Special Issues

Topic Collection: Minimally Invasive Surgery in Gynecological Oncology

· Topical Collection Issue Flyer

Name: Yoichi Aoki, MD, PhD

Affiliation: Department of Gynecological Oncology, Cancer Institute Hospital, Tokyo, Japan

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Interests: Gynaecological Surgery; Robotic Surgery; Laparoscopic Surgery

Name: Gabriele Siesto, MD, PhD

Unit of gynecology, Humanitas Research Hospital, Rozzano, Italy

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Interests: Applicazione della chirurgia mininvasiva/robotica nel trattamento dell'endometriosi pelvica profonda; Applicazione della chirurgia mininvasiva/robotica nel trattamento della recidiva di prolasso genitale; Chirurgia laparoscopica/robotica nella paziente con elevato profilo di rischio anestesiologico o con obesità patologica; Applicazione della chirurgia mininvasiva/robotica nel trattamento dei tumori maligni ginecologici allo stadio iniziale; Ruolo della chirurgia mininvasiva/robotica nel trattamento dei tumori ginecologici avanzati dopo chemioterapia neo-adiuvante

Name: Kristin L Bixel, MD

The Ohio State University Wexner Medical Center, Columbus, United States

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Interests: Gynecologic Oncology

Name: Gaetano Valenti

Department of General Surgery and Medical Surgical Specialties, University of Catania, Catania, Italy

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Interests: Ovarian Cancer; Gynaecology Oncology; Pelvic Surgery

Name: Vanna Zanagnolo

Gynecology Department, European Institute of Oncology (IEO), Milan, Italy

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Interests: Endometrial; Ovarian; Cervical; Vulvar and Vaginal Carcinoma

Name: Scott M. Eisenkop

Women's Cancer Center, Southern California, 4835 Van Nuys Blvd, Suite 208, Sherman Oaks, CA 91403, USA

Interests: Hysterectomy; Lymph Node Dissection; Robot Assisted Surgery

Topical Collection Information

Dear Colleagues,

In the twentieth century, gynecological surgery has evolved from open laparotomy for malignant tumors to laparoscopic hysterectomy, which rose in popularity in the 1990s. In 2000, the number of robotic surgery cases began to increase rapidly, and it has now become widespread.

The usefulness of laparoscopic surgery in early-stage endometrial cancer was shown in the LAP2 study, and now, minimal invasive surgery (MIS) plays a large role in gynecological surgery. Contrary to expectations, however, the LACC trial showed that in cervical cancer, MIS resulted in a poorer prognosis than open surgery, and the causes remain to be identified.

From the evolution of MIS as a diagnostic tool to its use as a definitive treatment, MIS, which lessens the burden on patients, is expected to play a major role in the effective use of the limited medical resources in the world today. The theme of this Top Collection of the European Journal of Gynaecological Oncology is “minimally invasive surgery in gynecologic oncology”, wherein new information on MIS and the latest information from experts is provided in the hope of MIS contributing to patient benefit.

Yoichi Aoki, Gabriele Siesto, Kristin L Bixel, Gaetano Valenti and Vanna Zanagnolo

Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at https://ejgo.imrpress.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All papers will be peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a double-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. European Journal of Gynaecological Oncology is an international peer-reviewed open access quarterly journal published by IMR Press.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is $1250. Submitted papers should be well formatted and use good English.

Keywords

Laparoscopic Surgery; Hysteroscopy; Vaginal Surgery; Ovarian Cancer; Endometrial Cancer; Cervical Cancer

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Single-site robotic-assisted hysterectomy and sentinel lymph node mapping for low-risk endometrial cancer: surgical technique and preliminary outcomes

Felix Chan, Cherynne Yuin Mun Johansson

European Journal of Gynaecological Oncology 2021, 42 (5): 966-972. DOI: 10.31083/j.ejgo4205145

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The staging of endometrial cancer has changed from clinical to surgical over the years. Lymph node disease is recognised as an important prognostic factor as well as an aid to tailoring adjuvant therapy. The development of sentinel lymph node mapping algorithms shows promise in diagnostic accuracy and reducing the morbidity associated with comprehensive lymphadenectomy. In select patients, it is feasible to perform sentinel lymph node mapping using minimally invasive surgical techniques. We present a series of single-site robotic-assisted laparoscopic hysterectomy and sentinel lymph node mapping for low-risk endometrial cancer focusing on the surgical technique required and perioperative outcomes.

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Laparoscopic cytoreductive surgery and HIPEC for advanced ovarian cancer

Rodríguez-Ortiz Lidia, Arjona-Sánchez Álvaro

European Journal of Gynaecological Oncology 2021, 42 (4): 613-614. DOI: 10.31083/j.ejgo4204095

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No abstract present.

