Objective. At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over-and understaging of tumor extent....Objective. At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over-and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation. Methods. From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich-Schiller-Univer-sity Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size ≥4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients. Results. The mean age of the patients was 54 years (26-80), and the mean body-mass-index was 24.8 (17.9-42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal para-aortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive para-aortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation. Conclusion. Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.展开更多
Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies.We evaluated the feasibility and oncologic value of l aparoscopic transperi-toneal pelvic and paraaortic lymphadenectomy in corr...Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies.We evaluated the feasibility and oncologic value of l aparoscopic transperi-toneal pelvic and paraaortic lymphadenectomy in correla-tion to complication rate and body ma ss index.Between August 1994and September 2003,pelv ic and /or paraaortic transperitoneal laparo scopic lymphadenectomy was performed in 650patients at the D epartment of Gy-necology of the Friedrich -Schiller University of Jena.Retrospective and prospective data collection and evalua-tion of videotapeswere possible in 606patients.Laparo-scopic lymphadenectomy was part of t he following surgi-cal procedures:staging laparoscop y in patientswith ad-vanced cervical cancer(n =133)or early ovarian cancer(n =44),trachelectomy in patients with early cervical cancer(n =42),laparoscopic -assisted radical vaginal hysterectomy in patients with cervical cancer(n =221),laparoscopy before exenteration in patients with pelvic re-currence(n =20),laparoscopic -assisted vaginal hys-terectomy or laparoscopic -assiste d radical vaginal hys-terectomy in patients with endometr ial cancer(n =112),and operative procedures for other i ndications(n =34).After a learning period of approxima tely 20procedures,a constant number of pelvic lymph nodes(16.9-21.9)was removed over the years.Pelvic lymphadenectomy took 28min,and parametric lymphadenectom y took 18min for each side.The number of removed para aortic lymph nodes increased continuously over the yea rs from 5.5to 18.5.Right -sided paraaortic,left -sided inframesenteric and left -sided infrarenal lymphadenec tomy took an average of36,28,and 62min,respectively.The number of removed lymph nodeswas independent from the body mass index of the patient.Duration of pelvic lymp hadenectomywas inde-pendent of body mass index,but right -sided paraaortic lymphadenectomy lasted significan tly longer in obese women(35vs.41min,P =0,011).The overall com-plication rate was 8.7%with 2.9%int raoperative(vessel or bowel injury)and 5.8%postoperative complicatio ns.No major intraoperative complicati on was encountered during the last 5years of the study.B y transperitoneal laparoscopic lymphadenectomy,an a dequate number of lymph nodes can be removed in an adequate time and independent from body mass index.The complication rate is low and can be minimized by standardization of theprocedure.展开更多
Paraaortic infrarenal lymphadenectomy is indicated in patients with gynecologic tumors of high metastasising potential and can be done successfully by laparoscopic approach. Vascular anomalies in this region are incid...Paraaortic infrarenal lymphadenectomy is indicated in patients with gynecologic tumors of high metastasising potential and can be done successfully by laparoscopic approach. Vascular anomalies in this region are incidental findings during these approaches and may increase the surgical complication rate. In this study, we have documented the frequency and pattern of the vascular anomalies in paraaortic region intraoperatively and on cadavers in an attempt to increase surgical safety. A total of 86 consecutive patients underwent laparoscopic infrarenal paraaortic lymphadenectomy by a standardised technique between 1st of January 2002 and 1st of March 2004. Of the 86, 52 were primary cervical, 5 recurrent cervical, 14 endometrial, 14 early ovarian and 1 vulvar tumor with positive groin and pelvic lymph nodes. In the same time, anatomical dissections of the