Heeseok Kang

Single-Port Access Laparoscopic-Assisted Vaginal Hysterectomy: A Novel Method with a Wound Retractor and a Glove

STUDY OBJECTIVE To present our initial experience with single port-access laparoscopic-assisted vaginal hysterectomy (SPA-LAVH) by use of a wound retractor and a glove. DESIGN Continuing, prospective study (Canadian Task Force classification II-3). SETTING University teaching, research hospital, and a tertiary care center. PATIENTS We performed the SPA-LAVH in 24 patients from May 6, 2008, through October 8, 2008. INTERVENTIONS All cases of SPA-LAVH were performed by a single surgeon (T. J. K.). MEASUREMENTS AND MAIN RESULTS We analyzed the data to determine the outcome of SPA-LAVH and compared the initial 10 cases (group A) and the latter 14 cases (group B) to consider the learning curve. Median and range are used to describe non-normal data. A total of 24 consecutive patients have undergone SPA-LAVH, for benign gynecologic conditions, including 16 uterine myomas and 8 cases of adenomyosis, regardless of body mass index or previous abdominal or pelvic surgery. All cases but 3 were performed exclusively through a single port. The median operative time, weight of the uterus, and estimated blood loss were 119 minutes (range 90 to 255 minutes), 347 g (range 225 to 732 g), and 400 mL (range 100 to 1000 mL), respectively. The decline in hemoglobin from before surgery to postoperative day 1 was from 0.7 to 4.3 g/dL, with a median of 2.05 g/dL. The median hospital stay (postoperative day) was 3 days (range 3 to 7). When we compared the operative outcomes between the 2 groups, there was a tendency toward a decreased operative time in group B, although the difference was not significant. However, there was a significant decrease in the estimated blood loss and hospital stay in group B (p = .00, = .04, respectively). CONCLUSION The SPA-LAVH was safe and effective, and the procedure could be learned over a short period of time. Additional experience and continued investigation are warranted.

Single Port Access Laparoscopic Adnexal Surgery

STUDY OBJECTIVE To estimate the feasibility, safety, and operative outcomes for the management of adnexal masses by single port access (SPA) laparoscopy with a wound retractor and a surgical glove. DESIGN A prospective single-center study (Canadian Task Force classification III). SETTING University hospital. PATIENTS Twenty-four well selected patients with adnexal masses on imaging scans recruited from June 2008 through January 2009. INTERVENTIONS Single port access laparoscopic adnexal surgery. MEASUREMENTS AND MAIN RESULTS Single port access laparoscopic adnexal surgery was successfully completed in 22 of 24 patients. The median age of the patients was 45 years (range 23-63 years), and the median body mass index was 22 (range 18-29). The median tumor size was 5 cm (range 3-12 cm). The median operative time was 70 minutes (range 40-128 minutes). The estimated blood loss was minimal (range 10-100mL). The postoperative course was uneventful in all patients. The median postoperative hospital stay was 1 day (range 1-3 days). No postoperative complications were observed at follow-up. The 2 failed cases were as follow: 1 required an additional trocar for adequate adhesiolysis, and the other a staging laparotomy because of the finding of a borderline ovarian malignancy on frozen section pathologic study. CONCLUSION The single port access laparoscopic adnexal surgery was safe and feasible and provided almost no visual scar.

The prognostic significance of the SUVmax (maximum standardized uptake value for F-18 fluorodeoxyglucose) of the cervical tumor in PET imaging for early cervical cancer: Preliminary results

OBJECTIVE The objective of this study was to evaluate the prognostic significance of the cervical tumor uptake of fluorine-18-labeled FDG (fluorodeoxyglucose) measured as the SUVmax (maximum standardized uptake value) by PET (Positron Emission Tomography) in patients with early cervical cancer treated with surgery+/-adjuvant therapy. METHODS Forty-four patients (FIGO clinical stage IB to IIA) with biopsy-proven cervical cancer underwent PET before surgery. The SUVmax of the primary cervical tumor mass was obtained and compared with pathological prognostic factors after the initial treatment. In addition, we investigated the recurrence pattern according to the SUVmax and analyzed independent risk factors associated with the recurrence of disease. RESULTS According to the tumor stage, the mean SUVmax significantly differed among groups (P=0.013). The SUVmax was significantly higher in patients with deep stromal invasion (>or=1 cm, P=0.0208), LVSI (lymph-vascular space invasion) (P=0.0429) and a pathologically confirmed large tumor size of more than 4 cm (P=0.0074) when compared to controls. Patients with a high SUVmax (>or=13.4) had a significantly reduced disease-free survival rate compared to patients with a low SUVmax (P=0.021). In addition, the SUVmax (>or=13.4) was a significant independent predictor of recurrence of cervical cancer after treatment with surgery (+/-adjuvant therapy) (P=0.0207). CONCLUSION Patients with early cervical cancer showing a high SUVmax (>or=13.4) of the cervical tumor should be considered at increased risk for disease recurrence after surgery and may need more aggressive multimodal treatment.

