospectively collected data on consecutive cervical cancer patients undergoing radical hysterectomy with a laparoscopic approach were analyzed retrospectively. Perioperative outcomes of women undergoing mLRH were compared to data from control patients who had undergone LRH with 5-mm instruments. Adjustment for potential selection bias in surgical approach was made with propensity score (PS) matching., Results: The study cohort consisted of 257 patients, 35 undergoing mLRH and 222 undergoing LRH. The two groups were comparable in terms of demographic and tumor characteristics. No significant differences were observed between groups in terms of operative time, blood loss, lymph node yield, amount of parametrial or vaginal cuff tissue removed, and percentage of intra- or postoperative complications, both in the entire cohort and in the PS matched group. No conversions were needed from mLRH to standard laparoscopy or from minilaparoscopy to open surgery. Conversion from standard laparoscopy to open surgery was necessary in 2 patients. A shorter hospital stay was observed among women who had mLRH than in those undergoing LRH [2 (1-10) vs 4 (1-14) days, p = 0.005]. This difference remained significant after PS matching., Conclusion: Our preliminary study suggests that in experienced hands minilaparoscopy is a feasible and safe technique for radical hysterectomy and yields results that are equivalent to those of LRH., (Copyright © 2013 Elsevier Ltd. All rights reserved.)

Objective: To report our experience with single-site robotic platform for IS3000 "Da Vinci" Si Surgical System to perform robotic single site hysterectomy (RSS-H), and to compare peri-operative results with a historical series of laparoendoscopic single site hysterectomies (LESS-H)., Methods: This is a retrospective case-control study, performed at the Gynecologic Oncologic Unit, National Cancer Institute "Regina Elena", Rome, and at the Gynecologic Oncologic Unit, Catholic University of the Sacred Heart, Rome, Italy between December 2011 and January 2013., Results: 19 women underwent RSS-H (cases) and 38 patients were submitted to LESS-H (controls) for early endometrial cancer. Pre-surgical procedures (port placement and docking) required a median time of 8 min in the RSS-H group and a median time of 2 min in the LESS-H group (p=0.0001). The median estimated blood loss was 75 ml in the cases and 30 ml in the controls (p=0.005). The median operative time, calculated from the beginning of intraperitoneal procedures to the skin closure, was 90 min in the cases and 107 ml in the controls (p=ns). The median time to discharge from the hospital was postoperative day two for both techniques., Conclusions: The few differences we registered do not seem clinically relevant, thus making the two procedures comparable., (Copyright © 2013 Elsevier Inc. All rights reserved.)

Study Objective: To compare perioperative outcomes and postoperative pain of minilaparoscopic (M-LPS) and laparoendoscopic single-site total hysterectomy (LESS)., Design: Prospectively randomized study (Canadian Task Force classification II-2)., Setting: Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Catholic University of the Sacred Heart, Rome., Patients: A total of 86 patients underwent total hysterectomy. Seventy-one met the inclusion criteria and were included in this study. Three of them refused randomization, 34 were randomly assigned to undergo to single-port hysterectomy and 34 to undergo to minilaparoscopy., Interventions: The operative technique is the same in the 2 groups with the exception of videolaparoscopy, port type, and some specific instruments. All surgical procedures were performed with an intrauterine manipulator. Single-port hysterectomy was performed through a multichannel single trocar inserted in the umbilicus. Minilaparoscopic hysterectomy was performed through one optical transumbilical 5-mm trocar and three 3-mm suprapubic ancillary ports., Measurements and Main Results: Sixty-eight patients met the inclusion criteria and were enrolled in the study. The baseline characteristics of the 2 groups were comparable. Median operative time was longer in LESS with respect to M-LPS (120 minutes vs 90 minutes; p = .038). There were no differences between the 2 groups for median estimated blood loss, ileus, and postoperative stay. Additional 5-mm port insertion was needed in 1 case (2.9%) in the M-LPS group and in 2 cases (5.9%) in the LESS group, respectively (p = .311). No patient had development of intraoperative or early postoperative complications. Patients in the M-LPS group experienced a minor pain at each evaluation, compared with patients who underwent LESS. The rescue analgesic requirement was similar in the 2 groups., Conclusions: Laparoscopic hysterectomy can be safely performed by M-LPS and LESS. M-LPS is associated with significantly lower operative time and less postoperative pain than LESS. Advantages of M-LPS hysterectomy than LESS have no noteworthy impact on the patients' early postoperative management. The decision on the best access to the hysterectomy might take into account the surgeon's skill and feeling with the different possible approaches., (Copyright © 2013 AAGL. Published by Elsevier Inc. All rights reserved.)