paraaortic region on 18 cadavers were performed at the Institute of Anatomy. Arterial or venous abnormalities were identified in 30.2% (26/86) of patients by laparoscopy. The most frequent anomalies were related to atypical renal arteries (pole arteries- 9 patients) and an abnormal course of lumbar veins directly draining in the left renal vein (15 patients). In one of the patients, the complete left renal vein went retroaortic to the inferior vena cava. In cadaveric dissections, vascular anomalies were noted in 44.4% (8/18) which included variations in renal and lumbar vessels and ovarian vessels. Duplicated inferior vena cava was the least common anomaly and was detected in only one case. During laparoscopic paraaortic inframesenteric and infrarenal lymphadenectomy, care must be taken because of possible abnormalities in arterially and venous system to avoid massive hemorrhage, transfusion and conversion to laparotomy.展开更多
Background: Simultaneous platin-based radiochemotherapy is the standard treatment for patients with advanced or nodal positive cancer of the uterine cervix. There is a large body of literature on therapy-related acute...Background: Simultaneous platin-based radiochemotherapy is the standard treatment for patients with advanced or nodal positive cancer of the uterine cervix. There is a large body of literature on therapy-related acute and late morbidity. Chemoradiation-associated necrosis of the uterus has not been described so far. Material, Methods and Results: We report on a patient who was treated by combined chemoradiation for histologically confirmed cervical cancer following laparoscopic staging. The patient was diagnosed with squamous cell cancer of the cervix FIGO IIIA (T3a pN1 M0 G2). External beam radiotherapy was applied using a 3-D-planned four-field technique, covering the pelvic lymph nodes and the primary tumour. The patient was given brachytherapy (single dosis of 5 Gy, covering the tumour, total dose 25 Gy). Cisplatin was simultaneously administered. Following chemoradiation the patient developed pelvic pain and an elevation of CRP in the presence of a normal leukocyte count. On MRI, recurrence was suspected. The patient underwent re-laparoscopy and necrosis of the uterus was diagnosed without any evidence of recurrence. Laparoscopic assisted hysterectomy with bilateral salpingoophorectomy was performed. Conclusion: In patients with persistent or incident pelvic pain, questionable findings in imaging techniques and/or elevated inflammation parameters following completion of chemoradiation for cervical cancer differential diagnosis should include examination for radiogenic necrosis of the uterus and other pelvic organs. Laparoscopy is an ideal technique to exclude or confirm this diagnosis.展开更多
Objective: Axis and support of the vagina can be restored by sacrocolporectopexy with preservation of coital function. We developed a new technique of transvaginal sacrocolporectopexy for patients with prolapse of ute...Objective: Axis and support of the vagina can be restored by sacrocolporectopexy with preservation of coital function. We developed a new technique of transvaginal sacrocolporectopexy for patients with prolapse of uterus and vagina or prolapse of the vaginal vault. Study design: During a 4-year period, 20 patients with vaginal vault prolapse and 83 patients with uterine and vaginal prolapse underwent transvaginal sacrocolporectopexy. Intra-and post-operative complications were recorded. After a mean follow-up period of 24 months (6-48), the result of surgery with respect to prolapse, incontinence, and sexuality was evaluated by patient interviews. Results: No serious perioperative complications occurred with the exception of one patient with bleeding from a presacral vein. Subjectively, 84 patients (82%) were cured of prolapse symptoms. One patient had recurrent grade II vault prolapse and four patients deve-loped a grade II rectocele. Five patients developed urge incontinence grade I. One patient developed fecal incontinence. No patient had coital problems as a sequelae of sacrocolporectopexy. Conclusion: Transvaginal sacrocolporectopexy is a safe procedure with a success rate comparable to sacrospinous fixation.展开更多
