Kittipat Charoenkwan

Twelve years experience with radical hysterectomy and pelvic lymphadenectomy in early stage cervical cancer

The objective of this study was to evaluate the outcome, prognostic factors and complications of early stage cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy (RHPL). The medical records of cervical cancer patients undergoing RHPL at Chiang Mai University Hospital over 12 years, between January 1995 and December 2006 were reviewed. There were 1,253 patients in the study period. The mean age was 44 years of age. Of these, 26.9% had prior diagnostic conisation. The maximum tumour size was 8 cm. The most common histology was squamous cell carcinoma (67%) followed by adenocarcinoma (23%). The distribution of FIGO staging was: stage IA 8.7%; stage IB 15.8%; stage IB1 61%; stage IB2 6.2%; and stage IIA 8.5%. Pelvic nodes, parametrial and vaginal margin involvement were detected in 15.9%, 10.7% and 3.8% of the patients, respectively. A total of 66.5% of patients underwent RHPL without adjuvant treatment; 12.1% received neoadjuvant chemotherapy. The estimated 10-year recurrence-free survival rate was 90%. Stage IB2/IIA, non-squamous cell carcinoma, nodal involvement and positive vaginal margins were independent, significant, poor prognostic factors. The most common long-term complication was lymphoedema. It was concluded that early stage cervical cancer patients treated with RHPL have long-term favourable outcome with minimal morbidity. Stage IB2 and IIA, non-squamous cell carcinoma, nodal and vaginal involvement were independent adverse prognostic factors.

Effects of Gel Lubricant on Cervical Cytology

OBJECTIVE To determine whether the use of lubricating gel during vaginal speculum examination affected cytologic interpretation in the conventional Pap smear. STUDY DESIGN Two consecutive cervical smears were obtained from 1334 patients undergoing Pap smear screening. The first smear (uncontaminated) was obtained using the routine collection technique. The second smear (gel-contaminated) was taken after applying a 1- to 1.5-cm ribbon of lubricating gel onto the external cervical os. Adequacy of Pap smear and discordance in diagnosis between the paired smears were examined. RESULTS The proportion of unsatisfactory smears was significantly higher in the gel-contaminated smears, 12.1% vs. 1.7% (p < 0.01). This difference was consistent across all reproductive groups. For patients who had smears satisfactory for cytologic evaluation, the discordance in cytologic diagnosis between the gel-contaminated and uncontaminated smears from the same patient was 0.3%. CONCLUSION Lubricating gel contamination of the cervix can adversely affect adequacy and cytologic diagnosis in the conventional Pap smear.

A prospective randomized study comparing retroperitoneal drainage with no drainage and no peritonization following radical hysterectomy and pelvic lymphadenectomy for invasive cervical cancer

To evaluate the postoperative morbidity and lymphocyst formation in invasive cervical cancer patients undergoing radical hysterectomy and pelvic lymphadenectomy (RHPL) with no drainage and no peritonization compared with retroperitoneal drainage and peritonization.

Pelvic node removal and disease-free survival in cervical cancer patients treated with radical hysterectomy and pelvic lymphadenectomy.

To examine the relationship between the number of pelvic nodes removed and 5‐year disease‐free survival in early‐stage cervical cancer patients who underwent radical hysterectomy and pelvic lymphadenectomy (RHPL).

Impact of histology on prognosis of patients with early-stage cervical cancer treated with radical surgery

To examine the effect of carcinoma cell type on tumor characteristics, tumor spread, tumor recurrence, and survival of patients with early‐stage cervical cancer who had radical hysterectomy and pelvic lymphadenectomy.

Routine prophylactic application of Monsel's solution after loop electrosurgical excision procedure of the cervix: Is it necessary?

Aim:  To determine the benefit of an immediate application of Monsels solution after loop electrosurgical excision procedure (LEEP) of the cervix for preventing postoperative bleeding.

A simplified technique for nerve-sparing type III radical hysterectomy: by reorganizing their surgical sequence, surgeons could more easily identify key nerves.

Nerve-sparing radical hysterectomy was developed in an attempt to minimize complications, including bladder, colorectal, and sexual dysfunction which are associated with disruption of the pelvic autonomic nerves during resection of the parametrium. In this article, the author proposes a simple, effective technique for identification and preservation of the pelvic nerves during type III radical hysterectomy. The essential technical considerations include the sequential approach to parametrial resection, starting from the posterior part, the direct visualization of the main nerve trunks at all sites during parametrial resection, and the avoidance of direct manipulation and unnecessary dissection of the nerves. Operative outcomes of 22 patients with cervical or uterine cancer who underwent type III radical hysterectomy from August 2008 to March 2010 were reviewed. Comparing with the earlier method performed at the authors institution, the present technique was associated with an increased proportion of patients who had a postvoid residual urine volume (PVR) under 50 mL at postoperative day 7 (55% vs 27%) and a shorter median duration before this PVR was reached (7 days vs 9 days). The systematic approach proposed in this article would make the nerve-sparing technique for radical hysterectomy more straightforward and applicable to various settings. A thorough understanding of anatomy and adequate surgical skills are always vital components of successful nerve-sparing radical hysterectomy.