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A comparison of laparoscopic and open surgery for early stage endometrial cancer with analysis of prognostic factors: a propensity score matching study

Hao Lin, Hung-Chun Fu, Fu-Tsai Kung, Yu-Jen Chen, Chan-Chao Chang Chien, Chen-Hsuan Wu, Ching-Chou Tsai, Yu-Che Ou

European Journal of Gynaecological Oncology 2021, 42 (4): 703-710. DOI: 10.31083/j.ejgo4204107

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Objective: We aimed to compare the short- and long-term outcomes of a laparoscopic approach with those of laparotomy for early stage endometrial cancer and attempted to identify factors predicting survival. Methods: Between 2007 and 2014, patients with clinical early stage endometrial cancer and a uterine size less than 10 cm receiving surgical treatment were reviewed. Kaplan-Meier and multivariate Cox regression model were used for survival analysis. Short- and long-term outcomes were compared between the two groups before and after 1 : 1 propensity score matching (PSM). Results: Finally 255 patients were enrolled, 177 received laparotomy and 78 received laparoscopic surgery. The patients receiving laparoscopic surgery had significant less blood loss and shorter hospital stay, but longer operative time. Before PSM, the 5-year disease-free survival (DFS) and overall survival (OS) rates were in favor of laparoscopic group (94.4 vs. 84.1%, p = 0.022; 97 vs. 90.5%, p = 0.060). Cox regression analysis showed that high-grade lesion (HR 11.35, 95% CI 4.06–31.07), non-endometrioid histology (HR 3.99, 95% CI 1.52–10.44), and age >60 (HR 3.35, 95% CI 1.60–7.00) were independent factors predicting recurrence while high-grade lesion (HR 10.38, 95% CI 2.44–44.15) and CA125 >35 (HR 3.02, 95% CI 1.07–8.55) were independent factors predicting death. After PSM, two comparable groups of 59 patients each were obtained. There were no significant differences in 5-year DFS and OS between the two groups. Conclusion: Our results showed that compared with laparotomy, laparoscopic surgery improved short-term outcomes, with similar survival results. Factors predicting survival were high-grade tumor, non-endometrioid histology, age >60, and CA125 >35.

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An innovative tissue model for robot-assisted radical hysterectomy and pelvic lymphadenectomy

Kota Umemura, Yosuke Kawai, Hiroko Machida, Ryosuke Uekusa, Atsushi Kunishima, Mayumi Okada, Hisao Ando, Michiyasu Kawai

European Journal of Gynaecological Oncology 2021, 42 (3): 482-487. DOI: 10.31083/j.ejgo.2021.03.2295

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Objective: The purpose of this study was to evaluate a new tissue model and to conduct a questionnaire survey to assess its feasibility for robot-assisted radical hysterectomy, colpotomy, and pelvic lymph node dissection training. Methods: Sixteen gynecologists (12 males, 4 females; mean age: 47.1 years; all attending doctors with an average experience of 9.3 robot-assisted surgeries) were trained in robot-assisted radical hysterectomy, colpotomy, and pelvic lymphadenectomy using a new uterine and pelvic lymph node model (mainly composed of PVA) from Fasotec Inc. The participants were trained by the author using a dual console. They performed all surgical procedures following the author's instructions. The time required for completion of the surgeries was measured. The surgical skills of the participants were evaluated by the author using the operative performance rating scale recommended by the American College of Surgeons. After training, the participants answered a questionnaire for the assessment of the model and the training using a 5-point Likert scale. Results: We found that the mean time taken for radical hysterectomy, colpotomy, and pelvic lymphadenectomy was 57.3 minutes (range: 45–75 minutes), 12.2 minutes (range: 8–17 minutes), and 60.7 minutes (range: 45–70 minutes), respectively; the total time taken was 136.5 minutes (range: 98–162 minutes). The questionnaire survey revealed that this model followed pelvic anatomy and was practically trainable. Conclusion: This is the first report of a tissue model relevant to the uterus and the pelvic lymph nodes, and robot-assisted training using this model was considered effective.

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Laparoscopic total vaginectomy for isolated vaginal recurrence of cervical cancer or high-grade squamous intraepithelial lesion after hysterectomy: a retrospective, single-centre cohort study

Kota Okamoto, Yoichi Aoki, Eiji Kondo, Yusuke Shimizu, Ai Ikki, Yuji Tanaka, Atsushi Fusegi, Makoto Nakabayashi, Makiko Omi, Tomoko Kurita, Terumi Tanigawa, Sachiho Netsu, Mayu Yunokawa, Hidetaka Nomura, Maki Matoda, Sanshiro Okamoto, Kohei Omatsu, Tomoaki Ikeda, Hiroyuki Kanao

European Journal of Gynaecological Oncology 2021, 42 (3): 494-498. DOI: 10.31083/j.ejgo.2021.03.2335