Radical trachelectomy in combination with pelvic and parametric lymphadenectomy is indicated in young patients with early cervical cancer and planned pregnancy. If pregnancy occurs, premature delivery is a known probl...Radical trachelectomy in combination with pelvic and parametric lymphadenectomy is indicated in young patients with early cervical cancer and planned pregnancy. If pregnancy occurs, premature delivery is a known problem in these patients. We evaluated if uterine blood supply is decreased after radical trachelectomy as one of various possible causes of preterm birth. Between October 2003 and April 2004, 14 consecutive patients with early cervical cancer underwent radical trachelectomy with pelvic and parametric lymphadenectomy. The uterine blood supply was measured as resistance index (RI) by Doppler sonography pre- and postoperatively. Doppler sonography of the uterine artery was also performed in 14 healthy students as a control cohort. Fourteen patients with histologically confirmed adenocarcinoma or squamous carcinoma of the cervix uteri stage Ia1 L1 to 1b1 underwent radical trachelectomy. Mean age of patients was 33.4 years (31- 37). On average, 11.5 mm (5- 23) of cervical length and 24.6 (14- 35) tumor- free lymph nodes were removed. Decrease of RI of the uterine artery was 0.06 on the right side (0.76- 0.70) and 0.07 (0.75- 0.68) on the left side. The absolute RI values after radical trachelectomy were not different compared to the values in the control group (0.76 versus 0.70 right side, 0.74 versus 0.68 left side). Uterine perfusion after radical trachelectomy with pelvic and parametric lymphadenectomy remains unchanged.展开更多
文摘Objective. At present, cervical cancer remains the only gynecologic tumor, which is staged by clinical examination according to FIGO. This is associated with a high percentage of over-and understaging of tumor extent. With the operative, especially laparoscopic staging, exact information about intraabdominal tumor spread, lymph node metastases, and involvement of adjacent organs is possible. However, the advantage of operative staging is still discussed controversially. The aim of this study is to describe the laparoscopic transperitoneal staging procedure in patients with cervical cancer and their oncologic outcome after primary chemoradiation. Methods. From November 1994 to October 2003, 456 consecutive patients with histologically confirmed primary cervical cancer were admitted to the Department of Gynecology of the Friedrich-Schiller-Univer-sity Jena, Germany. Out of these, 84 patients with locally advanced tumor (tumor size ≥4 cm) and/or lymph node involvement and/or tumor infiltration to bladder or rectum were selected by a standardized laparoscopic staging procedure for primary chemoradiation. Data of surgery, chemoradiation, and follow-up were analyzed retrospectively for these patients. Results. The mean age of the patients was 54 years (26-80), and the mean body-mass-index was 24.8 (17.9-42.2). Preoperative clinical evaluation showed a stage distribution according to FIGO with stage IB1 in 15.5%, IB2 in 15.5%, IIA in 8.3%, IIB in 23.8%, IIIA in 8.3%, IIIB in 21.4%, IVA in 6%, and IVB in 1.2%. In 15 out of 84 (17.8%) patients, intraabdominal tumor spread was diagnosed by laparascopy. In 24 out of 84 (28.5%) patients, invasion of bladder and/or rectum was proven histologically after biopsy. In 60 out of 84 (71%) patients, lymph node metastases were confirmed histologically. In 2 out of 13 patients with FIGO-stage Ib1, skip metastases in infrarenal para-aortic lymph nodes were seen. Removal of more than 5 pelvic and/or more than 5 positive para-aortic lymph nodes was associated with significant improvement of overall survival. According to the histological findings following laparoscopic staging in 36 out of 84 (43%) patients, a higher tumor stage was diagnosed. If tumor involvement of lymph nodes is also included, an upstaging in 73/84 (87%) of patients has to be noted down. Downstaging was not necessary in any patient following laparoscopic evaluation. Conclusion. Only operative staging gives exact information about tumor extension in patients with locally advanced and/or nodal positive cervical cancer and allows individual treatment planning. This can be done successfully by a transperitoneal laparoscopic approach without serious adverse effects delaying chemoradiation. Debulking of tumor-involved lymph nodes significantly improves overall survival and should be performed prior to primary chemoradiation. Laparoscopic staging should be the basis for all treatment studies in order to group patients according to true tumor extent.
