Gun Oh Chong

Learning curve of laparoscopic radical hysterectomy with pelvic and/or para-aortic lymphadenectomy in the early and locally advanced cervical cancer: comparison of the first 50 and second 50 cases.

Background: To compare the surgical and oncological outcomes and morbidity of the first 50 cases treated by laparoscopic radical hysterectomy with those of the second 50 cases. Methods: Between October 1994 and January 2004, we retrospectively reviewed the charts of 100 consecutive patients (International Federation of Gynecology and Obstetrics stages IA2 [n = 12], IB1 [n = 56], IB2 [n = 15], IIA [n = 15], and IIB [n = 2]) who underwent laparoscopic radical hysterectomy with pelvic and/or para-aortic lymphadenectomy. One hundred patients were divided into the first 50 cases (group 1) and second 50 cases (group 2). Results: Operating time, length of hospital stay, time to normal residual urine, and transfusion rate significantly decreased, and the acquired number of pelvic nodes significantly increased when comparing group 1 with group 2. The intraoperative and postoperative complication rates profoundly decreased in group 2 as compared with group 1. After a median follow-up of 66.5 months, 10 patients had a recurrence, 9 of whom died. The 5-year overall survival rates were 96% in group 1 and 90% in group 2, and 5-year disease-free survival rates were 92% in group 1 and 90% in group 2. Conclusions: Laparoscopic radical hysterectomy is a feasible and safe treatment modality in early and even locally advanced cervical cancer without decreasing survival. Surgical outcome was improved with experience, and the complication rate related to operation of group 1 was higher than that of group 2. There was no significant difference in survival between the 2 groups.

Robotic uterine artery preservation and nerve-sparing radical trachelectomy with bilateral pelvic lymphadenectomy in early-stage cervical cancer.

Objective: The aim of the study was to evaluate the safety and feasibility of robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy using the da Vinci surgical system. Methods: Three patients who were diagnosed with early-stage cervical cancer underwent robotic uterine artery preservation and nerve-sparing radical trachelectomy with bilateral lymphadenectomy from January 2010 to March 2010. The data were compared with those of 4 cases of total laparoscopic nerve-sparing radical trachelectomy that were performed from July 2004 to May 2005 and were previously reported. Results: In the robotic group, the mean console time was 275 minutes (range, 240-305 minutes). The mean postoperative hemoglobin change was 0.4 g/dL (range, 0.2-0.6 g/dL). The mean estimated blood loss was 23 mL (range, 15-40 mL), which is less than that of the laparoscopic group. There were no metastases detected in any of the cases, and the resection margins were negative in both groups. Conclusions: The robotic uterine artery preservation and nerve-sparing radical trachelectomy with pelvic lymphadenectomy were efficient in reducing blood loss and feasible methods such as other approaches.

Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: a comparison of the intraoperative and perioperative results of a single surgeon's initial experience.

Objective The aim of the study was to compare the initial surgical outcomes and learning curve of nerve-sparing robotic radical hysterectomy (RRH) with nerve-sparing total laparoscopic radical hysterectomy (TLRH) for the treatment of early-stage cervical cancer in the first 50 cases. Methods Between January 2008 and March 2012, 50 consecutive patients underwent nerve-sparing RRH. These patients were compared with a historic cohort of the first 50 consecutive patients who underwent nerve-sparing TLRH. Results Both groups were similar with respect to patients and tumor characteristics. The mean operating time in the RRH group was significantly longer than that in the TLRH group (230.1 ± 35.8 vs 211.2 ± 46.7 minutes; P = 0.025). The mean blood loss for the robotic group was significantly lower compared with the laparoscopic group (54.9 ± 31.5 vs 201.9 ± 148.4 mL; P < 0.001). There was no significant difference in the mean pelvic lymph nodes between the 2 groups (25.0 ± 9.9 vs 23.1 ± 10.4; P = 0.361). The mean days to normal residual urine were 9.6 ± 6.4 in RRH and 11.0 ± 6.2 in TLRH (P = 0.291). The incidence of intraoperative complication was profoundly lower in RRH compared with that of TLRH (0% vs 8%; P = 0.041). Moreover, no intraoperative transfusion was required in RRH, whereas 4 (8%) were required in TLRH (P = 0.041). In both groups, we found no evidence of a learning effect during the first 50 cases. Conclusions During the first 50 cases, surgical outcomes and complication rates of nerve-sparing RRH were found to be comparable to those of nerve-sparing TLRH. Moreover, the mean blood loss and intraoperative complication rate in the robotic group were significantly lower than those in the laparoscopic group. Surgical skills for nerve-sparing TLRH easily and safely translated to nerve-sparing RRH in case of experienced laparoscopic surgeon.

Oncologic results and surgical morbidity of laparoscopic nerve-sparing radical hysterectomy in the treatment of FIGO stage IB cervical cancer: long-term follow-up.