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Objective: We conducted a retrospective study in which we evaluated the feasibility and effectiveness of total vaginectomy for isolated vaginal recurrence of cervical cancer that had been treated surgically. Such recurrence is uncommon, and there is no consensus regarding the treatment strategy. Methods: Included in our study were 6 patients who, between January 2012 and December 2019, had undergone laparoscopic vaginectomy for vaginal recurrence of cervical cancer or high-grade squamous intraepithelial lesion that had been treated by hysterectomy. Results: The patients ranged in age from 49 to 78 years (median, 68 years). Vaginectomy time ranged from 128 to 385 minutes (median, 176.5 minutes), and estimated blood loss ranged from 40 to 310 mL (median, 105 mL). Patients' hospital stay ranged from 7 to 29 days (median, 14 days). Two intraoperative complications occurred: a grade 1 small bowel injury in 1 patient and a grade 1 bladder injury in another. An abdominal abscess developed postoperatively in 1 patient. Conclusions: Local control was achieved in 5 of the 6 patients. Our data support both the feasibility and effectiveness of laparoscopic total vaginectomy for isolated vaginal recurrence of cervical cancer or high-grade squamous intraepithelial lesion after hysterectomy.

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Lower leg compartment syndrome following laparoscopic uterine malignancy surgery for uterine cancer complicated by rheumatoid arthritis: a case report and literature review

Hanako Sato, Yasushi Kotani, Shiro Takamatsu, Mamiko Ohta, Reona Shiro, Kiko Yamamoto, Kosuke Murakami, Noriomi Matsumura

European Journal of Gynaecological Oncology 2021, 42 (3): 590-594. DOI: 10.31083/j.ejgo.2021.03.2296

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Background: Compartment syndrome is a condition in which an increased internal pressure in the upper/lower leg compartment results in circulatory disturbance causing muscle and nerve dysfunction. There have been five case reports of compartment syndrome following gynecologic laparoscopic surgery. We present this rare case herein with a review of the related literature. Case: The patient was a 44-year-old woman. She underwent laparoscopic modified radical hysterectomy for uterine cancer. During surgery, she wore elastic stockings from her toes to her knees. She also had intermittent pneumatic compression of the thighs and lower legs with the head down at 15 degrees. The operative time was 6 h and 49 min. She was diagnosed with compartment syndrome, and a decompression incision was indicated. Conclusion: After experiencing this case, we use the open leg position, releasing the high pelvic position for 10 min every 3 h, during which the nurse should decompress the foot.

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Endometrial cancer with tubal metastasis detected during laparoscopic surgery in a patient undergoing fertility-sparing treatment with medroxyprogesterone acetate: a case report and review of the literature

Imari Deura, Yuko Nagasawa, Ryo Kanamori, Eriko Shiraishi, Yuki Horage, Shiho Kuji, Tatsuru Ohara, Nao Suzuki

European Journal of Gynaecological Oncology 2021, 42 (3): 598-604. DOI: 10.31083/j.ejgo.2021.03.2334

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Objectives: Medroxyprogesterone acetate (MPA) therapy is useful as a fertility-sparing treatment for early endometrial cancer, but it poses a risk of progression and recurrence during the treatment. We report a case of endometrial cancer with tubal metastases after long-term MPA therapy and review the literatures focusing on the failure of fertility-sparing treatment. Case: A nulliparous, 40 years old woman was started on MPA therapy after being diagnosed with grade 1 endometrioid carcinoma confined to the endometrium. She achieved complete remission after 10 months of treatment, but no pregnancy was established by assisted reproductive technology (ART). Eleven months after the first MPA therapy ended, atypical endometrial hyperplasia was confirmed. The disease was in remission again after the second MPA therapy for 8 months. The patient did not become pregnant by subsequent ART. Finally, a total laparoscopic hysterectomy with bilateral salpingo-oophorectomy was performed. The gross pathological specimen revealed a 13 mm mass near the left uterine cornu. Histopathology showed a left tube metastasis. She was diagnosed with FIGO stage IIIA endometrial cancer and underwent the staging surgery by laparotomy. After the second surgery, adjuvant chemotherapy was initiated. After 13 months of disease-free survival, a recurrence was histologically detected at the vaginal stump. Following intracavitary radiation therapy, there was no evidence of disease for 10 months. Conclusions: The patient undergoing fertility-sparing treatment should be apprised of a risk of life-threatening progression of the disease. Once the patient has opted out of fertility preservation, definitive hysterectomy should be strongly recommended.

