Abstract Objective To assess the risk of occurrence of port-site metastases after robotic surgery for pelvic cancer. Methods Retrospective study from June 2007 to March 2013 of patients with ...gynecologic cancer who underwent robot-assisted surgery. We collected preoperative data, including characteristics of patients and FIGO stage, intraoperative data (surgery performed, number of ports), and postoperative data (occurrence of metastases, occurrence of port-site metastases). Results 115 patients were included in the study: 61 with endometrial cancer, 50 with cervical cancer and 4 with ovarian cancer. The surgical procedures performed were: hysterectomy with bilateral salpingo-oophorectomy, radical hysterectomy, pelvic lymphadenectomy, para-aortic lymphadenectomy and omentectomy. All surgical procedures required the introduction of 4 ports, 3 for the robot and 1 for the assistant. With a mean follow-up of 504.4 days (507.7 days for endometrial cancer, 479.5 days for cervical cancer, and 511.3 for ovarian cancer), we observed 9 recurrences but no port-site metastasis. Conclusion No port-site metastasis has occurred in our series. However, larger, prospective and randomized works are needed to formally conclude.
The purpose of this study was to assess the postoperative morbidity after radical hysterectomy (RH) for early-stage cervical cancer and to determine risk factors of severe perioperative morbidity.
...Data of two prospective trials on sentinel node biopsy for cervical cancer (SENTICOL I & II) were analysed. Patients having a radical hysterectomy were included between 2005 and 2012 from 25 French oncologic centers. Postoperative complications were prospectively recorded in a pre-specified analysis.
248 patients met the inclusion criteria. The median age was 44.5 years 25–85. 88.7% of patients had a stage IB1 disease. There were 71.4% epidermoid carcinomas and 25% adenocarcinomas. 125 patients (50.4%) had a laparoscopic-assisted vaginal RH, 88 patients (35.5%) had a total laparoscopic RH, 26 patients (10.5%) had an open RH and 9 patients (3.6%) had a robotic-assisted RH. Sixteen patients (6.4%) had intraoperative complications. On a multivariate analysis, intraoperative complications were significantly associated with BMI >30 kg/m2. The urinary, lymphovascular and neurologic complications rates were respectively 34.3%, 20.6% and 19.8%. 31 patients (12.5%) had severe postoperative complications (Clavien-Dindo ≥ 3 or CTCAE ≥ 3). On multivariate analysis, severe postoperative complications were associated with parametrial involvement, preoperative brachytherapy and inclusion in low surgical skills center.
This study based on prospective data showed that RH has low severe postoperative complications. The main complications were urinary infections and lower limb lymphedema. Patients with early-stage cervical cancer should be referred to expert center to ensure best surgical outcomes.
Abstract Objectives Residual disease after excision surgery is the main prognostic factor in advanced ovarian cancer. Open surgery can delay neoadjuvant chemotherapy initiation. Therefore, a ...minimally invasive method for evaluating resectability would be of great interest. Aim of our study is to evaluate a new technique for assessing the extent of peritoneal carcinomatosis, combining manual palpation and standard laparoscopy. Methods Prospective single-center study from October 2008 to January 2010. Patients with peritoneal carcinomatosis from gynecological malignancies were investigated by standard laparoscopy followed by laparoscopy plus manual palpation using Lapdisc® (Ethicon Inc.), at 43 abdominopelvic sites. When both techniques indicated resectability, standard cytoreduction surgery was performed via a midline laparotomy. The Fagotti, modified Fagotti, and Sugarbaker scores were computed. The diagnostic performance of each evaluation criterion was assessed by computing sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the receiver-operating characteristic curves (ROC-AUCs). Results Of the 29 included patients, 18 (62.1%) were considered to have resectable disease. Fourteen (14/18, 77.8%) had macroscopically complete cytoreduction. With Lapdisc® , sensitivity was 100%, specificity 73.3%, PPV 77.8%, NPV 100%, and ROC-AUC 0.87. Corresponding values were as follows: laparoscopy, 100%, 40%, 60.9%, 100%, and 0.70; Fagotti and modified Fagotti scores, 100%, 46.7%, 63.6%, 100%, and 0.73; Sugarbaker score, 64.3%, 93.3%, 90%, 73.7%, and 0.79. The ROC-AUCs showed significantly better performance of Lapdisc® than of standard laparoscopy ( P = 0.008). Conclusion Hand-assisted laparoscopy may perform better than laparoscopy alone for predicting the resectability of peritoneal carcinomatosis by increasing the number of sites evaluated.