Objectives: The aim of this study was to evaluate a long-term follow-up data for oncologic results and surgical morbidity of a laparoscopic nerve-sparing radical hysterectomy (NSRH) in the treatment of FIGO stage IB cervical cancer. Methods: This was a retrospective study that comprised consecutive 125 patients with cervical cancer stage IB1 (n = 105) and IB2 (n = 20) who underwent a laparoscopic NSRH (Piver type III) by a gynecologic oncologist without selecting patients from January 1999 to December 2007. Results: In regression analysis, the operating time (R2 linear = 0.311, P < 0.001) and estimated blood loss (R2 linear = 0.261, P < 0.001) were decreased, whereas the number of harvested pelvic lymph nodes (R2 linear = 0.250, P < 0.001) was increased. Seventeen patients (13.6%, 17/125) were found to have pelvic node metastasis. Para-aortic node metastasis had occurred in 2 patients (5.1%, 2/39). There were high urological complications (13/125, 10.4%) related to radical surgery. Forty-one patients (33%) needed transfusions. Positive surgical margins did not exist. Patients were able to self-void at a mean of 10.3 days postoperatively. The return rates to normal voiding function at postoperative 14 and 21 days were 92.0% and 95.2%, respectively. Thirteen patients (IB1 n = 9, IB2 n = 4) experienced a recurrence postoperatively. Six patients (IB1 n = 3, IB2 n = 3) died of recurrent disease. Five-year disease-free survival rates of cervical cancer IB1 and IB2 were 92% and 78%, respectively (P = 0.1772). Five-year overall survival rates of cervical cancer IB1 and IB2 were 96% and 83%, respectively (P = 0.0437). Conclusions: A laparoscopic NSRH for FIGO stage IB cervical cancer was comparable to open NSRH in terms of early recovery of bladder function. It did not compromise surgical radicality, but revealed high urological complications, long operating time, and much blood loss, compared with conventional radical hysterectomy. However, these surgical morbidities were corrected with increase in experiences.

Total Laparoscopic Nerve-Sparing Radical Trachelectomy

OBJECTIVES To evaluate the feasibility and operative morbidity of a total laparoscopic nerve-sparing radical trachelectomy with pelvic lymphadenectomy. METHODS Between July 2004 and May 2005, this procedure had been undergone to four consecutive young patients with early cervical cancer (one with stage IA2, three with stage IB1). It was distinguished from the conventional radical trachelectomy in that it consisted of a reanastomosis of uterine corpus and upper vagina via laparoscopic approach, and an autonomic nerve-sparing dissection under the magnified laparoscopic view. RESULTS The mean operative time and blood loss was 250 minutes and 185 mL, respectively. The pathologic diagnosis was all squamous cell carcinoma. There were no node metastasis and cancer-free cervical margin. Any wound defect and leakage from a stump were not found. There were no neurologic impairments such as bladder hypotonia. The mean follow-up period was 34 months. Only one patient (Case 1) received concurrent chemo-radiation due to recurrence, followed by no further sign of progression. Unfortunately, there has not been any pregnancy yet. CONCLUSION A total laparoscopic nerve-sparing radical trachelectomy is feasible and without any increase of morbidity, and has the potential to improve surgical outcomes, compared with a conventional radical trachelectomy.

Quantitative metabolic parameters measured on F-18 FDG PET/CT predict survival after relapse in patients with relapsed epithelial ovarian cancer

OBJECTIVE This study aimed to evaluate the prognostic value of quantitative metabolic parameters measured on F-18 FDG PET/CT (FDG PET/CT) at the time of the first relapse in patients with relapsed epithelial ovarian cancer (EOC). METHODS Fifty-six relapsed EOC patients were retrospectively included. Quantitative metabolic parameters including maximum standardized uptake value (SUVmax), whole-body metabolic tumor volume (WBMTV), and whole-body total lesion glycolysis (WBTLG) were measured on FDG PET/CT at the time of the first relapse. Post-relapse survival (PRS) was calculated from the date of diagnosis of relapsed disease to the date of death or last follow-up. Univariate and multivariate analyses for PRS were performed using clinical and quantitative metabolic parameters. RESULTS Thirty-two patients died from the disease during the follow-up period (median: 46.2 months). On univariate and multivariate analyses, the platinum-free interval, type of second-line treatment, WBMTV, and WBTLG were all significant prognostic factors for PRS. The subgroup of patients who were platinum-sensitive with low WBMTV and low WBTLG showed better prognosis, when compared with other subgroups (log-rank test, p<0.001). Patients treated with secondary cytoreductive surgery (SCS) followed by second-line chemotherapy showed significantly longer duration of PRS than patients treated with second-line chemotherapy only (mean PRS=61 vs. 36 months, χ(2)=8.68, p=0.032). CONCLUSION Our results suggest that quantitative metabolic parameters measured on FDG PET/CT at the time of the first relapse have significant predictive values for PRS. Incorporating quantitative metabolic parameters and conventional clinical parameters has a superior prognostic discrimination compared with conventional clinical parameters alone.

