There are limited data available to indicate whether oncological outcomes might be influenced by the uterine manipulator, which is used at the time of hysterectomy for minimally invasive surgery in ...patients with endometrial cancer. The current evidence derives from retrospective studies with limited sample sizes. Without substantial evidence to support its use, surgeons are required to make decisions about its use based only on their personal choice and surgical experience.
To evaluate the use of the uterine manipulator on oncological outcomes after minimally invasive surgery, for apparent early-stage endometrial cancer.
We performed a retrospective multicentric study to assess the oncological safety of uterine manipulator use in patients with apparent early-stage endometrial cancer, treated with minimally invasive surgery. The type of manipulator, surgical staging, histology, lymphovascular space invasion, International Federation of Gynecology and Obstetrics stage, adjuvant treatment, recurrence, and pattern of recurrence were evaluated. The primary objective was to determine the relapse rate. The secondary objective was to determine recurrence-free survival, overall survival, and the pattern of recurrence.
A total of 2661 women from 15 centers were included; 1756 patients underwent hysterectomy with a uterine manipulator and 905 without it. Both groups were balanced with respect to histology, tumor grade, myometrial invasion, International Federation of Gynecology and Obstetrics stage, and adjuvant therapy. The rate of recurrence was 11.69% in the uterine manipulator group and 7.4% in the no-manipulator group (P<.001). The use of the uterine manipulator was associated with a higher risk of recurrence (hazard ratio, 2.31; 95% confidence interval, 1.27–4.20; P=.006). The use of uterine manipulator in uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics FIGO I–II) was associated with lower disease-free survival (hazard ratio, 1.74; 95% confidence interval, 0.57–0.97; P=.027) and higher risk of death (hazard ratio, 1.74; 95% confidence interval, 1.07–2.83; P=.026). No differences were found regarding the pattern of recurrence between both groups (chi-square statistic, 1.74; P=.63).
In this study, the use of a uterine manipulator was associated with a worse oncological outcome in patients with uterus-confined endometrial cancer (International Federation of Gynecology and Obstetrics I–II) who underwent minimally invasive surgery. Prospective trials are essential to confirm these results.
Uterus transplantation is a novel surgical procedure that allows women with absolute uterine factor infertility to carry a pregnancy and give birth. While previous studies have explored the attitudes ...of women with absolute uterine factor infertility toward uterus transplantation, none have surveyed and compare their views with other groups of interest (Morris syndrome women, relatives of Morris syndrome and Rokitansky syndrome women, infertile women and women of childbearing age) in the same sociocultural setting. The objective of this study was to evaluate attitudes and insights regarding uterus transplantation among women with Rokitansky syndrome and other groups of interest.
We designed a cross-sectional study including five groups of women: women with Rokitansky syndrome, women with Morris syndrome, relatives of women with Morris and Rokitansky syndrome, infertile women, and childbearing-age women. We conducted an online survey through the REDCap platform. The link was distributed by mail, telephone and in hospital outpatient visits. Baseline demographic information was assessed and information regarding motherhood preferences, attitude toward uterus transplantation, preferred uterus graft and perception of risk of the procedure was collected.
We obtained a total of 200 responses, with a mean participant age of 34.5 years (±9.8). Overall, 17.5% (n = 35) were women with Rokitansky syndrome, 5.5% (n = 11) Morris syndrome women, 21.5% (n = 43) infertile women, 26.5% (n = 53) relatives of Morris and Rokitansky syndrome women and 29% (n = 58) childbearing-age women. 71.5% of women with Rokitansky syndrome would undergo uterus transplantations ahead of adoption and surrogacy with no statistically significant differences found between groups. Overall, more than one-half (58%) would prefer deceased over living donor.
The results of this survey indicate that uterus transplantation is desired by most women who would benefit from the procedure, including those with either Morris syndrome or absolute uterine factor infertility. This was also the preferred option for motherhood if absolute uterine factor infertility was diagnosed among surveyed infertility patients or women of childbearing age with no known reproductive difficulties. Overall, most respondents indicated a deceased donor was preferable to a living donor and that patients may not be sufficiently aware of potential risks of uterus transplantation, highlighting the importance of adequate counseling by medical providers.