Background and Objective: In less than 2 decades, laparoscopy has contributed to modification in the management of early cervical cancer patients, and all comparisons between open and laparoscopic-based radical operations showed an identical oncological outcome. The aim of this study is to describe surgical instrumentations and technique to perform total microlaparoscopy radical hysterectomy in early cervical cancer patients and report our preliminary results in terms of operative time and perioperative outcomes., Methods: Between January 1, 2012, and March 25, 2012, 4 consecutive early cervical cancer patients were enrolled in this study., Results: We performed 3 type B2 and 1 type C1-B2 total microlaparoscopy radical hysterectomy, and in all cases concomitant bilateral salpingo-oophorectomy and pelvic lymphadenectomy were carried out. Median operative time was 165 minutes (range: 155 to 215) (mean: 186), and median estimated blood loss was 30 mL (range: 20 to 50). Median number of pelvic lymph nodes removed was 12 (range: 11 to 15). All procedures were completed without 5-mm port insertion and without conversion. No intraoperative or early postoperative complications were reported., Conclusions: This report suggests a role of microlaparoscopy in the surgical management of early cervical cancer with adequate oncological results, superimposable operative time, and perioperative outcomes with respect to standard laparoscopy.

Objective: This study was designed to compare perioperative outcomes and postoperative pain of standard laparoscopic (S-LPS), minilaparoscopic (M-LPS), and laparoendoscopic single-site (LESS) hysterectomy., Methods: A single-institutional, matched, retrospective, cohort study was performed. Between May 2010 and March 2011, 85 consecutive women were submitted to a total laparoscopic hysterectomy by S-LPS, M-LPS, and single-port LESS. Perioperative outcomes of these three techniques were analyzed and compared., Results: Demographics and baseline characteristics of each group were absolutely comparable. The median operative time was longer [105 (range, 75-125) min] in the LESS group compared with the M-LPS group [90 (range, 60-120) min; p < 0.011] and S-LPS [80 (range, 50-110) min; p < 0.001]. No statistically significant differences have been reported for estimated blood loss or intra- and early postoperative complications. Postoperative pain control was better for LESS and M-LPS than S-LPS., Conclusions: M-LPS and LESS hysterectomy can be performed safely, and both seem to be associated with a halving of early postoperative pain with a lower request of analgesics.

Objective: To compare the peri-operative outcomes between total laparo-endoscopic single-site (LESS) and robotic approaches for the staging and treatment of early stage endometrial cancer patients., Methods: A multicentre retrospective study involving three Italian gynaecological groups and one American centre. The peri-operative outcomes of LESS and robotic approach were compared in similar groups of patients, with regard to surgical outcomes and intra- and post-operative parameters and complications., Results: During the study period, 75 patients submitted to a total LESS hysterectomy and 75 patients received a total robotic hysterectomy. The median operative time - 122 versus 175 min (p=0.0001) - and the estimated blood loss - 50 versus 80 mL (p=0.03) - were slightly more favourable in the LESS group. The intra-operative complications were equally distributed (p=0.99); in the robotic group there were 4 (5.3%) post-operative grade IIIb complications versus 1 (1.3%) in the LESS group (p=0.172)., Conclusions: The LESS and robotic approaches both appear reasonable and each may have benefits and limitations depending upon the patient population. Further studies are needed to validate these preliminary conclusions., (Copyright © 2012 Elsevier B.V. All rights reserved.)