Early solid food after cesarean section and postoperative ileus

Paralytic ileus a temporary inhibition of bowel motility is believed to follow all abdominal surgery. Surgeons have customarily withheld postoperative oral intake until the return of bowel function as evidenced by a presence of bowel sound a passing of flatus/stool and a feeling of hunger. The major concern has been that early oral intake would result in vomiting from severe paralytic ileus with subsequent aspiration pneumonia and wound dehiscence. This randomized controlled study was conducted to evaluate the effect of early solid oriental food compared with traditional feeding schedule after cesarean delivery on the incidence of postoperative ileus and patient’s satisfaction. (excerpt)

Surgical Outcomes of Patients with Stage IA2 Cervical Cancer Treated with Radical Hysterectomy

BACKGROUND This study was undertaken to evaluate the surgical outcomes of patients with stage IA2 cervical cancer treated with radical hysterectomy. Data for 58 patients who underwent modified radical hysterectomy or radical hysterectomy with pelvic lymphadenectomy between January 2003 and December 2012 at Chiang Mai University Hospital were retrospectively reviewed. The analysis included clinico-pathological risk factors (nodal metastasis, parametrial involvement), adjuvant treatment, 5-year disease-free survival and 5-year overall survival. All pathologic slides were reviewed by a gynecologic pathologist. Follow-up methods included at least cervical cytology and colposcopy with directed biopsy if indicated. Univariate analysis was performed to identify factors associated with median survival. At the median follow up time of 73 months, the 5-year disease-free survival and the 5-year overall survival were 97.4% and 97.4%, respectively. Two (3.4%) patients had pelvic lymph node metastases. In a univariate analysis, there was no statistically significant association between survival and prognostic factors such as age, histological cell type, lymph-vascular space invasion, vaginal margin status and lymph node status. Surgical and survival outcomes of women with stage IA2 cervical cancer are excellent. No parametrial involvement was detected in our study. Patients with stage IA2 cervical cancer may be treated with simple or less radical hysterectomy with pelvic lymphadenectomy.

Locoregional Spread and Survival of Stage IIA1 versus Stage IIA2 Cervical Cancer

This study was undertaken to compare surgical outcomes and survival rates of patients with the 2009 International Federation of Gynecology and Obstetrics (FIGO) stage IIA1 versus IIA2 cervical cancer treated with radical hysterectomy and pelvic lymphadenectomy (RHPL). Patients with stage IIA cervical cancer undergoing primary RHPL between January 2003 and December 2012 at Chiang Mai University Hospital were retrospectively reviewed. The analysis included clinicopathologic variables, i.e. nodal metastasis, parametrial involvement, positive surgical margins, deep stromal invasion (DSI)), lymph-vascular space invasion (LVSI), adjuvant treatment, and 5-year survival. The chi square test, Kaplan-Meier method and log-rank test were used for statistical analysis. During the study period, 133 women with stage IIA cervical cancer, 101 (75.9 %) stage IIA1, and 32 (24.1 %) stage IIA2 underwent RHPL. The clinicopathologic variables of stage IIA1 compared with stage IIA2 were as follows: nodal metastasis (38.6% vs 40.6%, p=0.84), parametrial involvement (10.9% vs 15.6%, p=0.47), positive surgical margins (31.7% vs 31.3%, p=1.0), DSI (39.6% vs 53.1%, p=0.18), LVSI (52.5% vs 71.9%, p=0.05) and adjuvant radiation (72.3% vs 84.4%, p=0.33). With a median follow-up of 60 months, the 5-year disease-free survival (84.6% vs 88.7%, p=0.67) and the 5-year overall survival (83.4% vs 90.0%, P=0.49) did not significantly differ between stage IIA1 and stage IIA2 cervical cancer. In conclusion, patients with stage IIA1 and stage IIA2 cervical cancer have comparable rates of locoregional spread and survival. The need for receiving adjuvant radiation was very high in both substages. The revised 2009 FIGO system did not demonstrate significant survival differences in stage IIA cervical cancer treated with radical hysterectomy. Concurrent chemoradiation should be considered a more suitable treatment for patients with stage IIA cervical cancer.