J.B.M.Z. Trimbos

A nerve‐sparing radical hysterectomy: guidelines and feasibility in Western patients

Surgical damage to the pelvic autonomic nerves during radical hysterectomy is thought to be responsible for considerable morbidity, i.e., impaired bladder function, defecation problems, and sexual dysfunction. Previous anatomical studies and detailed study of surgical techniques in various Japanese oncology centers demonstrated that the anatomy of the pelvic autonomic nerve plexus permits a systematic surgical approach to preserve these nerves during radical hysterectomy without compromising radicality. We introduced elements of the Japanese nerve-preserving techniques and carried out a feasibility study in ten consecutive Dutch patients. The technique involved three steps: first, the identification and preservation of the hypogastric nerve in a loose tissue sheath underneath the ureter and lateral to the sacro-uterine ligaments; second, the inferior hypogastric plexus in the parametrium is lateralized and avoided during parametrial transsection; third, the most distal part of the inferior hypogastric plexus is preserved during the dissection of the posterior part of the vesico-uterine ligament. The clinical study showed that the procedure is feasible and safe, except possibly when used with very obese patients and patients with broad, bulky tumors. Surgical preservation of the pelvic autonomic nerves in radical hysterectomy deserves consideration in the quest to improve both cure and quality of life in cervical cancer patients.

Diagnostic hysteroscopy in abnormal uterine bleeding: a systematic review and meta‐analysis

Background  This study was conducted to assess the accuracy and feasibility of diagnostic hysteroscopy in the evaluation of intrauterine abnormalities in women with abnormal uterine bleeding.

Objective assessment of sexual arousal in women with a history of hysterectomy

Objective  The potential contribution of psychological and anatomical changes to sexual dysfunction following hysterectomy is not clear. Radical hysterectomy for cervical cancer causes surgical damage to the autonomic nerves which are responsible for the increased vaginal blood flow during sexual arousal. Simple hysterectomy causes more limited nerve disruption. Photoplethysmographic assessment of vaginal pulse amplitude objectively measures vaginal blood flow during sexual arousal. We hypothesised that damage of the autonomic nerves results in a disrupted vaginal blood flow response during sexual stimulation.

Clear cell carcinoma compared to serous carcinoma in early ovarian cancer: same prognosis in a large randomized trial.

Background: An analysis was performed comparing survival of patients with clear cell carcinoma (CCC) to patients with serous adenocarcinoma (SAC) in early ovarian cancer. Furthermore, a literature search was done to clarify the clinical and histopathological features of clear cell tumors of the ovary. Methods: Between November 1990 and March 2000, 448 patients with ovarian cancer International Federation of Gynecology and Obstetrics stages I to IIa were enrolled in the European Organisation for Research and Treatment of Cancer-Adjuvant Chemotherapy in Ovarian Neoplasm Trial, a randomized study comparing adjuvant platinum-based chemotherapy to observation after surgical treatment in patients with early ovarian cancer. Results: Sixty-three patients (14.1%) with CCC were compared with 156 patients (34.8%) with serous tumors. A significant difference was found in the International Federation of Gynecology and Obstetrics stage Ic with capsule rupture, 28 (44.4%) of 63 patients with CCC and 29 (18.6%) of 156 patients with SAC (P < 0.001). Recurrences occurred in 25% of the patients, and this was similar in the CCC and SAC groups. No significant difference was found in overall survival between patients with CCC and patients with SAC in both treatment arms together. In the observation arm, the 5-year disease-free survival was 71% in the CCC group versus 61% in the SAC group, whereas in the chemotherapy arm, the 5-year disease-free survival was higher in the SAC group compared with the CCC group (78% vs 60%). Both differences were not statistically significant. Conclusions: The present study showed no worse prognosis in patients with CCC as compared with patients with serous carcinoma in early ovarian cancer.