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Stage IA endometrial cancer recurrence around the ureter after laparoscopic surgery

Rikiya Sano, Yoshiaki Ota, Soichiro Suzuki, Takuya Moriya, Mitsuru Shiota

European Journal of Gynaecological Oncology 2021, 42 (2): 360-364. DOI: 10.31083/j.ejgo.2021.02.2292

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Minimally invasive surgery has become a standard treatment for early-stage endometrial cancer. Its outcomes are not inferior to those of open surgery, and it has a good prognosis. Thus, there have been a few studies on recurrence patterns in low-risk endometrial cancer. We described the case of a 45-year-old multiparous woman with the International Federation of Gynecology and Obstetrics stage IA, grade 1 endometrioid endometrial cancer, who was treated with laparoscopic modified radical hysterectomy with bilateral adnexectomy and pelvic lymph node dissection. The patient developed isolated recurrence around the left ureter 27 months later, which was also laparoscopically resected. Pathologically, she had a low risk of recurrence; therefore, we had to review our surgical procedures. The findings of a recent study have led to the development of the theory that there is a laparoscopy-specific recurrence pattern. We discussed this recurrence pattern in relation to our patient's case and aimed that our findings will prompt to reconsider laparoscopic surgery in preventing tumor spread and recurrence in early-stage low risk endometrial cancer.

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Introduction of minimally invasive surgery for the treatment of endometrial cancer in Japan: a review

Yuichiro Miyamoto, Michihiro Tanikawa, Kenbun Sone, Mayuyo Mori-Uchino,Tetsushi Tsuruga, Yutaka Osuga

European Journal of Gynaecological Oncology 2021, 42 (1): 10-17. DOI: 10.31083/j.ejgo.2021.01.2264

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Minimally invasive surgery is now becoming the standard surgical method for early stage endometrial cancer. In this review, we describe the path minimally invasive surgery has travelled from being an exceptional treatment to be the current standard in Japan. At the beginning of the 21th century, laparoscopic surgery has been employed for the treatment of gynecologic malignancies including cervical cancer and endometrial cancer. Robotic-assisted surgical system, which appeared a little later than laparoscope, has begun to be actively applied to surgical treatments for gynecologic malignancies that require particularly elaborate technologies. Both laparoscopic and robotic surgery have attracted the attention of surgeons because they enable safe, precise and less invasive surgery. Since the safety of minimally invasive surgery depends largely on the skill and experience of the surgeon, there is an urgent need to establish an educational system for implementing minimally invasive surgery. Here we describe various issues regarding minimally invasive surgery that Japan is currently facing, such as the medical economy, regulations by the Japanese health insurance system, a shortage of surgeons, the roles of academic organizations to educate surgeons and guide the appropriate implementation of minimally invasive surgery.

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The current evidence for the use of minimally-invasive surgery in endometrial cancer

Joseph J. Noh, Tae-Joong Kim

European Journal of Gynaecological Oncology 2021, 42 (1): 18-25. DOI: 10.31083/j.ejgo.2021.01.2297

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The aim of the present study is to review the current available data regarding the use of minimally-invasive surgery in endometrial cancer patients and investigate the feasibility and safety of it for cancer control. We also reviewed the current understanding of sentinel lymph node mapping and the use of robotic surgery in endometrial cancer. Studies have consistently demonstrated better short-term outcomes of minimally-invasive surgery in endometrial cancer compared to laparotomy such as less blood loss, shorter hospital stay, and fewer wound complications. Large randomized clinical trials and meta-analyses also suggest the feasibility and safety of minimally-invasive surgery in terms of oncologic outcomes especially in patients with early stage disease. Although evidence for advanced stage disease and patients with high risk for recurrence are still lacking, the current available data seem to support the use of minimally-invasive surgery for those patient groups as well. A large body of literature supports the role of sentinel lymph node mapping in endometrial cancer with a high sensitivity and a low false negative rate, as well as a favorable negative predictive value. Studies also show that robotic surgery is a safe and effective alternative to conventional laparoscopic surgery for endometrial cancer staging but further long-term data are required. Further prospective studies with long-term follow-up are warranted to evaluate the feasibility and safety of minimally-invasive surgery especially in patients with advanced stage disease and high risk for recurrence. However, the current available data support the use of minimally-invasive surgery in all patient groups of endometrial cancer.

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Surgical approach in early stage cervical cancer: the Asian view point

Hiroko Machida, Hiroshi Yoshida, Kenji Izumi, Rie Nakajima, Miwa Yasaka, Tetsuji Iida, Masae Ikeda, Masako Shida, Takeshi Hirasawa, Mikio Mikami

European Journal of Gynaecological Oncology 2021, 42 (1): 30-37. DOI: 10.31083/j.ejgo.2021.01.2270

