Farr Nezhat

A case‐controlled study of total laparoscopic radical hysterectomy with pelvic lymphadenectomy versus radical abdominal hysterectomy in a fellowship training program

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29–78 years). The mean pelvic lymph node count was 31 (range, 10–61) in the TLRH group versus 21.8 (range, 8–42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100–600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200–464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2–11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.

Fertility-sparing Robotic-assisted Radical Trachelectomy and Bilateral Pelvic Lymphadenectomy in Early-stage Cervical Cancer

A combined pelvic lymphadenectomy with radical vaginal trachelectomy is an alternative to radical hysterectomy in the treatment of young women with cervical cancer desiring fertility preservation. This technique requires advanced vaginal surgery skills not commonly acquired. In an attempt to simplify the procedure we preformed what we believe to be the first case of robotic-assisted radical trachelectomy. A 30-year-old woman, gravida 1, para 1, desiring fertility preservation was given the diagnosis of invasive adenocarcinoma on cervical cone excision. The patient was treated with robotic-assisted pelvic lymphadenectomy and radical trachelectomy. We hope robotic-assisted radical trachelectomy will become an option for select women with early-stage cervical cancer who desire fertility preservation.

Vacuum-assisted closure in the treatment of complex gynecologic wound failures

BACKGROUND Complex wound failures are a source of significant morbidity and mortality. They are costly and time consuming to treat, and may evolve into chronic, debilitating conditions. Vacuum‐assisted closure is a novel wound healing technique applying subatmospheric pressure to wounds to expedite healing. CASES We report the successful use of vacuum‐assisted closure therapy on three patients on a gynecologic oncology service with complex wound failures of various chronicity. In all cases, vacuum‐assisted closure therapy was well tolerated and demonstrated efficacy within 48 hours of initiation. CONCLUSION We conclude that vacuum‐assisted closure therapy should be included in the armamentarium of the gynecologist addressing complex wound failures.

Minimally invasive surgery in gynecologic oncology: Laparoscopy versus robotics

The role of laparoscopy has evolved from a diagnostic tool to an integral approach to management of gynecologic malignancies. This surgical approach has afforded patients the benefits of shorter hospitalizations, more rapid recoveries, smaller incisions, less need for analgesics, and fewer complications. Additionally, specific to gynecologic malignancies, improved visualization and shorter intervals to postoperative treatments are advantages to minimally invasive surgery. However, laparoscopy is limited by its long learning curve, counterintuitive motions, and two-dimensional views. To overcome these challenges of laparoscopy, technology has expanded to include computer-enhanced technology in the form of robotics. Robotic-assisted surgery provides three-dimensional views, intuitive motions, less operator fatigue, tremor filtration facilitating more precise movements, and possesses a shorter learning curve. Robotic-assisted surgery has also paved a pathway to telesurgery and telementoring. This may expand the availability of advanced minimally invasive surgeries throughout the globe. However, robotic-assisted procedures are not without limitations-cost, bulky size, lack of haptic feedback, limited instrumentation, and larger required incisions.

Robotic-assisted Laparoscopic Partial Bladder Resection for the Treatment of Infiltrating Endometriosis

This article reveals our surgical approach for treatment of a patient with severe pelvic and infiltrative bladder endometriosis with mucosal involvement using robotic-assisted laparoscopic excision and cystotomy repair. To our knowledge, this is the first case of total robotic-assisted laparoscopic partial bladder resection for the treatment of endometriosis. This article also discusses the pros and cons of robotic-assisted surgery and the current literature on infiltrative bladder endometriosis.

Analysis of survival after laparoscopic management of endometrial cancer.

STUDY OBJECTIVE To assess the effect of laparoscopic surgery on the survival of women with early-stage endometrial cancer and to analyze the factors that affect survival. DESIGN Retrospective cohort study (Canadian Task Force classification II-2). SETTING Tertiary teaching hospital. PATIENTS Women with clinical stage I and II endometrial cancer (International Federation of Gynecology and Obstetrics staging, 1971) from January 1993 through June 2003. INTERVENTION Demographic, surgical, perioperative, and pathologic characteristics of women treated with laparoscopy or laparotomy were compared by use of Fishers exact test or the Student t test. Recurrence-free and overall survival was calculated by use of the Kaplan-Meier method. Stratified analyses were performed with the log-rank test for factors affecting survival (surgical stage, histologic study, and grade). MEASUREMENTS AND MAIN RESULTS Sixty-seven and 127 women were treated with laparoscopy and laparotomy, respectively. Median follow-up was 36.3 months for the laparoscopy group and 29.6 months for the laparotomy group. The complication rates in the 2 groups were comparable. Women undergoing laparoscopy had shorter hospital stay and less morbidity related to infection. The 2- and 5-year estimated recurrence-free survival rates for the laparoscopy and laparotomy groups (93 % vs 91.7% and 88.5% vs 85%, respectively), as well as the overall 2- and 5-year survival rates (100% vs 99.2% and 100% vs 97%, respectively) were similar. CONCLUSIONS Laparoscopic surgery in women with early-stage endometrial carcinoma resulted in survival rates similar to laparotomy, although a small sample size precludes definitive conclusions. A larger randomized comparison of the 2 techniques is needed to validate these findings.