Background
The outcomes of paraaortic lymphadenectomy were compared for the treatment of gynecological malignancies to identify the most appropriate surgical approach.
Methods
Our retrospective, ...multicentric study included 1304 patients who underwent paraaortic lymphadenectomy for gynecological malignancies. The patients were categorized into the following five groups based on treatment type: transperitoneal laparoscopy (group A,
n
= 198), extraperitoneal laparoscopy (group B,
n
= 681), robot-assisted transperitoneal laparoscopy (group C,
n
= 135), robot-assisted extraperitoneal laparoscopy (group D,
n
= 44), and laparotomy (group E,
n
= 246).
Results
The prevalence of cancer types differed according to the surgical approach: there were more ovarian cancers in group E and more cervical cancers in groups B and D (
p
< 0.001). Estimated blood loss was higher in group E (844.2 mL) than in groups treated with minimally invasive interventions (115.8–141.5 mL,
p
< 0.005). For infrarenal dissection, fewer nodes were removed in group C compared with the other approaches (16 vs. 21 nodes, respectively,
p
< 0.05). The average operative time ranged from 169 min for group A to 247 min for group E (
p
< 0.001). Length of hospital stay was 14 days for group E versus 3.5 days for minimally invasive procedures (
p
< 0.05). The early postoperative grade 3 and superior Dindo–Clavien complications occurred in 9–10% of the patients in groups B-D, 15% of the patients in group E, and only 3% and 4% for groups A and C, respectively. The most common complication was lymphocele.
Conclusions
Laparotomy increases preoperative and postoperative morbidity. The robot-assisted transperitoneal approach demonstrated a poorer lymph node yield than laparotomy and extraperitoneal approaches.
Prophylactic surgery remains the most effective modality for reducing both breast and ovarian cancer rate in woman at high risk, such as BRCA1 or BRCA2. Autologous breast reconstruction with ...bilateral deep inferior epigastric perforator (DIEP) flap allows predictable and durable results. However, existing two-step approach separating salpingo-oophorectomy and reconstruction could even make DIEP flap impossible, or make insufflation more difficult during laparoscopy. Other authors described one-step procedure but with open laparotomy. The goal of this study was to verify the feasibility of a simultaneous procedure, including laparoscopic salpingo-oophorectomy.
We included BRCA mutation careers scheduled for simultaneous laparoscopic salpingo-oophorectomy, and bilateral breast reconstruction with DIEP flaps. The first step of the procedure was laparoscopic salpingo-oophorectomy and ports had to be strategically placed to avoid interference with the following procedure. The second step was bilateral breast reconstruction with DIEP flaps. We reviewed medical charts. Surgical procedure was analyzed for duration, revisions and surgical complications.
During 1-year period, eight patients agreed to a simultaneous procedure. All of them were BRCA positive, mean age was 38.3years (range, 39–50), and mean BMI was 28.3kg/m2 (range, 21–33). The mean duration of the entire procedure was 524minutes (range, 405–630) and the mean hospital stay 9.2 days (range, 8–14). There was 100% flap survival. No abdominal wall dehiscence occurred.
One-step procedure for prophylactic surgery of ovarian and breast hereditary malignancies is feasible. First salpingo-oophorectomy with open laparoscopy then bilateral immediate or delayed breast reconstruction with DIEP flaps can be performed.
La chirurgie prophylactique reste une méthode très efficace pour réduire le risque de cancer du sein et de l’ovaire chez la femme à haut risque comme dans les mutations BRCA1 ou BRCA2. La reconstruction mammaire autologue par lambeau perforant DIEP (deep inferior epigastric perforator) permet un résultat satisfaisant et durable. Cependant, l’approche en deux étapes séparant salpingo-ovariectomie et reconstruction mammaire autologue peut, d’une part, rendre impossible la réalisation du lambeau DIEP, d’autre part, compliquer l’insufflation nécessaire à la laparoscopie. Certains auteurs ont décrit une procédure en une seule étape mais avec laparotomie systématique. Le but de cette étude était de vérifier la faisabilité d’une procédure laparoscopique simultanée à la reconstruction mammaire bilatérale par double DIEP.