Outcome and reproductive function after cumulative high-dose combination chemotherapy with bleomycin, etoposide and cisplatin (BEP) for patients with ovarian endodermal sinus tumor

OBJECTIVE The aim of this study was to investigate the outcome and reproductive function of patients with ovarian endodermal sinus tumor (EST) after cumulative high-dose combination chemotherapy with bleomycin, etoposide and cisplatin (BEP). METHODS Between 1995 and 2006, 1034 patients with the diagnosis of ovarian cancer were treated at a single institution. Among these patients, 51 had a confirmed diagnosis of malignant ovarian germ cell tumor (MOGCT) including 20 cases of EST. We retrospectively reviewed those patients with EST, who received BEP as adjuvant chemotherapy. The doses were 15 mg/day of bleomycin on days 1 to 3, 100 mg/m(2)/day IV of etoposide on days 1 to 3 and 20 mg/m(2)/day of cisplatin on days 1 to 5. The median number of total cycles was six (range between three and nine). RESULTS The median age of the patients with EST was 18 years (range 5 to 36). All except two were nulliparous. The overall survival rate was 90% at a median follow-up of 70 months. Two patients (10%) had disease recurrence in the pelvis. Of the 15 patients who were treated with fertility-sparing surgery, all had regular menstruation following the completion of adjuvant chemotherapy, and two of these patients had pregnancies with live birth deliveries and no complications. CONCLUSION In patients with EST, the cumulative high-dose BEP regimen resulted in excellent overall survival and did not seem to impair ovarian function.

The use of misoprostol before hysteroscopic surgery in non-pregnant premenopausal women: a randomized comparison of sublingual, oral and vaginal administrations

BACKGROUND The aim of the present study was to evaluate the efficacy of misoprostol administered orally, vaginally, or sublingually on cervical ripening before hysteroscopic surgery in premenopausal non-pregnant women. METHODS Non-pregnant premenopausal women scheduled for operative hysteroscopy (with a 10-mm hysteroscope) were assigned by computerized randomization to receive 400 mg of misoprostol, administered either orally or vaginally 6-8 h prior to surgery or 400 mg sublingually 2-4 h prior to surgery. The primary outcome in this study was the preoperative cervical width as measured by the largest number of Hegar dilators. The time to Hegar number 10 was also recorded along with side effects related to misoprostol and complications during surgery for each group. RESULTS Patients were randomized to receive sublingual (n = 47), oral (n = 47) or vaginal (n = 47) misoprostol. The three groups were comparable in terms of age, BMI (body mass index), parity, gravidity, history of vaginal delivery, post-operative pathological findings and surgeon type. The preoperative cervical width [sublingual: 7.5 +/- 2.0 mm (8, 3-10); oral: 7.5 +/- 1.9 mm (7, 4-10); vaginal: 7.6 +/- 2.4 mm (8, 1-10)] was statistically similar among the groups. The time to Hegar number 10, side effects and complications during the hysteroscopy were comparable among the three groups. CONCLUSION A limitation of this study was that the surgeons, but not the patients, were blinded to the test procedures. Nevertheless we found that sublingual, oral and vaginal misoprostol were equally effective for cervical priming before hysteroscopic surgery in premenopausal non-pregnant women.