Objective: We sought to assess feasibility and perioperative outcomes for laparoendoscopic single-site surgery (LESS) in early endometrial cancer., Study Design: This was a retrospective multicentric study of 100 early endometrial cancer cases undergoing LESS from July 2009 through July 2011., Results: All patients underwent total hysterectomy and bilateral salpingo-oophorectomy by LESS. Pelvic and paraaortic lymphadenectomy were performed in 48 and 27 patients, respectively. A median of 16 pelvic lymph nodes (range, 1-33) and 7 paraaortic lymph nodes (range, 2-28) were retrieved. Both median operative time (129 minutes; range, 45-321) and estimated blood loss (70 mL; range, 10-500) were greater when staging lymphadenectomy was performed (P values = .001). Four intraoperative and 4 postoperative complications were observed. Conversion to standard laparoscopy and laparotomy was necessary for completion of 1 case each. Patients responded positively regarding cosmetic result and minimal postoperative pain control., Conclusion: LESS further minimizes the invasive nature of surgery and is feasible for treatment of early-stage endometrial cancer., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background: In the last few years, technical advances have produced a dramatic shift from traditional open surgery toward a minimally invasive approach, even in oncological procedures. We present our initial experience with laparoendoscopic single-site surgery (LESS) in the surgical treatment of early-stage endometrial cancer patients., Methods: Between July 2009 and May 2010, 20 consecutive low-risk early endometrial cancer patients were enrolled in this single institution prospective cohort trial., Results: The median age of the patients was 57 years (range = 42-68) and median body mass index was 24 kg/m(2) (range = 21-30). Median operative time was 105 min (range = 85-155) and median estimated blood loss was 20 ml (range = 10-180). The larger skin and fascial incision required for the single-port approach was 2.5 cm (median = 2.2 cm; range = 2.0-2.5). No laparoscopic/laparotomic conversion was registered, and no insertion of additional ports was necessary. Median ileus was 16 h (range = 12-20) and median time to discharge was 1 day (range = 1-2). All patients were completely satisfied with the cosmetic results and postoperative pain control., Conclusions: Laparoendoscopic single-site surgery could represent a surgical option for extra-fascial hysterectomy in early-stage endometrial cancer patients, with the potential to further decrease invasiveness of the conventional laparoscopic approach.

Study Objective: To evaluate whether the systematic use of an intrauterine manipulator influences the accuracy of frozen section analysis in early-stage endometrial cancer., Design: Case-control study (Canadian Task Force classification II-1)., Patients: Three hundred fourteen consecutive women with early-stage endometrial cancer., Interventions: Between January 2004 and December 2009, 314 women with early-stage endometrial cancer underwent staging at laparoscopy (case group) or laparotomy (control group). All women in the case group underwent total laparoscopic hysterectomy using an intrauterine manipulator., Measurements and Main Results: The positive predictive value of frozen section analysis for myometrial infiltration, histotype, and grade of differentiation was 97.2%, 100%, and 97.2%, respectively. The correct diagnosis rate was of 85.7%. The accuracy of frozen section analysis, rate of correct diagnosis, and rate of tumor vascular invasion did not seem to be significantly modified by systematic use of an intrauterine manipulator for total laparoscopic hysterectomy compared with total abdominal hysterectomy in early-stage endometrial cancer staging., Conclusions: Frozen section analysis of early-stage endometrial cancer is highly accurate, and systematic use of an intrauterine manipulator does not represent a bias for correct evaluation of the specimen., (Copyright © 2011 AAGL. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate the differences of the amount of paracervical lymphatic structures removed when performing classical type III, modified type II and nerve-sparing radical hysterectomy (RH)., Material and Methods: Open macroscopic or laparoscopic pelvic dissections in 18 fresh adult female cadavers after lymphatic channels and nodes staining by Lipiodol dye solution injection of the uterine cervix., Results: We distinguished three different lymphatic pathways: 1) the supraureteral paracervical pathway (vascular portion of paracervix-uterine artery and superficial uterine vein), identified in 96% of cases, and removed in all types of RH, 2) the infraureteral paracervical pathway (vascular portion of paracervix-deep uterine vein), identified in 22% of cases, and removed by type III and nerve-sparing RH, and 3) the neural paracervical pathway (nervous portion of paracervix), identified in 7% of cases, and removable only by type III RH. No evidence of stained lymphatic structures running into the vesicouterine and uterosacral ligaments was found., Conclusion: Nerve-sparing RH offers the most effective ratio between oncological safety and surgical-related complications, and would be particularly useful in patients with high risk of paracervical involvement while our results suggest caution in the use of modified type II RH in patients at low-moderate risk of paracervical involvement, unless the use of adjuvant radiotherapy, because of the large amount of potentially lymph-bearing paracervical tissue leaved in situ. Classical type III RH affords the complete resection of all paracervical lymphatic pathways potentially draining the cervix, however this procedure implies a high risk of lesions of the autonomous nerves of pelvic organs., (Copyright (c) 2009 Elsevier Ltd. All rights reserved.)