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Objective: To examine the current practice of radical hysterectomy for early-stage cervical cancer in Asia after the Laparoscopic Approach to Cervical Cancer (LACC) trial. Methods: A cross-sectional study was conducted in Asia to examine the prevalence and management of women with early-stage cervical cancer. The study was conducted among gynecologic oncologists at leading hospitals in the Asian Society of Gynecologic Oncology Council members. A systematic literature review was performed to examine the association between survival outcomes and surgical approach after the LACC trial. Results: Seven countries participated voluntarily in the study. The incidence, mortality, and centralization of treatment in early-stage cervical cancer were different among the seven countries. The number of specialized centers per population density in Japan was higher than that in the other countries. Minimally invasive surgery (MIS) approach for cervical cancer was common in Korea (56%) and Hong Kong (80-90%), but not in the other countries (2-20%). In the systematic review, there was a significant difference in survival outcomes between MIS and open surgery (recurrence, hazard ratio 1.83, 95% confidence interval 1.27-2.62). MIS without a uterine manipulator or making a vaginal cuff closure produced similar recurrence rates compared with open surgery (MIS without uterine manipulator vs open-surgery: 10.5% vs 10.1%, and MIS with cuff closure vs open-surgery 7.2% vs 10.1%; all P > 0.05). Conclusion: The prevalence of MIS for early-stage cervical cancer varies across Asian regions after the LACC trial. Surgical methods to avoid tumor spillage may be useful for improving survival.

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Short-term outcomes for patients with endometrial cancer who received robot-assisted modified radical hysterectomy: A retrospective observational study

Tomohito Tanaka, Shoko Ueda, Shunsuke Miyamoto, Shinichi Terada, Hiromi Konishi, Yuhei Kogata, Satoe Fujiwara, Yoshimichi Tanaka, Kohei Taniguchi, Kazumasa Komura, Masahide Ohmichi

European Journal of Gynaecological Oncology 2021, 42 (1): 90-95. DOI: 10.31083/j.ejgo.2021.01.2262

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Objective: Minimally invasive surgery is a standard treatment for endometrial cancer patients with uterine-confined disease. Robot-assisted surgery has been covered under public insurance since 2018 in Japan. The aim of the current study was to compare the short-term outcomes between robot-assisted modified radical hysterectomy (RAMRH) and total laparoscopic modified radical hysterectomy (TLMRH). Methods: A total of 190 patients with endometrial cancer who had undergone RAMRH or TLMRH were retrospectively reviewed. Short-term outcomes, including surgical time, estimated blood loss, complications, and hospital stay, were compared between the groups. Results: Among 190 patients, including 67 with RAMRH and 123 with TLMRH, the median (interquartile range [IQR]) surgical time was 247 (IQR: 221-313) min in RAMRH and 271 (IQR: 236-280) min in TLMRH. The estimated blood loss was less than 10 mL in most cases. There was 1 major vessel injury and 1 vescio-vaginal fistula in the RAMRH group. In contrast, there were 2 bladder injuries, 1 bowel injury, 2 obturator nerve injuries, 1 major vessel injury, and 2 pelvic abscesses in the TLMRH group. The median hospital stay was 10 (IQR: 10-10) days in RAMRH and 9 (IQR: 9-10) days in TLMRH. Conclusion: Robot-assisted procedures were not associated with poorer short-term outcomes than laparoscopy in patients with endometrial cancer.

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The impact of post-operative voiding trial on length of stay following laparoscopic hysterectomy: a prospective, randomized control trial

Michelle Davis, Kathryn Barletta, Alexcis Ford, Roni Nitecki, Kevin M. Elias, Ross Berkowitz, Colleen Feltmate

European Journal of Gynaecological Oncology 2021, 42 (1): 110-117. DOI: 10.31083/j.ejgo.2021.01.2293

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Objective: Same day discharge (SDD) is feasible following laparoscopic hysterectomy (TLH) in gynecologic oncology patients resulting in low complication and re-admission rates. Following vaginal surgery, backfill or active voiding trials have been shown to reduce hospital discharge with a catheter. The aim of this study is to determine if performing an active backfill voiding trial (AVT) vs. passive voiding trial (PVT) leads to expedited discharge following TLH. Methods: Subjects scheduled for SDD TLH were enrolled and randomized to an AVT or a PVT. The primary outcome was length of stay. Secondary outcomes include time to void, catheter replacement, admission to the extended recovery unity (ERU), post-operative pain, and complications. Results: 121 patients were randomized: 60 to an AVT and 61 to a PVT. There was a statistically significant reduction in median length of stay for patients undergoing an AVT vs. PVT (271.5 minutes vs. 329 minutes, P = 0.015). Median time to void was also decreased with an AVT vs. PVT (30 minutes vs. 289 minutes, P < 0.001). There was no difference in median pain score (2), catheter replacement, peri-operative complications, or overnight admissions between the two groups. Conclusion: There is a significant reduction in time to void and total length of stay in patients randomized to a backfill voiding trial following TLH with no increased patient discomfort. While the numbers of post-operative admissions were low and underpowered to detect a difference in admission rate, these data will help to streamline post-operative care for SDD gynecologic oncology patients.

