Wolfgang Michels

Laparoscopic-assisted radical vaginal hysterectomy (LARVH): prospective evaluation of 200 patients with cervical cancer.

OBJECTIVE The purpose of this study was to determine the survival of cervical cancer patients treated with laparoscopically assisted radical vaginal hysterectomy (LARVH). We quantify morbidity and correlate survival with known risk factors. METHODS Between August 1994 and June 2002, 200 patients with cervical cancer (TNM stage 1a1, L1 n = 6, 1a2 n = 21, 1b1 n = 89, 1b2 n = 26, 2a n = 11, 2b n = 45, 3a n = 1, 4 n = 1; squamous cell carcinoma 76.5%, adenocarcinoma 23.5%) were treated with LARVH (type II n = 102, type III n = 98). RESULTS Paraaortic lymphadenectomy was performed in 170 (85%) patients and pelvic lymphadenectomy was performed in all 200 patients. In 26 (13%) patients positive lymph nodes were found. Major intraoperative injuries occurred in 6% of patients. Postoperative complications occurred in 8% of patients. Incidence of complications decreased significantly when comparing the first half with the second half of patients. After a median follow-up time of 40 months, overall 5-year survival could be projected to 83%; 18.5% of patients experienced recurrence with 35% exclusively extrapelvic and 11% of patients died of recurrence. Independent prognostic factors for recurrence-free survival were tumor stage, lymph node status, and combined involvement of lymphovascular and angiovascular space. In the absence of these risk factors projected 5-year survival was 98%. CONCLUSION Patients with tumor <4 cm, negative lymph nodes, and the absence of the combination of angio- and lymphovascular space involvement can be identified by laparoscopic staging and are ideal candidates for LARVH.

Validation of the accuracy of the sentinel lymph node procedure in patients with vulvar cancer: Results of a multicenter study in Germany

OBJECTIVE To investigate the diagnostic accuracy of the sentinel node procedure in patients with vulvar cancer, a multicenter study was launched in Germany in 2003 involving 7 oncology centers. PATIENTS AND METHODS Between 2003 and 2006, 127 women with primary T1-T3 vulvar cancer were entered in the study and treated with sentinel node removal after application of (99m)Technetium labeled nanocolloid and/or blue dye. Subsequently, in all women a complete inguinofemoral lymphadenectomy and the adequate vulvar operation were performed. Sentinel lymph nodes were examined by routine pathologic examination (H&E), followed by step-sectioning and immunhistochemistry if negative. RESULTS The sentinel node procedure was successful in 125 out of 127 cases, in 2 cases no sentinel nodes were detected. 21 patients received unilateral lymphadenectomy, 103 women were operated on both groins. In 39 women out of 127, positive lymph nodes in one or both groins were identified (30.7%). In 36 women, the sentinel nodes were also positive (sensitivity 92.3%). We had three cases with a false negative sentinel node (false negative rate: 7.7%), all of these women presenting with tumors in midline position. One tumor was a T1 tumor (10 mm), 2 tumors being classified as T2 (40 and 56 mm, respectively). In one additional case (18 mm T1 tumor, midline position), the sentinel was positive in the right groin, but false negative on the left side. CONCLUSIONS This study shows that identification of SLN in squamous cell cancer of the vulva is feasible, however not highly accurate depending on tumor localization and size. The false negative rate seems to be acceptable if the procedure is restricted to stage 1 tumors with clinically negative lymph node status. Tumors situated in or close to the midline seem to be less suitable for this procedure. Implementation of SLNB into clinical practice should be performed with care and only by experienced teams as to avoid preventable groin relapses.

Comparison of written reports of mammography, sonography and magnetic resonance mammography for preoperative evaluation of breast lesions, with special emphasis on magnetic resonance mammography

Patients with abnormal breast findings (n = 413) were examined by mammography, sonography and magnetic resonance (MR) mammography; 185 invasive cancers, 38 carcinoma in situ and 254 benign tumours were confirmed histologically. Sensitivity for mammography was 83.7%, for sonography it was 89.1% and for MR mammography it was 94.6% for invasive cancers. In 42 patients with multifocal invasive cancers, multifocality had been detected by mammography and sonography in 26.2%, and by MR mammography in 66.7%. In nine patients with multicentric cancers, detection rates were 55.5, 55.5 and 88.8%, respectively. Carcinoma in situ was diagnosed by mammography in 78.9% and by MR mammography in 68.4% of patients. Combination of all three diagnostic methods lead to the best results for detection of invasive cancer and multifocal disease. However, sensitivity of mammography and sonography combined was identical to that of MR mammography (ie 94.6%).

Learning laparoscopic-assisted hysterectomy.