Cervical cancer (CC) remains an important health problem representing the second most frequent malignancy in women, with 470 000 new cases/year and 280 000 deaths, 80% of which occur in developing countries. In the last few years, new theoretical developments and advances in technology resulted in novel surgical approaches aimed at improving the therapeutic efficacy and/or reducing treatment related side effects. In particular, the authors focused their attention on the most relevant novelties related to the laparoscopic approach to CC treatment, and on the issue of modulation of surgical radicality. Moreover, the possible perspectives of sentinel lymph node concept and robotic surgery, as well as clinical issues related to conservative procedures including ''nerve sparing'' and ''fertility sparing'' strategies, have been evaluated.

The objective was to assess the feasibility, the operative and postoperative outcome, and complications in the use of minilaparotomy for type II and III radical hysterectomy (RH) and pelvic lymphadenectomy (PLN) in early-stage cervical/endometrial cancer. A pilot study on 91 consecutive patients submitted to type II and III RH and PLN for early-stage cervical/endometrial cancer was performed between March 2002 and May 2003 in the Division of Gynecologic Oncology (UCSC, Rome). Thirty-two of 91 cases (35.2%) were eligible for minilaparotomy. The mean operative time was 156.7 min, whereas the mean intraoperative estimate of blood loss was 303.7 ml. A mean number of 32.7 pelvic lymph nodes and 6.2 common iliac nodes were removed. Ileus and removal of bladder catheter were on mean postoperative day 2.4 and 3.4, respectively. The mean number of postoperative days spent in the hospital was 3.7. Intra- and postoperative parameters were compared to laparotomy controls and literature data on laparoscopy and Pfannenstiel incision, showing substantially comparable results. Minilaparotomy is acceptable for selected patients undergoing radical abdominal hysterectomy (RAH) and PLN and does not compromise the adequacy of the procedure. It can be considered as an alternative to the classic midline vertical incision or even to the Pfannenstiel incisions and laparoscopy.

Radical hysterectomy represents the treatment of choice for FIGO stage IA2-IIA cervical cancer. It is associated with several serious complications such as urinary and anorectal dysfunction due to surgical trauma to the autonomous nervous system. In order to determine those surgical steps involving the risk of nerve injury during both classical and nerve-sparing radical hysterectomy, we investigated the relationships between pelvic fascial, vascular and nervous structures in a large series of embalmed and fresh female cadavers. We showed that the extent of potential denervation after classical radical hysterectomy is directly correlated with the radicality of the operation. The surgical steps that carry a high risk of nerve injury are the resection of the uterosacral and vesicouterine ligaments and of the paracervix. A nerve-sparing approach to radical hysterectomy for cervical cancer is feasible if specific resection limits, such as the deep uterine vein, are carefully identified and respected. However, a nerve-sparing surgical effort should be balanced with the oncological priorities of removal of disease and all its potential routes of local spread.

Abstract: Background: To evaluate the feasibility and the predictive value of cone biopsy before performing radical hysterectomy in locally advanced cervical cancer patients showing complete clinical response to neo-adjuvant chemoradiation. Methods: Between March 2010 to March 2012 74 consecutive FIGO stage IIA2-IIB patients were submitted to neo-adjuvant chemoradiation. All complete clinical responder patients were enrolled in this pilot trial. Results: Fifty-seven out of 74 patients (77%) showed complete clinical response and were enrolled in the study. Forty-two out of 57 patients (74%) underwent successful pre-completion surgery cone biopsy with a median cone's tissue diameter of 24 mm (range 18–35). In 33 out of 42 patients (58%) a complete pathological response was found. In the remaining 5 (9%) and 4 (7%) a microscopic partial and partial response was found, respectively. All 33 cases (58%) with negative cone showed complete pathological response in the radical hysterectomy specimens. Patients with microscopic residual tumor foci in the cone showed negative residual cervical and paracervical tissue at definitive diagnosis, whereas in patients with partial response macroscopic residual disease in the surgical specimens was found. The negative predictive value of cone biopsy, MRI and PET/CT in the prediction of pathological status of the cervical and paracervical tissue was 100%, 79% and 79%, respectively (Table 2). Conclusions: In this study we observed that, in locally advanced cervical patients showing complete clinical response to neo-adjuvant chemoradiation, the cone biopsy feasibility was almost 75%, and that there is a complete pathological correspondence between cone and definitive pathology. [Copyright &y& Elsevier]