Prognostic significance of VEGF expression in patients with bulky cervical carcinoma undergoing neoadjuvant chemotherapy

BackgroundThe prediction of response to treatment would be valuable for managing cervical carcinoma with neoadjuvant chemotherapy.MethodsTo this end, the expression of VEGF was analyzed by immunohistochemistry using paraffin-embedded pre-treatment cervical biopsy tissues. This study included 29 patients with bulky IB to IIA cervical squamous cell carcinoma treated with neoadjuvant chemotherapy.ResultsFifteen (51.7%) of 29 patients were scored as VEGF-positive. Response to chemotherapy (complete response or residual tumor with less than 3 mm stromal invasion) was observed in eight patients (27.6%), and it was negatively associated with VEGF expression (P = 0.009). With logistic regression analysis, VEGF positivity continued to be an independent predictor for poor response (P = 0.032). In addition, the progression-free survival rate was significantly lower in patients with VEGF-positive tumors (P = 0.033).ConclusionPretreatment assessment of VEGF expression may provide additional information for identification of patients with cervical cancer who had a low likelihood of response to neoadjuvant chemotherapy and an unfavorable prognosis.

A review of the technique and complications from 2,012 cases of laparoscopically assisted vaginal hysterectomy at a single institution.

Aims:  To present our experience of modified laparoscopically assisted vaginal hysterectomy (LAVH) and to evaluate the surgical outcomes and complications.

Factors associated with complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy.

Objective. To identify risk factors for complications and conversion to laparotomy in women undergoing laparoscopically assisted vaginal hysterectomy (LAVH). Design. Retrospective study. Setting. Tertiary referral hospital. Population. All 2012 consecutive women who underwent LAVH for non‐malignant diseases in a single institution. Methods. Retrospective study. Main outcome measures. Operative complications and conversion to laparotomy. Results. Most of the LAVHs were successful, but conversion to laparotomy was required in 97 women (4.8%) because of pelvic adhesion (n= 71), large uterine size (n= 18) or bowel injury (n= 8). There were 45 women (2.2%) with complications (bladder injury, 26; bowel injury, 9; vascular injury, 9; and ureteral injury, 1). A history of previous cesarean section (twice or more) was a significant risk factor for complications [odds ratio (OR) 3.38]. A body mass index ≥30 kg/m2 (OR 2.98), history of previous myomectomy (OR 6.19) and uterine weight ≥500 g (OR 3.24) independently influenced the risk of conversion to laparotomy. Conclusions. Risk factors identified in this study include a history of previous cesarean section (twice or more) and myomectomy, body mass index ≥30 kg/m2 and uterine weight ≥500 g. The findings may be useful in counseling women preoperatively about the potential complications of LAVH.

Prognostic significance of p-STAT3 in patients with bulky cervical carcinoma undergoing neoadjuvant chemotherapy

Aim:  To better predict treatment responses for managing bulky cervical carcinoma with neoadjuvant chemotherapy (NAC).

MR Imaging in Endometrial Carcinoma as a Diagnostic Tool for the Prediction of Myometrial Invasion and Lymph Node Metastasis

PURPOSE The purpose of this study was to evaluate the factors that are associated with the accuracy of magnetic resonance (MR) imaging for predicting myometrial invasion and lymph node metastasis in women with endometrial carcinoma. MATERIALS AND METHODS We retrospectively reviewed the medical records and preoperative MR imaging reports of 128 women who had pathologically proven endometrial carcinoma. We compared the MR imaging and the histopathology findings. RESULTS The sensitivity, specificity and accuracy for identifing any myometrial invasion (superficial or deep) were 0.81, 0.61 and 0.74, respectively; these values for deep myometrial invasion were 0.60, 0.94 and 0.86, respectively. The sensitivity, specificity and accuracy of MR imaging for detecting lymph node metastasis were 50.0%, 96.6% and 93.0%, respectively. The patients who were older, had more deliveries and a larger tumor size more frequently had incorrect prediction of deep myometrial invasion (p=0.034, p=0.044, p=0.061, respectively). A higher tumor grade, a histology other than the endometrioid type, myometrial invasion on MR findings and a larger tumor size were associated with a more frequent false-negative prediction of lymph node metastasis (p=0.018, p=0.017, p=0.002, p=0.047, respectively). A larger tumor size was also associated with more frequent false-positive results (p=0.009). CONCLUSIONS There are several factors that make accurate assessment of myometrial invasion or lymph node metastasis difficult with using MRI; therefore, the patients with these factors should have their MR findings cautiously interpreted.