Kelly J. Manahan

Robotically assisted total laparoscopic radical trachelectomy for fertility sparing in stage IB1 adenosarcoma of the cervix.

Adenosarcomas are rare cervical tumors with unknown optimal treatment, which often affects young women. A 23-year-old woman was found to have a stage IB1 adenosarcoma of the cervix. She underwent a robotically assisted total laparoscopic radical trachelectomy with the placement of abdominal cerclage for the sparing of fertility.

Robotically assisted laparoscopic radical hysterectomy compared with open radical hysterectomy.

Background: Radical hysterectomy is a common and effective treatment of early cervical cancer. Modern advances include the use of robotic assistance to perform equivalent minimally invasive procedures. The purpose was to compare surgical and short-term outcomes, as well as margins, between robotic-assisted laparoscopic radical hysterectomy and open radical hysterectomy. Methods: The first 30 cases of robotically assisted type III radical hysterectomy for cervical cancer were compared with the 30 previous cases of open type III radical hysterectomy. Body mass index, length of operation, nodal yield, margins, estimated blood loss, hospital stay, and complications were all documented and compared. Results: The 30 patients undergoing robotically assisted laparoscopic radical hysterectomy were similar in body mass index to the women undergoing open radical hysterectomy (34 kg/m2 robotic, 32 kg/m2 open, P = 0.22). The mean operating time was 154 minutes compared with 166 minutes in the open arm (P = 0.36). The mean blood loss was 165 mL compared with 323 mL in the open arm (P = 0.001). The mean pelvic nodal yield was 25 nodes compared with 26 nodes in the open group (P = 0.45). The mean parametrial margin size was not significantly different between groups. The mean postoperative length of stay was 1.4 days compared with 2.8 days for the open cases (P < 0.001). Urinary retention was significantly more common in the robotic arm. Conclusions: Radical surgery for cervical cancer can be accomplished using the da Vinci surgical system (Intuitive Surgical, Sunnyvale, Calif) with acceptable blood loss, operating time, parametrial margins, and nodal yield. Future studies need to address long-term outcomes.

Loop electrosurgical excision procedure for partial upper vaginectomy

OBJECTIVES Partial upper vaginectomy consists of removal of the vaginal apex and is indicated for the diagnosis and treatment of vaginal intraepithelial neoplasia and recurrent cancer. We present a novel surgical approach to partial upper vaginectomy by use of the loop electrosurgical excision procedure. STUDY DESIGN A total of 15 consecutive patients with abnormal vaginal cytologic results were treated by the loop electrosurgical excision procedure for partial upper vaginectomy. After submucosal injection of local anesthetic, the loop electrode was used to resect the upper third of the vagina. An iodoform vaginal pack was placed for 24 hours. All patients with high-grade vaginal intraepithelial neoplasia received intravaginal 5-fluorouracil cream postoperatively. RESULTS The mean blood loss was 0 mL, and the mean surgical time was 30 minutes. A complication developed in 1 patient (7%). One case of invasive carcinoma was diagnosed. No recurrences have developed in any patients with vaginal intraepithelial neoplasia after hysterectomy. CONCLUSIONS The loop electrosurgical excision procedure for partial upper vaginectomy can be performed quickly, with minimal blood loss, minimal complications, and minimal recurrence of neoplasia, and it provides a histologic specimen for evaluation.

Peritoneal fluid urea nitrogen and creatinine reference values

OBJECTIVE To evaluate urea nitrogen and creatinine levels in peritoneal fluid. METHODS We prospectively evaluated 20 consecutive women having radical hysterectomy with lymphadenectomy. On postoperative days 2 and 3, serum, urine, and peritoneal fluid samples were tested for urea nitrogen and creatinine. Using power analysis we calculated an adequate sample size to be 16 patients. RESULTS The mean urea nitrogen was 11 mg/dL in serum, 11 mg/dL in peritoneal fluid, and 469 mg/dL in urine. The mean creatinine was .9 mg/dL in serum, 1.0 mg/dL in peritoneal fluid, and 141 mg/dL in urine. Urea nitrogen and creatinine values in peritoneal fluid and serum were essentially identical. Urine urea nitrogen and creatinine values were significantly greater than serum and peritoneal values (47 to 157 times greater) (P < .011). On postoperative days 2 and 3, serial levels of serum, peritoneal fluid, and urine urea nitrogen and creatinine in the same subject showed no significant variation (P ranging from .19 to .31). CONCLUSION Normal reference values of urea nitrogen and creatinine in peritoneal fluid are equivalent to serum values and significantly less than urine levels.

5-Millimeter Trocar-Site Bowel Herniation Following Laparoscopic Surgery

Because bowel herniation can occur through a small trocar site, the authors suggest all port sites be closed to avoid this complication.

Ovarian cancer risk assessment: a tool for preoperative assessment

OBJECTIVES The objective of this pilot study was to determine if the combination of CA 125, menopausal status and prealbumin can be used to accurately predict ovarian cancer in women with pelvic masses. STUDY DESIGN Preoperative serum CA 125, prealbumin and menopausal status were prospectively determined. Results were formulated into an ovarian cancer risk assessment (OCRA) score and compared with final surgical pathology. RESULTS OCRA was studied in 130 women. No cancers were found in women with a score less than 200. For all cancers, an OCRA score ≥ 200 had a sensitivity of 96%, specificity of 95% and positive predictive value of 95%. When the OCRA score of ≥ 200 was evaluated for its ability to predict ovarian cancer, the sensitivity, specificity, and positive predictive value were 100%, 83%, and 78%, respectively. CONCLUSIONS In this pilot study, OCRA was able to predict which women with pelvic masses were more likely to have ovarian cancer. The scoring system easily applied clinically and may help facilitate appropriate referral of women to gynecologic oncologists for optimal care.

Treatment of advanced or recurrent cervical cancer with Cisplatin or Cisplatin containing regimens: a cost effective analysis.

Background: Trials have demonstrated improvements in survival with adding paclitaxel (P) or topotecan (T) to cisplatin (C) for the treatment of advanced cervical cancer. We sought to evaluate the cost effectiveness of these regimens. Methods: A decision model was developed based on Gynecologic Oncology Group (GOG) protocols 169 and 179. Arm 1 is 6 cycles of cisplatin. Arm 2 is 6 cycles of CP while arm 3 is 6 cycles of CT. Parameters include overall survival (OS), cost and complications. Sensitivity analyses were performed. Results: The incremental cost-effectiveness ratio (ICER) for C versus CP is

Assessment of False-negative Ascites Cytology in Epithelial Ovarian Carcinoma: A Study of 313 Patients.

13,654/quality-adjusted life-year (QALY) gained. For CT compared to C, the ICER is

Is the routine use of bevacizumab in the treatment of women with advanced or recurrent cancer of the cervix sustainable

152,327/QALY. When compared simultaneously, CT is dominated. At a willingness to pay (WTP) threshold of

CA 125 and Grade 1 Endometrial Cancer: Analyzing the Risk of Metastases [22P]

50,000/QALY, C is the preferred option but CP is acceptable. Sensitivity analyses suggest that CT would become the preferred option if it was to improve OS to 24 months (compared to 9.4 months). Conclusions: In this model, CP is an acceptable alternative to cisplatin for the treatment of these patients with an increase in cost of only