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Study of laparoscopic monopolar devices and its thermal effects

Motoki Matsuura, Masato Tamate, Sachiko Nagao, Muna Nishio, Tadahi Okada, Yoko Nishimura, Kyoko Isoyama, Noriko Terada, Tsuyoshi Saito

European Journal of Gynaecological Oncology 2021, 42 (1): 118-121. DOI: 10.31083/j.ejgo.2021.01.2311

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Objective: Energy devices are frequently used in minimally invasive surgeries (MIS). For MIS involving gynecologic malignancies, energy devices should be used cautiously to prevent thermal injuries to nearby organs. We evaluated monopolar electrosurgery devices and measured increases in temperature in the tissue and device. Methods: Briefly, the surface of a porcine tissue was incised using short and long activation times. Subsequently, the maximum temperature at the tip of the monopolar device, the cooling time required to reach a temperature of 60 °C, and the maximum tissue temperature were recorded. Results: Longer activation time was correlated with a higher tip temperature. With all activation times, there was an increase in the tip temperature that exceeded 100 °C. The cooling time to reach 60 °C was faster with the short activation times than with the long activation times. Even with the same output, the temperature decreased faster in the coagulation mode, suggesting that the cooling times were shorter with lower outputs. The tissue temperature dropped to 60 °C or less within 1 s in the cut mode but required approximately 2 s in the coagulation mode at 40 W. The temperature of the dissected tissue increased to 60 °C or higher; the cooling time was longer with high output and in the coagulation mode. Conclusions: We revealed that the activation of the monopolar device under routine use conditions exceeded a temperature of 100 °C. Additionally, the temperatures of the tip and tissue were significantly higher in proportion to the output and time. For MIS involving gynecologic malignancies, careful attention is necessary to avoid thermal injury.

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Outcomes and complications of total laparoscopic hysterectomy after conization

Kaori Hoshino, Yasuyuki Kinjo, Hiroshi Harada, Taeko Ueda, Yoko Aoyama, Midori Murakami, Seiji Kagami, Yusuke Matsuura, Kiyoshi Yoshino

European Journal of Gynaecological Oncology 2021, 42 (1): 122-128. DOI: 10.31083/j.ejgo.2021.01.2319

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Objective: High-grade squamous intraepithelial lesion (HSIL)/cervical intraepithelial neoplasia (CIN) 3, and stage IA1 cervical cancer are often diagnosed after cervical conization. Additional resection is required in some cases, and total laparoscopic hysterectomy (TLH) after conization requires attention due to the postoperative changes around the cervix. Methods: This single-center retrospective study investigated the perioperative outcomes and complications of TLH with or without conization. Patients diagnosed with CIN or stage IA1 cervical cancer were grouped according to whether conization was performed before TLH. The perioperative outcomes, complications, and oncological outcomes were compared for 32 patients who underwent TLH after conization (cone-TLH group) and 18 patients who underwent TLH alone (TLH group). Results: The mean interval between conization and TLH was 14.8 ± 5.2 weeks. There were no significant differences between the cone-TLH and TLH groups in terms of surgical time (186.3 ± 48.1 min vs. 179.8 ± 34.6 min, P = 0.61), blood loss (100 [5-500] mL vs. 100 [5-560] mL, P = 0.79), length of hospital stay (4.7 ± 1.4 days vs. 4.6 ± 1.0 days, P = 0.86), or recurrence rate. One patient in the cone-TLH group experienced a ureter injury. Conclusions: Although the outcomes were comparable between TLH alone and TLH after conization, care is needed to avoid ureter complications.

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Cesarean scar perforation in laparoscopic hysterectomy for endometrial cancer: a case report

Azusa Kimura, Kenro Chikazawa, Ken Imai, Ito Takaki, Tomoyuki Kuwata, Ryo Konno

European Journal of Gynaecological Oncology 2021, 42 (1): 179-182. DOI: 10.31083/j.ejgo.2021.01.2256

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Perioperative complications tend to increase when performing hysterectomy in patients with a history of caesarean section. Therefore, the laparoscopic hysterectomy procedure requires careful consideration. Herein, we report the case of a patient with a history of caesarean section who underwent total laparoscopic hysterectomy for endometrial cancer. A 59-year-old woman was diagnosed with stage IA endometrial cancer preoperatively, and she underwent laparoscopic hysterectomy, bilateral adnexectomy, and pelvic lymphadenectomy. During these procedures, the bladder was observed to tightly adhere to the scar of a previous caesarean section, and the uterine was perforated due to detachment near the uterus to avoid damage to the bladder. After 2 years, there were no symptoms of recurrence. Our findings further demonstrated that bladder adhesions should be considered in laparoscopic surgery for patients with endometrial cancer who have a history of caesarean section.

