Christhardt Köhler

Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer.

OBJECTIVE The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors. METHODS Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98). RESULTS Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%. CONCLUSION Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.

Detection of disseminated tumor cells in patients with cervical cancer

AbstractPurpose. Detection of disseminated tumor cells in a cohort of patients presenting the entire spectrum of invasive cervical cancer. Methods. Disseminated tumor cells were detected in blood samples taken at different times during surgery or in bone marrow aspirates by a HPV type-specific nested PCR enzyme immunoassay (n-PCR-EIA). A group of 24 patients with HPV-positive cervical cancers representing early and late stages were evaluated, and 15 patients with breast cancer and without HPV-related genital disease served as controls. Results. Disseminated tumor cells were detected in blood samples and/or bone marrow aspirates of 6 of 24 patients. A significant association was found between detectable disseminated tumor cells and recurrent disease (P=0.013) and between disseminated tumor cells and survival of the patients (P=0.0054). There was also a clear association between the presence of disseminated tumor cells and tumor size and/or positive lymph node status which, however, was not statistically significant. There was no evidence of increased shedding of tumor cells during surgery. Conclusion. Detection of disseminated tumor cells in blood or bone marrow may prove to be of prognostic value, particularly for early-stage cervical cancers.

Resection of presacral ganglioneurofibroma by laparascopy

Background. Tumors of the retrorectal space are rare. They comprise a heterogeneous group of benign or malignant tumors that cause similar symptoms due to their location in presacral space. If possible, complete surgery excision is the therapy of choice mainly through a sacral, abdominal–sacral, or a pure abdominal or perineal axis. Case report. A 15-year-old asymptomatic patient was diagnosed with a retrouterine tumor during her first gynecological examination. Magnetic resonance imaging of the pelvis showed a 10 × 8.5 × 7-cm encapsulated presacral tumor. Retrorectal ganglioneurofibroma was removed by laparoscopy with preservation of the sympathetic and parasympathetic nerves and the sacral roots of the ischiadic nerves. No sensory or motoric dysfunction of the legs, bladder, or rectum was observed postoperatively. Conclusion. This is the first case report of a complete endoscopic removal of large presacral ganglioneurofibroma in an asymptomatic woman.

Renaissance der Operation nach Schauta

ZusammenfassungDas 100-jährige Bestehen der Radikaloperation nach Schauta ist Anlass, diese lange in Vergessenheit geratene Operationsmethode neu zu bewerten. Mit der Möglichkeit der sicheren laparoskopischen Entfernung der paraaortalen und pelvinen Lymphknoten beim Zervixkarzinom war der Weg offen für die Wiedereinführung der vaginalen radikalen Hysterektomie nach Schauta. Bei primär operablen Tumoren wird die Lymphonodektomie laparoskopisch ausgeführt und bei negativen Lymphknoten sowie Ausschluss von Blasenbefall oder Rektuminfiltration mit der laparoskopisch assistierten radikalen vaginalen Hysterektomie verbunden.Kombiniert laparoskopisch-vaginale Operationstechniken erlauben ein individualisiertes, risikoangepasstes Vorgehen beim Zervixkarzinom. Ein nervenschonendes Vorgehen führt auch bei großen Tumoren zur Erhaltung der motorischen Blasenfunktion bei hoher Radikalität und lokoregionärer Sicherheit. Frühe Tumorstadien können durch laparoskopisch assistierte radikale Trachelektomie so operiert werden, dass eine Erhaltung der Fertilität unter Beachtung onkologischer Standards möglich ist.Mit der laparoskopisch assistierten radikalen vaginalen Hysterektomie und der etablierten abdominalen Operation nach Wertheim stehen heute alternativ zwei onkologisch gleichwertige Operationsverfahren zur Therapie des frühen Zervixkarzinoms zur Verfügung.Abstract100 years of radical vaginal hysterectomy according to Schauta is an occasion to evaluate the value of this “forgotten” surgical technique. The possibility of laparoscopic removal of paraaortic and pelvic lymph nodes in patients with cervical cancer opened the way for the reintroduction of “Schautas operation”. In a curative approach to primary tumors lymphonodectomy is performed laparoscopically. In presence of negative lymph nodes and if bladder and rectum are free of disease laparoscopic assisted radical vaginal hysterectomy is performed.A combination of laparoscopic and vaginal surgical techniques permits individualized, risk-adjusted approaches to cervical carcinoma. Even in cases of large tumors, a nerve-sparing approach to radical vaginal hysterectomy results in maintenance of motoric bladder function with high surgical radicality and locoregional safety. It is possible to surgically treat early tumor states by laparoscopically assisted radical trachelectomy to preserve fertility when oncological standards are observed.At present, the laparoscopically assisted radical vaginal hysterectomy and the well-established abdominal Wertheim operation represent two oncologically equivalent surgical procedures available for treatment of early cervical carcinoma.