Total laparoscopic hysterectomy versus da Vinci robotic hysterectomy: is using the robot beneficial?

Objective To compare the outcomes of total laparoscopic to robotic approach for hysterectomy and all indicated procedures after controlling for surgeon and other confounding factors. Methods Retrospective chart review of all consecutive cases of total laparoscopic and da Vinci robotic hysterectomies between August 2007 and July 2009 by two gynecologic oncology surgeons. Our primary outcome measure was operative procedure time. Secondary measures included complications, conversion to laparotomy, estimated blood loss and length of hospital stay. A mixed model with a random intercept was applied to control for surgeon and other confounders. Wilcoxon rank-sum, chi-square and Fishers exact tests were used for the statistical analysis. Results The 124 patients included in the study consisted of 77 total laparoscopic hysterectomies and 47 robotic hysterectomies. Both groups had similar baseline characteristics, indications for surgery and additional procedures performed. The difference between the mean operative procedure time for the total laparoscopic hysterectomy group (111.4 minutes) and the robotic hysterectomy group (150.8 minutes) was statistically significant (p=0.0001) despite the fact that the specimens obtained in the total laparoscopic hysterectomy group were significantly larger (125 g vs. 94 g, p=0.002). The robotic hysterectomy group had statistically less estimated blood loss than the total laparoscopic hysterectomy group (131.5 mL vs. 207.7 mL, p=0.0105) however no patients required a blood transfusion in either group. Both groups had a comparable rate of conversion to laparotomy, intraoperative complications, and length of hospital stay. Conclusion Total laparoscopic hysterectomy can be performed safely and in less operative time compared to robotic hysterectomy when performed by trained surgeons.

Robot-assisted laparoscopic surgery in gynecology: scientific dream or reality?

OBJECTIVE To analyze the feasibility, safety, advantages, and disadvantages of using robotic technology for gynecologic surgeries in a large group of patients. DESIGN Retrospective study (Canadian Task Force classification II-3). SETTING Tertiary endoscopic referral centers. PATIENT(S) Eighty-seven patients requiring laparoscopic treatments for benign gynecologic conditions. INTERVENTION(S) Charts reviewed from robotic-assisted gynecologic operative laparoscopies. MAIN OUTCOME MEASURE(S) Length of surgery, time for robot assembly and disassembly, rate of conversion to laparotomies, and complications. RESULT(S) Between January 2006 and August 2007, 137 robotically assisted gynecologic procedures were performed in 87 patients. The da Vinci Surgical System was used. The average length of the surgeries was 205 minutes (60-420 minutes). Assembly of the robot lasted 16 minutes (10-27 minutes) when disassembly took 2.5 minutes (2-6 minutes). There were no conversions to laparotomy. There were three complications. CONCLUSION(S) Robotic-assisted technology, in its present state, is enabling more surgeons to perform endoscopic surgery. Its advantages are 3D Vision and a faster learning curve for suturing and operating while sitting. Its an exciting enabling technology with a great future.

Laparoscopic management of adnexal masses the opportunities and the risks.

Suspected ovarian neoplasm is a common clinical problem affecting women of all ages. Although the majority of adnexal masses are benign, the primary goal of diagnostic evaluation is the exclusion of malignancy. It has been estimated that approximately 5–10% of women in the United States will undergo a surgical procedure for a suspected ovarian neoplasm during their lifetime. Despite the magnitude of the problem, there is still considerable disagreement regarding the optimal surgical management of these lesions. Traditional management has relied on laparotomy to avoid undertreatment of a potentially malignant process. Advances in detection, diagnosis, and minimally invasive surgical techniques make it necessary now to review this practice in an effort to avoid unnecessary morbidity among patients. Here, we review the literature on the laparosopic approach to the treatment of the adnexal mass without sacrificing the principles of oncologic surgery. We highlight potentials of minimally invasive surgery and address the risks associated with the laparoscopic approach.

New techniques in radical hysterectomy.

Purpose of review To review the recent literature regarding modifications of abdominal radical hysterectomy as well as development of new approaches including laparoscopic, vaginal, and robotic radical hysterectomy. Recent findings Nerve-sparing radical hysterectomy technique allows for significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates with absence of abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to a traditional abdominal radical hysterectomy approach that yields comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers and larger series describing successful treatment of cervical cancer with robotic radical hysterectomy are soon to be published. Summary There are a number of approaches to performing radical hysterectomy. The feasibility and safety of these techniques have been well established. Preliminary oncologic outcome data are encouraging. The decision to utilize newer techniques depends on the patient and type of practice, as well as the surgeons comfort level with laparoscopy, robotics, or vaginal surgery.