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A modified technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation through a mini-laparotomy

Zen Watanabe, Hideki Tokunaga, Masumi Ishibashi, Shogo Shigeta, Keita Tsuji, Tomoyuki Nagai, Masahito Tachibana, Muneaki Shimada, Nobuo Yaegashi

European Journal of Gynaecological Oncology 2021, 42 (1): 183-188. DOI: 10.31083/j.ejgo.2021.01.2278

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Radical trachelectomy is an optional fertility-sparing treatment for early-stage cervical cancer, and recently, the minimally invasive approach (MIA) has become a major trend in radical trachelectomy. MIA radical trachelectomy requires a more careful surgical technique to avoid tumor spillage and exposure of the cancerous tissue under carbon dioxide pneumoperitoneum to reduce the risk of recurrence. We present a case of a 33-year-old nulliparous woman with stage IB1 cervical cancer who underwent MIA radical trachelectomy through a combination of laparoscopic surgery and mini-laparotomy, mainly to prevent postoperative complications and tumor spread during cervical amputation. A Papanicolaou test suggested the diagnosis of squamous cell carcinoma of the cervix without any symptoms such as atypical bleeding. The subsequent biopsy revealed squamous cell carcinoma with stromal invasion of the cervix. Cervical amputation was performed extracorporeally through a small incision in the lower abdomen. There were no perioperative complications. The patient was discharged on postoperative day 13. The final pathological evaluation revealed residual microinvasive cancer of the endocervical canal with clear margins, no lymphovascular space involvement, and 27 negative lymphatic nodes. The joint of the neo-cervix and vagina had healed completely without erosion or stenosis of the cervical canal, and no problems occurred during sexual intercourse. No cancer recurrence or menstrual disorders have been reported in the short postoperative period of 6 months. The surgical technique of laparoscopic radical trachelectomy combined with extracorporeal cervical amputation may be an acceptable alternative to reduce the risk of recurrence by preventing intraperitoneal tumor spillage.

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Robotic hysterectomy with pelvic lymphadenectomy for early endometrial cancer in a patient with situs inversus totalis using 3D-CT analysis: a case report

Hideaki Yajima, Eiji Kondo, Masafumi Nii, Michiko Kaneda, Kenta Yoshida, Tomoaki Ikeda

European Journal of Gynaecological Oncology 2021, 42 (1): 189-192. DOI: 10.31083/j.ejgo.2021.01.2294

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Background: Pelvic lymphadenectomy should be considered the standard of care for endometrial cancer patients with intermediate-risk. In such cases, lymph node assessment may be performed via a minimally invasive approach. Situs inversus totalis is a congenital condition wherein the major visceral organs are reversed or mirrored from their normal anatomical positions. Reports state that performing surgery on patients with this condition is difficult due to the anatomical abnormality. However, few clinical studies have been conducted to evaluate the efficacy of robotic surgery for endometrial cancer patients with situs inversus totalis because it is technically challenging. Case presentation: A 69-year-old woman with situs inversus totalis (gravida 2 para 2) was brought to our hospital due to a uterine tumor. Endometrial biopsy showed grade 1 endometrioid carcinoma. Using 3 dimensional -computed tomography reconstruction, her common iliac arteries and veins were found to be reversed or mirrored from their normal positions. She underwent hysterectomy with pelvic lymphadenectomy using the multi-articulated arms or 3 dimensional high-definite vision of the da Vinci^® surgical system, and 19 lymph nodes were harvested. She was followed up for 24 months without signs of recurrence. Conclusion: The multi-articulated arms or 3 dimensional high-definite vision of the da Vinci^® surgical system may be a feasible and safe approach for performing a pelvic lymphadenectomy on patients with situs inversus totalis using 3 dimensional computed tomography analysis.

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Laparoscopic ureteral reconstruction in gynaecological recurrent cancer surgeries: an initial case series study

Yuji Tanaka, Yusuke Shimizu, Ai Ikki, Kota Okamoto, Atsushi Fusegi, Makoto Nakabayashi, Makiko Omi, Tomoko Kurita, Terumi Tanigawa, Yoichi Aoki, Sachiho Netsu, Mayu Yunokawa, Hidetaka Nomura, Maki Matoda, Sanshiro Okamoto, Kohei Omatsu, Hiroyuki Kanao

European Journal of Gynaecological Oncology 2020, 41 (6): 975-981. DOI: 10.31083/j.ejgo.2020.06.2258

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In combined resection of the bladder and ureter during laparoscopic surgery for gynaecological recurrent cancer, some cases require laparoscopic ureteral reconstruction techniques. In the open surgery approach, it has been reported that gynaecological advanced or recurrent tumour surgeries solely conducted by a gynaecologic group, with combined resection of multiple organs, improves the prognosis. However, to the best of our knowledge, in the minimally invasive surgery approach, there are no reported case series in the field of gynaecological recurrent tumour surgery conducted by only a gynaecologic group, with combined resection of the bladder and ureter. Therefore, we conducted this pilot study to describe the feasibility of laparoscopic gynaecologic recurrent malignant tumour surgery involving ureteral reconstruction. We retrospectively searched our patient database for women with gynaecological cancer who underwent laparoscopic ureteral reconstruction techniques in gynaecological recurrent cancer surgeries. Nine patients underwent laparoscopic ureteral reconstruction for long-segment ureteral defects in gynaecologic surgeries. In all cases, R0 surgical resection were successfully performed. The ureteral defect lengths ranged from 3.5-10 cm (median, 4 cm). The Boari flap was necessary in one of the eight cases with a ureteral defect of less than 8 cm. The ureteral defect was less than 12 cm in all cases, but substitution was required in three cases. In all cases except one, no urinary complications occurred. In conclusion, it is feasible for a gynaecologist to perform laparoscopic ureteral reconstruction combined resection of the bladder and ureter during laparoscopic surgery for gynaecological recurrent cancer.

