Fabrice Narducci

Early experience of robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein

OBJECTIVEnTo describe our early experience with robotic-assisted laparoscopy for extraperitoneal para-aortic lymphadenectomy up to the left renal vein, including Da Vinci robot positioning.nnnMETHODSnSix patients underwent robotic-assisted laparoscopy using the Da Vinci apparatus. The patients included a man with a pT2 non-seminomatous germ cell tumour of the left testicle treated by chemotherapy with an incomplete response (mature teratoma), four women with locally advanced cervical cancer, and one case of bulky cancer of the vaginal cuff. The procedure was carried out using four port sites: one for the camera, one each for the no. 1 and no. 3 arms of the Da Vinci robot system, and one for the assistant.nnnRESULTS AND CONCLUSIONnRobotic-assisted lymphadenectomy carried out using the Da Vinci system was safe and effective with a short learning period for an experienced oncological team. A larger prospective study is now required to evaluate this procedure further.

Vaginal evisceration after hysterectomy: the repair by a laparoscopic and vaginal approach with a omental flap

BACKGROUNDnVaginal evisceration is generally repaired by vaginal or abdominal route. We describe two cases of vaginal evisceration using a combined laparoscopic and vaginal approach employing an omental flap.nnnCASESnCase 1: A radical abdominal hysterectomy was performed in a premenopausal patient for a FIGO IB1 cervical cancer. Four months later, she was found to have a vaginal cuff dehiscence which was repaired by a vaginal approach. Two months later, she had a vaginal cuff evisceration which was repaired using a combined laparoscopic and vaginal approach employing an omental flap with good success. Case 2: A postmenopausal woman who underwent an abdominal hysterectomy and pelvic lymphadenectomy for a FIGO IB endometrial cancer was noted to have a vaginal evisceration two months after primary surgery. This was also successfully repaired using a combined laparoscopic and vaginal approach employing an omental flap.nnnCONCLUSIONnThe combined laparoscopic and vaginal approach with omental flap is effective for repair of a vaginal cuff dehiscence with bowel evisceration. The addition of laparoscopy provides an opportunity for inspection of the small bowel, the peritoneal toilet, and mobilization of an omental flap.

Low incidence of port-site metastases after laparoscopic staging of uterine cancer.

OBJECTIVEnTo estimate the incidence of clinically detected port-site metastases (PSM) in patients with endometrial and cervical cancer treated at two gynecologic oncology services with extensive experience.nnnMETHODSnAll eligible uterine cancer patients laparoscopically staged at Centre Oscar Lambret in Lille and Institut Claudius Regaud in Toulouse, France, were reviewed. MEDLINE database was searched to identify articles on PSM after laparoscopic procedures for cervical and endometrial cancer.nnnRESULTSnDuring the study period, 1216 laparoscopic procedures for uterine cancer were performed. 921 patients underwent laparoscopic staging for cervical cancer and 295 for endometrial cancer. The overall incidence of PSM in our institutions was 0.4% per procedure (5 patients), and the incidence of PSM after laparoscopy for cervical and endometrial cancer was 0.43% and 0.33%, respectively. Excluding patients with peritoneal carcinomatosis, the rate of port-site recurrence in our series lowered to 0.16%, and the rate of isolated PSM to 0%. The median time to the development of PSM was 8 months (range 6-48), the median overall survival from diagnosis for all patients was 26 months (range 7-30), and median survival from recurrence was 5 months (range 1-20).nnnCONCLUSIONnAlthough PSM is recognized as a complication of laparoscopy for ovarian cancer. PSM is a rare complication of laparoscopic staging for endometrial and cervical cancer. The majority of patients with PSM presented with associated synchronous disease. The incidence of isolated PSM can be maintained virtually to 0% by an adequate operative technique. We believe that PSM in patients with uterine cancer cannot be used as an argument against laparoscopic staging in uterine cancer.

Indications and teaching of fertility preservation in the surgical management of gynecologic malignancies: European perspective

Young women affected by a malignant tumor have to cope, after the announcement of diagnosis, with the treatment and its secondary effects. Indeed, some of them may definitively impact on their fertility potential. Especially in pelvic tumors, treatments are more or less mutilating, either by a direct surgical resection of pelvic organs or by destruction of their functioning after chemotherapy or radiation therapy. Surgeons are often at the front line in the management of gynecologic tumors. It is important for them to be aware not only of the surgical techniques currently available to preserve fertility, but as well of their indications and limits, according to the tumor type or its treatment. This knowledge will enable them to deliver fair information to the patient or couple, keeping in mind that, multidisciplinarity is of a paramount importance and referring a patient to a more experienced team, is sometimes the best solution. Through a literature review, we report on the most recent results of the different options available today according to cancer localization as well as some opinions concerning indications, management, organization of care, and teaching of these techniques.

What is the normal tissues morbidity following Helical Intensity Modulated Radiation Treatment for cervical cancer

BACKGROUND AND PURPOSEnTo report on normal tissues morbidity following IMRT for cervix cancer.nnnMATERIAL AND METHODSnThe first 61 patients of a prospective series were included. 50 Gy to the PTV 1(pelvis) and 60 Gy to the PTV 2 (centro-pelvic disease and GTV nodes) were delivered concomitantly in 28 fractions, followed by a brachytherapy boost. For the small bowel, 50 Gy was the maximal dose, while V45 and V40 had to be <50 cc and 200 cc, respectively. For the bladder, rectum and sigmoid structures, 60 Gy was the maximal dose, and V45 and V40 had to be <20% and <50%. Acute and late toxicity data were prospectively collected.nnnRESULTSnThe median follow-up period was 40 months (range: 23-60). 30% and 90% of acute and moderate late side effects were reported respectively. Considering the AUC data of the organs at risk (OAR) DVH, late morbidity and doses were significantly linked (p⩽0.03), predominantly between 10 Gy and 40 Gy, considering the small bowel and sigmoid colon. The high dose regions exhibited no significant impact.nnnCONCLUSIONnThe moderate dose volumes represent the predominant cause of morbidity after IMRT. Prospective trials are thus required to investigate new ways of dose distribution within the OAR.

Paraaortic Laparoscopic Node Dissections

Paraaortic lymph node dissection (PA lnd) is an important staging technique, with significant implications. Beyond the poor prognostic impact of involved paraaortic nodes, this knowledge alters further primary tumor management. Although not considered in FIGO staging system of cervix carcinoma, demonstration of paraaortic node involvement usually triggers the extension of pelvic chemoradiation fields up to the renal pedicle. In endometrial carcinoma, positive nodes upstage the disease to stage IIIC2, and extended-field radiation therapy and chemotherapy are considered. In ovarian carcinomas, this situation corresponds to a FIGO IIIC disease and implies chemotherapy.