Understanding the problem of inadequately staging early ovarian cancer

BACKGROUND Early ovarian cancer patients are often incompletely staged during initial surgery.(1-3) This omission can have serious adverse consequences for the prognosis of patients as the completeness of surgical staging has been identified as an independent prognostic parameter for survival.(4,5) The reasons for the problem of inadequate staging of early ovarian cancer are largely unknown. We have analysed the data of a large randomised trial in early ovarian cancer in which detailed information of the surgical staging procedure was monitored.(5) METHODS Data of the EORTC Adjuvant ChemoTherapy In Ovarian Neoplasm (ACTION) Trial were used in which 448 early ovarian cancer patients were randomised between postoperative chemotherapy in one arm and observation following surgery in the other. In this trial strict criteria for surgical staging were advised but optimal, complete staging was performed in only 1/3 of patients. Staging characteristics of the incompletely staged patients were analysed and factors that could explain the failure to perform a complete staging were studied. RESULTS Sampling of para-aortic nodes was omitted in 78% of the incompletely staged patients, while 52% of these patients had no pelvic lymph node dissection. Taking blind biopsies from different peritoneal sites was not performed in more than 1/3 of the incompletely staged group. Omission of the staging steps ranged from 3% (infracolic omentectomy) to 55% (biopsy of the right hemi-diaphragm). A significant difference (p=0.04) between the fraction of completely staged patients was found when comparing institutes who entered less than 5 patients (21%) versus those who included more than 20 patients (37%) in the trial. CONCLUSIONS Even in a randomised trial in which comprehensive surgical staging was strongly advised in the study protocol the majority of patients (66%) were incompletely staged. Factors relating to a lack of surgical skills attributed most to the number of incompletely staged patients, but insufficient knowledge of the tumour behaviour and routes of spread of ovarian cancer also contributed substantially to this problem. Multicentre trials recruiting patients from many institutes with small volume contribution to the study, run the risk of inadequate adherence to the study protocol.

Classification of radical hysterectomy adopted by the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer.

The Piver classification of radical hysterectomy for the treatment of cervical cancer is outdated and misused. The Surgery Committee of the Gynecological Cancer Group of the European Organization for Research and Treatment of Cancer (EORTC) produced, approved, and adopted a revised classification. It is hoped that at least within the EORTC participating centers, a standardization of procedures is achieved. The clinical indications of the new classification are discussed

Nerve-sparing radical hysterectomy versus conventional radical hysterectomy in early-stage cervical cancer. A systematic review and meta-analysis of survival and quality of life

BACKGROUND AND AIMS Survival after radical hysterectomy (RH) for early-stage cervical cancer is good. Hence quality of life (QOL) after treatment is an important issue. Nerve-sparing radical hysterectomy (NSRH) improves QOL by selectively sparing innervation of bladder, bowel and vagina, reducing therapy-induced morbidity. However, the oncological outcome and the functional outcome after NSRH are subjects of debate. We aim to present the best possible evidence available regarding both QOL and survival after NSRH in early-stage cervical cancer. METHODS Systematic review and meta-analysis on studies comparing NSRH and RH. RESULTS Forty-one studies were included, and 27 were used for the meta-analysis. There was no difference in 2-, 3- and 5-year overall survival: the risk ratios (RRs) were respectively 1.02 (95% CI 0.99-1.05, n=879), 1.01 (95% CI 0.95-1.08, n=1324) and 1.03 (95% CI 0.99-1.08, n=638). No difference was found in 2-, 3- and 5-year disease-free survival: RR 1.01 (95% CI 0.95-1.05, n=1175), 0.99 (95% CI 0.94-1.03, n=1130) and 1.00 (95% CI 0.95-1.06, n=933) respectively. Post-operative time to micturition was significantly shorter in the NSRH group: standardized mean difference (SMD) -0.84 (CI 95% -1.07 to -0.60). CONCLUSIONS NSRH can be considered safe and effective for early-stage cervical cancer since short- and long-term survival do not differ from those of conventional RH, while bladder function after NSRH is significantly less impaired.

An individual prediction of the future (disease-free) survival of patients with a history of early-stage cervical cancer, multistate model

To evaluate the possibility to give a prediction of the future (disease-free) survival, given the fact that a patient with a history of early-stage cervical cancer has been disease free for a specific period after treatment. Between January 1984 and April 2005, 615 patients with cervical cancer stages I–IIA underwent radical hysterectomy with or without adjuvant radiotherapy. The Kaplan–Meier method was used to detect statistical significance and multistate risk models to estimate the influence of covariates and to generate predicted survival curves by simulation. Simulations were done for patients with positive lymph nodes (n= 123), patients with negative lymph nodes (n= 492), and 4 hypothetical patients. The 5-year cancer-specific survival and disease-free survival of the entire group was 84% and 76%, respectively. The probability of death of the two lymph node groups and the four hypothetical patients was demonstrated in predicted cumulative probability plots. It is possible with multistate risk models to give a detailed prediction of the future (disease-free) survival, given the fact that a patient has been disease free for a specific period after treatment. This possibility is an important step forward to improve the quality of cancer care.