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Human papillomavirus genotyping is a reliable prognostic marker of recurrence for high-grade cervical intraepithelial neoplasia (CIN2-3) with positive margins after loop electrosurgical excision procedure

Ha Na Yun, Woo Dae Kang, U Chul Ju, Seok Mo Kim

European Journal of Gynaecological Oncology 2020, 41 (6): 969-974. DOI: 10.31083/j.ejgo.2020.06.2231

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Objective: The study was performed to determine whether the human papillomavirus (HPV) genotype result from the HPV DNA chip test (HDC) was predictive of recurrent high-grade cervical intraepithelial neoplasia (CIN2-3) in patients with positive margins after a loop electrosurgical excision procedure (LEEP). Methods: A total of 184 patients with histologically confirmed CIN2-3 identified at the margin of a LEEP specimen were followed with HDC testing, hybrid capture II (HC2) analysis, and cytology examinations. Post-LEEP monitoring was conducted at 3, 6, 9, 12, 18, and 24 months during the first two years and annually thereafter. Results: Of the 184 patients, the HC2 test was positive in 179 patients (97.3%) and the HDC test was positive in 181 patients (97.6%) before the LEEP. The overall agreement between the HC2 and HDC tests was 98.9%. Forty-six (25.0%) patients developed a recurrence, and those who experienced a relapse tested positive for the same high-risk HPV genotype detected before the LEEP. Identifying the same high-risk HPV genotype by HDC testing during the follow-up period had a negative predictive value and a sensitivity of 100% in diagnosing recurrent lesions. HPV-18 was related to recurrent CIN2-3. A significant association between HPV-18 infection and recurrent CIN2-3 was found (p < 0.05). Conclusions: In patients with CIN2-3 identified at the margins of a LEEP specimen, the persistence of the same high-risk HPV infection, especially HPV-18, should be regarded as a risk factor for recurrent CIN2-3. After a LEEP, such patients require particular attention with short-term follow-up.

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Minimally invasive surgery in radical hysterectomy for cervical cancer

Chyi-Long Lee, Kuan-Gen Huang, Peng-Teng Chua

European Journal of Gynaecological Oncology 2020, 41 (6): 852-857. DOI: 10.31083/j.ejgo.2020.06.2260

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Complete resection of an endometrial cancer lesion by hysteroscopic tumor resection combined with photodynamic diagnosis: a case report

Yusuke Matoba, Kouji Banno, Yusuke Kobayashi, Kosuke Tsuji, Iori Kisu, Daisuke Aoki

European Journal of Gynaecological Oncology 2020, 41 (6): 1050-1055. DOI: 10.31083/j.ejgo.2020.06.2204

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Introduction: Treatment for early endometrial cancer (EC) has been shifting to less invasive surgery, including several reports of hysteroscopic tumor resection. Complete tumor resection is desired in these treatments. Photodynamic diagnosis (PDD) is the technique to increase the complete resection rate by red fluorescence of the lesion and has improved the prognosis of cystoscopic tumor resection for early bladder cancer. In gynecology, we showed that hysteroscopic PDD has high sensitivity for EC. Here, we report a case of EC in which no residual malignant lesions were found pathologically in hysterectomy after hysteroscopic tumor resection with PDD. Case: The patient was 54 years old when she was diagnosed with atypical endometrial hyperplasia by endometrial biopsy, but suspected to have EC on magnetic resonance imaging. Hysteroscopic tumor resection was planned for the definitive diagnosis. PDD was used in hysteroscopic surgery after informed consent was obtained. Under hysteroscopy, a tumefactive lesion was found on the anterior wall of the uterine cavity to near the left oviductal orifice, and was PDD-positive. The PDD-positive lesion was resected completely under hysteroscopy. The hysteroscopic specimen was pathologically diagnosed as endometrioid carcinoma, grade 1. Laparoscopic hysterectomy and bilateral salpingo-oophorectomy were then performed, but no residual malignancy was found in resected specimens. There has been no recurrence at one year after surgery without no adjunct therapy. Conclusion: Complete resection of endometrial cancer was achieved by hysteroscopic tumor resection with PDD. This case suggests that hysteroscopic surgery may be a less invasive treatment option for early EC.

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