OBJECTIVE: The aim of this study was to evaluate the factors considered for proficiency and to estimate the number of procedures needed to achieve competence in laparoscopic-assisted vaginal hysterectomy in a teaching hospital. METHODS: The length of the learning curve, duration of surgery, change of hemoglobin (in grams per liter), conversion rate, and intra- and postoperative complications were evaluated. Cases were analyzed according to the order for the individual surgeon. RESULTS: Thirty-three surgeons performed 929 laparoscopic-assisted vaginal hysterectomies during the study period. Analyzing the duration of surgery and rate of complications, we decided on a cutoff of 30 cases. Eight surgeons with more than 30 cases performed 668 laparoscopic-assisted vaginal hysterectomies. Their initial 30 cases (group A, the first 30 cases) were compared with their subsequent cases (group B, cases 31 and after). Patient age, body mass index, and uterine weight did not differ between the groups. The intraoperative complication rate dropped from 4.2% to 0.5% (P = .001), hemoglobin drop decreased from −0.8 ± 0.9 g/L to −0.5 ± 1.0 g/L (P = .002), and postoperative complications dropped from 12.9% to 7.0% (P = .017). The duration of surgery was also shorter (148.8 ± 45.4 minutes versus 125.1 ± 46.5 minutes), but this difference was taken from the results of 1 surgeon. CONCLUSION: A learning experience of 30 laparoscopic-assisted vaginal hysterectomies was necessary in our institution to reach a low level of complications. Duration of the surgical procedure was not an adequate study endpoint to assess a learning effect. LEVEL OF EVIDENCE: II-3

Establishing a new technique of laparoscopic pelvic and para-aortic lymphadenectomy☆

Objective To assess the number of operations necessary to develop and standardize a laparoscopic approach to pelvic and para-aortic lymphadenectomy, with radicality and number of complications as quality markers. Methods Over 4 years, 108 women had complete laparoscopic pelvic and para-aortic lymphadenectomies combined with laparoscopy-assisted radical vaginal hysterectomies for primary therapy of cervical cancer. Complete data and videotapes were available for 99 women. Operating time and radicality for specific anatomic subareas were measured by review of video documentation and histologic lymph node counts. Intra- and postoperative complications were recorded prospectively. To analyze the progress of surgery, we compared two groups of women, one operated on at the beginning of our study (early group, subjects 6–35) and one operated on in the final period of the study (late group, subjects 79–108). Results The operating time for pelvic and para-aortic lymphadenectomy increased constantly. Comparing the early and late groups for para-aortic lymphadenectomy, there was an increase in mean operating time (34.8 versus 73.2 minutes; P < .001) and mean histologic lymph node yield (5.1 versus 10.6; P < .001). For pelvic lymphadenectomy, mean operating time increased slightly (60.7 versus 69.7 minutes; not significant) but mean histologic lymph node count decreased over time (24.3 versus 21.0; not significant). Retrospective evaluation of videotapes showed that the radicality of lymphadenectomy improved continuously in all evaluated subareas. Conclusion Establishment of a protocol for para-aortic and pelvic lymphadenectomy took 100 operations. Video documentation was a more reliable indicator of progress in technical performance than were histologic lymph node counts.

Laparoscopically assisted vaginal hysterectomy as an alternative to abdominal hysterectomy in patients with fibroids

Objective: Introduction of laparoscopically assisted vaginal hysterectomy (LAVH) was evaluated for its usefulness to replace abdominal hysterectomy in fibroids.Study design: A total of 240 women with a mean age of 46.7 years underwent hysterectomy over a period of one year. The technique of LAVH was introduced starting in the second quarter of the study period. Clinical data of 60 patients undergoing either LAVH or abdominal hysterectomy for fibroids were compared in a cross-sectional study by χ2 and t-test.Results: A comparison between the first and the last quarter of the study period showed that the rate of abdominal hysterectomies decreased from 66% to 12%, whereas LAVH increased from 0 to 40% (p<0.05). The rate of vaginal hysterectomies remained between 34% and 48%. Compared to abdominal hysterectomy, LAVH operating time was about 1/3 longer, hospital stay was shorter (3 days), and LAVH proved more cost-effective than abdominal hysterectomy (significance of all differences: p<0.05).Conclusions: LAVH is a valid alternative to abdominal hysterectomy in fibroids.

Das Verhalten von Antioxidanzien nach Schnittentbindung und Substitution von Multibionta® N, Inzolen® und selenase®

Summary□Patients and Method: In 29 women with the necessity to terminate pregnancy via Cesarean section, lipid peroxidation and antioxidative state were investigated before and 24 hours after the surgical intervention as well as after substitution of antioxidants and trace elements.□Results: The results indicate that administration of antioxidants protects at least partially from consequences of surgically induced oxidative burden.