Comparison study of single-port (Octoport™) and four-port total laparoscopic hysterectomy

OBJECTIVE To compare the perioperative surgical outcomes and complication rates between single-port total laparoscopic hysterectomy and conventional four-port total laparoscopic hysterectomy. STUDY DESIGN Between June 2009 and April 2011, 56 patients underwent total laparoscopic hysterectomy. Of these 56 patients, 28 underwent single-port (Octoport™) total laparoscopic hysterectomy and 28 underwent conventional four-port total laparoscopic hysterectomy. We analyzed the following parameters for all the patients: age, body mass index, operative time, blood loss, change in hemoglobin level, vaginal stump suture time and length of hospital stay. RESULTS The general characteristics of the patients were similar in both groups. There were no statistically significant differences in blood loss, hemoglobin change, length of postoperative hospital stay and complication rate. However, the mean operative time of the single-port group was significantly longer than that of the four-port group (93.5±24.0min vs. 78.7±17.4min; P=0.011). The operative time for vaginal stump suture was profoundly decreased with experience in the single-port group. CONCLUSION With the exception of operative time, the surgical outcomes and incidence of complications of the single-port group were comparable to those of the four-port group. However, the operative time decreased in the single-port group with increasing experience.

Robot-assisted total preservation of the pelvic autonomic nerve with extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy for cervical cancer.

Objective To evaluate our short-term clinical outcomes of robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy as part of nerve-sparing radical hysterectomy. Methods Between March 2011 and June 2012, we observed prospectively 28 consecutive patients who underwent robot-assisted autonomic nerve-sparing extended systematic lymphadenectomy, including the superior and inferior gluteal, presacral (subaortic), common iliac, and lower para-aortic nodes. Results The predominant International Federation of Gynecology and Obstetrics stage was IB1 (15 patients), followed by IB2 (5 patients), IA2 (3 patients), IIA1 (3 patients), and IIA2 (2 patients). The mean ± SD total operating time was 308.8 ± 54.9 minutes, and the mean ± SD console time was 280.0 ± 46.0 minutes. The mean ± SD blood loss was 102.7 ± 153.8 mL. The mean ± SD acquired pelvic lymph node was 27.1 ± 9.3, the mean ± SD extended lymph node was 19.2 ± 9.6, and the mean ± SD total lymph node was 46.3 ± 14.5. A total of 10 patients (35.7%) had nodal metastasis; among them, 6 patients (21.4%) had single pelvic nodal metastasis, 3 patients (10.7%) had concurrent pelvic and extended nodal metastasis, and one patient (3.6%) had single extended nodal metastasis. No intraoperative complications that required treatment occurred; however, ureterovaginal fistula was identified in 4 patients (14.3%) and ureter stricture in 4 patients (14.3%) after radiotherapy. After a median follow-up of 10 months (range, 1–16 months), there was no pelvic recurrence; however, one patient had recurrence at transposition site of ovary. Conclusions With the advantage of delicate movement of robot instrument, robot-assisted systematic extended lymphadenectomy with total preservation of pelvic autonomic nerves did not compromise the radicality, and its surgical technique was feasible and safe. By using this approach, we could harvest more lymph nodes and have a high rate of metastatic nodes without disturbing voiding function; however, there was increased rate of urological complications. Moreover, long-term survival benefit after an extended systematic lymphadenectomy must be evaluated.

The effect of nonperitonization and laparoscopic lymphadenectomy for minimizing the incidence of lymphocyst formation after radical hysterectomy for cervical cancer.

Objectives: To determine the clinical effect of nonperitonization and laparoscopic lymphadenectomy using bipolar electrocautery after radical hysterectomy for cervical cancer compared with peritonization and open lymphadenectomy using monopolar electrocautery. Materials and Methods: This was a retrospective study of 180 patients who underwent a radical hysterectomy and pelvic lymph node dissection (PLND) for cervical cancer from August 1998 to August 2007. The patients were composed of the Peritonization + Laparotomy group (group A; n = 98, 196 PLND) and the Nonperitonization + Laparoscopy group (group B; n = 82, 164 PLND). Group B left the peritoneum in front of the PLND open. Two closed-suction drains were placed at each side of the PLND. Results: Group B statistically showed a lesser total amount of lymphatic drainage (P = 0.001), shorter duration of inserted drains (P < 0.001), and shorter length of hospital stay (P < 0.001), compared with group A. The formation of lymphocysts occurred in 30 patients (41 lymphocysts) of group A and 5 patients (5 lymphocysts) of group B. Lymphocyst formation of group B had a statistically lower incidence than that of group A (P < 0.001). Lymphocyst formation was associated with an increase in the total amount of lymphatic drainage in group A (P = 0.090) and group B (P = 0.041) and a pathologic type of adenocarcinoma in group B (P = 0.016). Surgical experiences were not correlated with lymphocyst formation. Conclusions: The omission of peritonization and laparoscopic lymphadenectomy using bipolar electrocautery in early-stage cervical cancer were more effective than peritonization and open lymphadenectomy using monopolar electrocautery in minimizing the incidence of lymphocyst formation.

Clinical significance of serum albumin level in pregnancy-related hypertension.

Aim:  To evaluate the usefulness of serum albumin level as a marker of severity in pregnancy‐related hypertension.