Nous avons inclus les patientes porteuses de mutation BRCA prévues pour une procédure simultanée de salpingo-ovariectomie laparoscopique et mastectomie suivie de reconstruction mammaire bilatérale par double DIEP. La première étape était laparoscopique et les ports ont dû être placés stratégiquement pour éviter toute lésion des vaisseaux perforants. La seconde étape était la mastectomie avec reconstruction bilatérale des seins par lambeaux DIEP. Nous avons recueilli les informations issues des dossiers médicaux. Nous avons analysé la durée de la procédure, les reprises et les complications chirurgicales.
Pendant l’année étudiée, huit patients ont bénéficié d’une procédure simultanée. Toutes étaient BRCA positif, l’âge moyen était de 38,3ans (33–50), et l’IMC moyen était 28,3kg/m2 (21–33). La durée moyenne de l’intervention était de 524minutes (405–630) et la durée moyenne du séjour hospitalier de 9,2jours (8–14). La survie des lambeaux était de 100 %. Nous n’avons relevé aucune déhiscence de la paroi abdominale (voussure, éventration).
La chirurgie prophylactique simultanée des seins et des ovaires avec reconstruction bilatérale autologue par double DIEP est faisable. La première étape est la salpingo-ovariectomie laparoscopique, pouvant être suivie par la mastectomie et la reconstruction mammaire bilatérale par lambeaux de double DIEP.
Purpose
Patients with locally advanced cervical cancer (LACC) are usually treated with concurrent chemoradiotherapy. Extended-field chemoradiotherapy is indicated in case of para-aortic node ...involvement at initial assessment. 18-Fluoro-2-deoxy-
d
-glucose positron emission tomography/computed tomography (18-FDG PET/CT) is currently considered to be the most accurate method of detection of node or distant metastases. The goal of this study was to evaluate the accuracy of PET at detecting para-aortic lymph node metastases in LACC patients with a negative morphological imaging.
Methods
Patients from five French institutions with LACC and both negative morphologic (magnetic resonance imaging, CT scan) and functional (PET or PET/CT) findings at the para-aortic level and distantly were submitted to a systematic infrarenal para-aortic node dissection either by laparoscopy or laparotomy. On the basis of pathological results, sensitivity, specificity, and positive and negative predictive values of PET/CT were assessed for para-aortic lymph node involvement.
Results
A total of 125 LACC patients (stage IB2–IVA disease with two local recurrences) fulfilled the inclusion criteria. All had an ilio-infrarenal para-aortic lymphadenectomy, either by laparoscopy (
n
= 117) or laparotomy (
n
= 8). Twenty-one patients (16.8%) had pathologically proven para-aortic metastases. Among them, 14 (66.7%) had negative PET/CT. Overall morbidity of surgery was 7.2%. All but one of the complications were mild and did not delay chemoradiotherapy. Sensitivity, specificity, and positive and negative predictive value of the PET/CT were 33.3, 94.2, 53.8, and 87.5%, respectively, for the detection of microscopic lymph node metastases.
Conclusions
Laparoscopic staging surgery seems warranted in LACC patients with negative PET scan who are candidates for definitive concurrent chemoradiotherapy or exenteration.
The initial management of early-stage ovarian cancer consists of staging surgery including pelvic and para-aortic lymphadenectomy. The use of the sentinel lymph node (SLN) procedure in this setting ...may decrease the morbidity associated with this surgery. The objective of this review was to evaluate the feasibility of the SLN procedure in ovarian cancer diagnosed at an early stage by comparing the different techniques used and their accuracy. A systematic literature search was performed on PubMed and ClinicalTrials.gov for articles in English or French about the SLN technique in ovarian cancer. Ten studies were included in the analysis, with a total of 179 patients. The main tracers used were Technetium-99m, indocyanine green, and patent blue, and the most common site of injection was the proper ovarian and unfundibulopelvic ligaments. The overall detection rate was 87.7%. Of the small number of cases of lymph node metastasis reported, the SLN procedure had a sensitivity of 90.9% and a negative predictive value of 98.8%. The sentinel node procedure appears to be feasible and safe and could be reliable in determining the lymph node status of patients with early-stage ovarian cancer.
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