文摘Lymphadenectomy is an integral part of staging and treatment of gynecologic malignancies.We evaluated the feasibility and oncologic value of l aparoscopic transperi-toneal pelvic and paraaortic lymphadenectomy in correla-tion to complication rate and body ma ss index.Between August 1994and September 2003,pelv ic and /or paraaortic transperitoneal laparo scopic lymphadenectomy was performed in 650patients at the D epartment of Gy-necology of the Friedrich -Schiller University of Jena.Retrospective and prospective data collection and evalua-tion of videotapeswere possible in 606patients.Laparo-scopic lymphadenectomy was part of t he following surgi-cal procedures:staging laparoscop y in patientswith ad-vanced cervical cancer(n =133)or early ovarian cancer(n =44),trachelectomy in patients with early cervical cancer(n =42),laparoscopic -assisted radical vaginal hysterectomy in patients with cervical cancer(n =221),laparoscopy before exenteration in patients with pelvic re-currence(n =20),laparoscopic -assisted vaginal hys-terectomy or laparoscopic -assiste d radical vaginal hys-terectomy in patients with endometr ial cancer(n =112),and operative procedures for other i ndications(n =34).After a learning period of approxima tely 20procedures,a constant number of pelvic lymph nodes(16.9-21.9)was removed over the years.Pelvic lymphadenectomy took 28min,and parametric lymphadenectom y took 18min for each side.The number of removed para aortic lymph nodes increased continuously over the yea rs from 5.5to 18.5.Right -sided paraaortic,left -sided inframesenteric and left -sided infrarenal lymphadenec tomy took an average of36,28,and 62min,respectively.The number of removed lymph nodeswas independent from the body mass index of the patient.Duration of pelvic lymp hadenectomywas inde-pendent of body mass index,but right -sided paraaortic lymphadenectomy lasted significan tly longer in obese women(35vs.41min,P =0,011).The overall com-plication rate was 8.7%with 2.9%int raoperative(vessel or bowel injury)and 5.8%postoperative complicatio ns.No major intraoperative complicati on was encountered during the last 5years of the study.B y transperitoneal laparoscopic lymphadenectomy,an a dequate number of lymph nodes can be removed in an adequate time and independent from body mass index.The complication rate is low and can be minimized by standardization of theprocedure.
文摘Paraaortic infrarenal lymphadenectomy is indicated in patients with gynecologic tumors of high metastasising potential and can be done successfully by laparoscopic approach. Vascular anomalies in this region are incidental findings during these approaches and may increase the surgical complication rate. In this study, we have documented the frequency and pattern of the vascular anomalies in paraaortic region intraoperatively and on cadavers in an attempt to increase surgical safety. A total of 86 consecutive patients underwent laparoscopic infrarenal paraaortic lymphadenectomy by a standardised technique between 1st of January 2002 and 1st of March 2004. Of the 86, 52 were primary cervical, 5 recurrent cervical, 14 endometrial, 14 early ovarian and 1 vulvar tumor with positive groin and pelvic lymph nodes. In the same time, anatomical dissections of the paraaortic region on 18 cadavers were performed at the Institute of Anatomy. Arterial or venous abnormalities were identified in 30.2% (26/86) of patients by laparoscopy. The most frequent anomalies were related to atypical renal arteries (pole arteries- 9 patients) and an abnormal course of lumbar veins directly draining in the left renal vein (15 patients). In one of the patients, the complete left renal vein went retroaortic to the inferior vena cava. In cadaveric dissections, vascular anomalies were noted in 44.4% (8/18) which included variations in renal and lumbar vessels and ovarian vessels. Duplicated inferior vena cava was the least common anomaly and was detected in only one case. During laparoscopic paraaortic inframesenteric and infrarenal lymphadenectomy, care must be taken because of possible abnormalities in arterially and venous system to avoid massive hemorrhage, transfusion and conversion to laparotomy.