To evaluate the reliability of sagittal abdominal diameter (SAD)-a surrogate of visceral obesity-in magnetic resonance imaging, and its accuracy to predict the surgical morbidity of aortic ...lymphadenectomy.
We conducted a multicenter reliability (phase 1) and accuracy (phase 2) cohort study in three Spanish referral hospitals. We retrospectively analyzed data from the STELLA-2 randomized controlled trial that included high-risk endometrial cancer patients undergoing minimally invasive surgical staging. Patients were classified into subgroups: conventional versus robotic-assisted laparoscopy, and transperitoneal versus extraperitoneal technique. In the first phase, we measured the agreement of three SAD measurements (at the umbilicus, renal vein, and inferior mesenteric artery) and selected the most reliable one. In phase 2, we evaluated the diagnostic accuracy of SAD to predict surgical morbidity. Surgical morbidity was the main outcome measure, it was defined by a core outcome set including variables related to blood loss, operative time, surgical complications, and para-aortic lymphadenectomy difficulty.
In phase 1, all measurements showed good inter-rater and intra-rater agreement. Umbilical SAD (u-SAD) was the most reliable one. In phase 2, we included 136 patients. u-SAD had a good diagnostic accuracy to predict surgical morbidity in patients undergoing transperitoneal laparoscopic lymphadenectomy (0.73 in ROC curve). It performed better than body mass index and other anthropometric measurements. We calculated a cut-off point of 246 mm (sensitivity: 0.56, specificity: 0.80).
u-SAD is a simple, reliable, and potentially useful measurement to predict surgical morbidity in endometrial cancer patients undergoing minimally invasive surgical staging, especially when facing transperitoneal aortic lymphadenectomy.
To describe the development and characteristics living donor uterine transplantation program of the Hospital Clínic (Barcelona, Spain) and to report the first successful procedure in Southern Europe.
...A 31-year-old female suffering of Rokitansky Syndrome underwent uterus transplant from her living sister, as a part of our research protocol. Before the transplant, the patient underwent an in vitro fertilization procedure and twelve embryos were obtained and cryopreserved. The uterus obtention procedure was performed entirely by robotic surgery and lasted 10h, being the main objective to obtain arterial and venous pedicles of good quality in order to ensure the vitality of the graft. The surgical procedure in the recipient was performed by laparotomy and the vascular anastomoses were performed in a terminolateral fashion, with polypropylene 8-0, the vaginal cuff of the graft was sutured to the recipient vaginal vault and the round and utero-sacral ligaments were fixed to the remaining recipient ligaments. Immunosuppressive treatment was prescribed following the protocols from other groups modified according to the solid organ transplantation protocols from our center.
The donor and recipient were discharged without any major complications. The recipient ultrasound scan showed a normal flow in both uterine arteries and veins. A grade II rejection was treated with high dose corticoids with subsequent normal biopsies and a vaginal stricture was treated with the placement of an esophageal stent for 4 weeks. The patient had her first menstrual period 47 days after the surgery.
The case reported here open new options in Spain for a wide group of patients that had no medical solution for a disease that deeply impairs their quality of life.
Uterine transplantation has proven to be a viable solution in cases of absolute uterine factor infertility. Performing uterine explant surgery is one of the most difficult gynecologic surgical ...challenges owing to the complexity of the uterine vascular system. The goal of this video is to demonstrate uterine explant surgery and highlight the critical anatomy involved in this procedure.
In this video, we display, narrate, and illustrate key portions of right pelvic dissection, which was subsequently performed bilaterally to achieve hysterectomy from a living donor for the purpose of uterine transplantation.
University hospital.
The donor was a 39-year-old woman, and the receptor sister suffers from Rokitansky syndrome. A careful right site pelvic dissection was visualized in this operation during a hysterectomy with the aim of performing a uterine graft implantation in a living donor (Research Ethics Committee and the Assistance Ethics Committee of Hospital Clínic de Barcelona HCB/2016/0111 and Bioethics Committee of Catalunya Study included in ClinicalTrials.org registry NCT04314869).
The donor's surgery was performed entirely using robotic surgery (DaVinci Xi, Intuitive Survival Inc.).
Assessment of uterine graft transplant viability.
