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      Vaginal-Assisted Laparoscopic Radical Hysterectomy: Rationale, Technique, Results

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          Abstract

          The authors conclude that vaginal-assisted laparoscopic radical hysterectomy is an oncologic viable alternative to abdominal radical hysterectomy, laparoscopic-assisted radical vaginal hysterectomy, totally laparoscopic radical hysterectomy, and robotic radical hysterectomy.

          Abstract

          Objective:

          Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications.

          Methods:

          The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumor-adapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin.

          Results:

          All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively.

          Conclusion:

          VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with early-stage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.

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          Most cited references36

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          Randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer.

          Stage Ib and IIa cervical carcinoma can be cured by radical surgery or radiotherapy. These two procedures are equally effective, but differ in associated morbidity and type of complications. In this prospective randomised trial of radiotherapy versus surgery, our aim was to assess the 5-year survival and the rate and pattern of complications and recurrences associated with each treatment. Between September, 1986, and December, 1991, 469 women with newly diagnosed stage Ib and IIa cervical carcinoma were referred to our institute. 343 eligible patients were randomised: 172 to surgery and 171 to radical radiotherapy. Adjuvant radiotherapy was delivered after surgery for women with surgical stage pT2b or greater, less than 3 mm of safe cervical stroma, cut-through, or positive nodes. The primary outcome measures were 5-year survival and the rate of complications. The analysis of survival and recurrence was by intention to treat and analysis of complications was by treatment delivered. 170 patients in the surgery group and 167 in the radiotherapy group were included in the intention-to-treat analysis; scheduled treatment was delivered to 169 and 158 women, respectively, 62 of 114 women with cervical diameters of 4 cm or smaller and 46 of 55 with diameters larger than 4 cm received adjuvant therapy. After a median follow-up of 87 (range 57-120) months, 5-year overall and disease-free survival were identical in the surgery and radiotherapy groups (83% and 74%, respectively, for both groups), 86 women developed recurrent disease: 42 (25%) in the surgery group and 44 (26%) in the radiotherapy group. Significant factors for survival in univariate and multivariate analyses were: cervical diameter, positive lymphangiography, and adeno-carcinomatous histotype. 48 (28%) surgery-group patients had severe morbidity compared with 19 (12%) radiotherapy-group patients (p = 0.0004). There is no treatment of choice for early-stage cervical carcinoma in terms of overall or disease-free survival. The combination of surgery and radiotherapy has the worst morbidity, especially urological complications. The optimum therapy for each patient should take account of clinical factors such as menopausal status, age, medical illness, histological type, and cervical diameter to yield the best cure with minimum complications.
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            Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer.

            To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer. We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006. Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function. Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.
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              A comparison of laparoscopic radical hysterectomy and pelvic lymphadenectomy and laparotomy in the treatment of Ib-IIa cervical cancer.

              To compare the feasibility, morbidity, and survival outcome of the laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH+LPL) with abdominal radical hysterectomy and pelvic lymphadenectomy (ARH+APL) for FIGO stage Ib-IIa cervical carcinoma. The consecutive cases with FIGO Ib-IIa cervical cancer from August 1998 to December 2005 were documented, including 90 patients underwent LRH+LPL, and 35 patients underwent ARH+APL as control group. The clinic data of perioperative periods and survival were compared between groups. In laparoscopy group the operating time increased significantly (262.99+/-67.6 min vs. 217.2+/-71.56 min, P=0.001), and the recovery time of bowel decreased significantly (1.96+/-0.62 days vs. 2.40+/-1.06 days, P=0.025). No significant difference was found between groups when the blood loss during operation (369.78+/-249.94 ml vs. 455.14+/-338.05 ml, P=0.125), numbers of the pelvic lymph nodes resected (21.28+/-8.39 vs. 18.77+/-9.47, P=0.151), recovery time of bladder function and postoperative hospital stays were compared. All laparoscopic procedures were completed successfully except 2 cases converted to laparotomy. The median follow-up was 26 months (range 5 to 84 months). Ten and five cases lost to follow-up in laparoscopy and laparotomy group, respectively. Excluding the lost cases, the recurrence rate (13.75% vs. 12%, P>0.05) and the mortality rate (10% vs. 8%, P>0.05) between groups was similar. Our data demonstrated that cervical cancer could be treated successfully with LRH+LPL with similar efficacy and recurrence rates to ARH+APL. LRH+LPL is a safe and effective alternative to conventional abdominal surgery for stage Ib-IIa cervical cancer, and should be used if the surgeon is sufficiently trained. Its clinical value should be confirmed by multicenter randomized clinic trials.
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                Author and article information

                Contributors
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Radiooncology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Journal
                JSLS
                JSLS
                jsls
                jsls
                JSLS
                JSLS : Journal of the Society of Laparoendoscopic Surgeons
                Society of Laparoendoscopic Surgeons (Miami, FL )
                1086-8089
                1938-3797
                Oct-Dec 2011
                : 15
                : 4
                : 451-459
                Affiliations
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Radiooncology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Department of Gynecology, Charité - Universitätsmedizin Berlin, Berlin, Germany.
                Author notes
                Address correspondence to: Christhardt Koehler, MD, Charité Universitätsmedizin Berlin, Campus Mitte, Department of Gynecology, Charitéplatz 1, 10117 Berlin, Germany. Telephone: ++49-30-450664058, Fax: ++49-30-450564906, E-mail: christhardt.koehler@ 123456charite.de
                Article
                11-04-059
                10.4293/108680811X13176785203879
                3340952
                22643498
                34b16fef-da53-4976-aa70-e6c21c563e7d
                © 2011 by JSLS, Journal of the Society of Laparoendoscopic Surgeons.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial No Derivatives License ( http://creativecommons.org/licenses/by-nc-nd/3.0/), which permits for noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited and is not altered in any way.

                History
                Categories
                Scientific Papers

                Surgery
                laparoscopic radical hysterectomy,cervical cancer,urologic complications,radical hysterectomy

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