文摘Background: Simultaneous platin-based radiochemotherapy is the standard treatment for patients with advanced or nodal positive cancer of the uterine cervix. There is a large body of literature on therapy-related acute and late morbidity. Chemoradiation-associated necrosis of the uterus has not been described so far. Material, Methods and Results: We report on a patient who was treated by combined chemoradiation for histologically confirmed cervical cancer following laparoscopic staging. The patient was diagnosed with squamous cell cancer of the cervix FIGO IIIA (T3a pN1 M0 G2). External beam radiotherapy was applied using a 3-D-planned four-field technique, covering the pelvic lymph nodes and the primary tumour. The patient was given brachytherapy (single dosis of 5 Gy, covering the tumour, total dose 25 Gy). Cisplatin was simultaneously administered. Following chemoradiation the patient developed pelvic pain and an elevation of CRP in the presence of a normal leukocyte count. On MRI, recurrence was suspected. The patient underwent re-laparoscopy and necrosis of the uterus was diagnosed without any evidence of recurrence. Laparoscopic assisted hysterectomy with bilateral salpingoophorectomy was performed. Conclusion: In patients with persistent or incident pelvic pain, questionable findings in imaging techniques and/or elevated inflammation parameters following completion of chemoradiation for cervical cancer differential diagnosis should include examination for radiogenic necrosis of the uterus and other pelvic organs. Laparoscopy is an ideal technique to exclude or confirm this diagnosis.
文摘Objective: Axis and support of the vagina can be restored by sacrocolporectopexy with preservation of coital function. We developed a new technique of transvaginal sacrocolporectopexy for patients with prolapse of uterus and vagina or prolapse of the vaginal vault. Study design: During a 4-year period, 20 patients with vaginal vault prolapse and 83 patients with uterine and vaginal prolapse underwent transvaginal sacrocolporectopexy. Intra-and post-operative complications were recorded. After a mean follow-up period of 24 months (6-48), the result of surgery with respect to prolapse, incontinence, and sexuality was evaluated by patient interviews. Results: No serious perioperative complications occurred with the exception of one patient with bleeding from a presacral vein. Subjectively, 84 patients (82%) were cured of prolapse symptoms. One patient had recurrent grade II vault prolapse and four patients deve-loped a grade II rectocele. Five patients developed urge incontinence grade I. One patient developed fecal incontinence. No patient had coital problems as a sequelae of sacrocolporectopexy. Conclusion: Transvaginal sacrocolporectopexy is a safe procedure with a success rate comparable to sacrospinous fixation.
文摘Radical trachelectomy in combination with pelvic and parametric lymphadenectomy is indicated in young patients with early cervical cancer and planned pregnancy. If pregnancy occurs, premature delivery is a known problem in these patients. We evaluated if uterine blood supply is decreased after radical trachelectomy as one of various possible causes of preterm birth. Between October 2003 and April 2004, 14 consecutive patients with early cervical cancer underwent radical trachelectomy with pelvic and parametric lymphadenectomy. The uterine blood supply was measured as resistance index (RI) by Doppler sonography pre- and postoperatively. Doppler sonography of the uterine artery was also performed in 14 healthy students as a control cohort. Fourteen patients with histologically confirmed adenocarcinoma or squamous carcinoma of the cervix uteri stage Ia1 L1 to 1b1 underwent radical trachelectomy. Mean age of patients was 33.4 years (31- 37). On average, 11.5 mm (5- 23) of cervical length and 24.6 (14- 35) tumor- free lymph nodes were removed. Decrease of RI of the uterine artery was 0.06 on the right side (0.76- 0.70) and 0.07 (0.75- 0.68) on the left side. The absolute RI values after radical trachelectomy were not different compared to the values in the control group (0.76 versus 0.70 right side, 0.74 versus 0.68 left side). Uterine perfusion after radical trachelectomy with pelvic and parametric lymphadenectomy remains unchanged.