Good quality arterial and venous pedicles were obtained during the surgery. The difficulty of this procedure is the extensive vascular dissection that has to be done to isolate the veins that drain the uterus until the hypogastric vein.
Pelvic anatomy dissection for obtaining the graft from the donor in uterus transplantation is complex, and robotic-assisted laparoscopic surgery may help to provide a clear and more precise visualization.
Purpose
To assess the impact of laparoscopic extraperitoneal paraaortic staging in therapeutic planning and prognosis of patients with locally advanced cervical cancer (LACC) as compared with imaging ...staging.
Methods
Retrospective multicenter study of stage IB2 and IIA2 to IVA (FIGO 2009) LACC patients who were candidates for primary chemoradiotherapy. The study (surgical) group included 634 patients undergoing laparoscopic/robotic extraperitoneal paraaortic staging treated with extended-field radiotherapy (EFRT) if lymph node involvement was confirmed. The control (imaging) group included 288 patients treated with EFRT when lymph node involvement was suspected on positron emission tomography-computed tomography scans and/or magnetic resonance imaging.
Results
In the study group, a median of 13 (range 9–17) lymph nodes were removed, with a rate of positive paraaortic nodes of 18%, with metastatic size ≤ 5 mm in 20.4% of cases. Paraaortic EFRT was administered to 18% of patients in the study group and in 58% of controls. In 34% of patients from the surgical group, EFRT was modified according to surgical findings with respect to imaging staging. The median follow-up in the study and control groups was 3.7 and 4.8 years, respectively. In both groups, the overall survival and cancer-specific disease-free survival were similar. The time interval between diagnosis and starting EFRT was 18 days longer in the study group, without differences in overall survival as compared with controls (hazard ratio 1.00, 95% confidence interval 0.998–1.005;
p
= 0.307).
Conclusions
Laparoscopic extraperitoneal paraaortic staging in LACC patients is safe and modified therapeutic planning, allowing better selection of candidates for EFRT.
To evaluate the clinical value of postreatment plasmatic levels of the squamous cell carcinoma antigen (SCC-Ag) as a survival independent prognostic factor in patients with LACC.
Retrospective, ...multicenter study including LACC patients (FIGO 2009 stages IB2, IIA2-IVA) managed at the Gynecology Oncological Units corresponding to eight reference hospitals in Spain between 2000 and 2016. Receiver operating characteristic (ROC) curve analysis was used to determine the cut-off values of postreatment SCC-Ag levels in prediction of survival. Survival curves were calculated by using the Kaplan-Meier method and were compared with the log-rank test. Cox models were used to analyze different factors in terms of their prognosis predictive value.
The study included 447 patients with a median follow-up time of 53 months (IQR 26–101) and median pre- and postreatment SCC-Ag levels of 3.4 ng/ml (IQR 1.2–11) and 0.8 ng/ml (IQR 0.5–1.2), respectively. The cut-off level of pretreatment SCC-Ag was 11.75 ng/ml (sensibility 37.5%; specificity 80.5%) and that of postreatment SCC-Ag was 1.24 ng/ml (sensibility 34.6%; specificity 83.1%). In a multivariate Cox regression analysis, factors that were independent predictors of OS were: FIGO stage (HR 2.12; 95%CI 1.18–3.8; p = 0.011), paraaortic lymph node involvement (HR 3.56; 95%CI 2.04–6.2; p < 0.0001), postreatment SCC-Ag level ≥ 1.2 ng/ml (HR 1.95; 95%CI 1.11–3.44; p = 0.02) and incomplete response to treatment (HR 4.5; 95%CI 2.5–8.11; p < 0.0001).
Postreatment plasmatic SCC-Ag level ≥ 1.2 ng/ml was an independent risk factor for the survival of patients with LACC. Further factors influencing survival included: paraaortic lymph node involvement, advanced disease and poor response to concomitant chemoradiotherapy.
•Postreatment SCC-Ag ≥1.2 ng/ml is an independent risk factor for LACC patients.•Patients with postreatment SCC-Ag ≥1.2 ng/ml show poorer overall survival.•Aortic lymph node involvement is an independent risk factor for LACC patients.•Advanced stages and incomplete response to therapy are risk factors for LACC patients.
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