Zhiqing Liang

The Outcome of Laparoscopic Radical Hysterectomy and Lymphadenectomy for Cervical Cancer: A Prospective Analysis of 295 Patients

ObjectivesCervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy and transperitoneal approach for lymphadenectomy have become the standard techniques for invasive cervical cancer. We report the indications, techniques, results, and oncological outcome in a single center experience.MethodsBetween February 2001 and June 2007 we performed laparoscopic radical hysterectomies for cervical cancer in 295 patients. Their initial techniques, operation data, complications, postoperative course, oncological outcome, and survival were evaluated.ResultsOut of 295 procedures, 290 were successful. Para-aortic lymphadenectomy was performed in 156 patients (52.9%), and pelvic lymphadenectomy was performed in all 295 patients. The median blood loss was 230 mL (range, 50–1200 mL). The mean operation time was 162 min (range, 110–350), which included the learning curves of 3 surgeons. In 5 cases (1.7%), conversion to open surgery was necessary due to bleeding (3 cases), bowel injury (1 case), and hypercapnia (1 case). Other major intraoperative injuries occurred in 12 patients (4.1%). Positive lymph nodes were detected in 80 cases (27.1%), lymphovascular space invasion in 54 cases (18.3%), and surgical margins were negative for tumor in all patients. The mean hospital stay was 10.3 days. Postoperative complications occurred in 10.8% patients, ureterovaginal fistula in 5 cases, vesicovaginal fistula in 4, ureterostenosis in 3 cases, deep venous thrombosis in 9 cases, lymphocyst in 4 cases, lymphedema in 5 cases, and 1 case with trocar insertion site metastasis. Other medical problems included 47 cases (15.9%) of bladder dysfunction and 62 cases (21.0%) of rectum dysfunction or constipation. The median follow-up was 36.45 months (range, 8–76 months). Recurrences or metastasis occurred in 48 patients (16.3%). Of these patients, 43 (14.6%) have died of their disease, and 5 (1.7%) are alive with disease. The overall disease-free survival was 95.2% for Ia, 96.2% for Ib, 84.5% for IIa, 79.4% for IIb, 66.7% for IIIa, and 60.0% for IIIb.ConclusionLaparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2–IIb cervical carcinoma. With more experience it is envisaged that IIb stage patients can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available, our follow-up data for up to 76 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcome.

Laparoscopic nerve-sparing radical hysterectomy with fascia space dissection technique for cervical cancer: Description of technique and outcomes

OBJECTIVES The objectives of this study were to describe our laparoscopic nerve-sparing radical hysterectomy (LNSRH) technique and to assess the feasibility and safety of the procedure, as well as its impact on voiding function. We introduce a fascia space dissection technique in order to preserve the pelvic splanchnic nerve, the hypogastric nerve and the bladder branch of the inferior hypogastric plexus under magnification (×10.5) during laparoscopic radical hysterectomy (LRH) with pelvic lymphadenectomy. METHODS From October 2006 to November 2009, 163 consecutive patients with cervical cancer underwent laparoscopic radical hysterectomy (LRH) and pelvic lymphadenectomy, with 82 women undergoing LNSRH with fascia space dissection technique (LNSRH group) and 81 undergoing LRH (LRH group). Data from 163 patients were prospectively collected and compared. Post-operative assessment of bladder function included the following: the time to recover the ability to void spontaneously and to achieve a post-void residual urine (PVR) volume of less than 50 ml, with urination function graded. RESULTS The laparoscopic nerve-sparing radical hysterectomy procedure was completed successfully and was conducted safely in all of the patients. There were no conversions to open surgery in the two groups. The median operative duration in the LNSRH and the LRH groups were 163.52±34.47 min and 132.13±31.42 min, respectively. Blood loss was 142.12±62.38 ml and 187.69±68.63 ml, respectively. The time taken to obtain a post-void residual urine volume of less than 50 ml after removal of the urethral catheter was 7.42±2.35 d (5-18 d) in LNSRH group and was 16.75±7.73 d (5-35 d) in LRH group (P<0.05). The bladder void function recovery to Grades 0-I was 76 (92.7%) for the LNSRH group and 59 (72.8%) for the LRH group. A mean follow-up of 22.3 (5-42) months was adhered to, and no patient had a recurrence or metastasis. CONCLUSIONS The technique described in this preliminary study appears to be safe, feasible, and easy in our population, with satisfactory recovery of voiding function.

Laparoscopic transient uterine artery occlusion and myomectomy for symptomatic uterine myoma

OBJECTIVE To compare clinical outcomes of laparoscopic transient uterine artery ligation plus myomectomy (LTUAL) to simple laparoscopic myomectomy (LM) for symptomatic myomas. DESIGN Comparative observational study. SETTING Medical centers. PATIENT(S) One hundred sixty-seven patients with symptomatic myomas. INTERVENTION(S) Eighty-four patients underwent LTUAL and LM; 83 patients underwent LM only. MAIN OUTCOME MEASURE(S) Operative time, blood loss, gonadal hormone level, uterine artery resistance index, menorrhea, pregnancy rate, and recurrence rate of myoma. RESULT(S) The intraoperative blood loss in the LTUAL group was lower than in the LM group. The menstrual blood volume (MBV) and the menstrual period of the LTUAO group was unchanged after operation relative to the prediseased volume. No significant difference was found in the resistance index of the uterine artery blood flow, the recurrence rate, and the fertility rate between the LTUAL and LM groups. CONCLUSION(S) LTUAL and LM are a promising surgical treatment for symptomatic uterine myoma and did not produce any appreciable adverse effect on fertility.

Laparoscopic Resection of Presacral Teratomas

Presacral and retrorectal space tumors are relatively rare lesions, the location of which can result in the onset of symptoms that are not well-defined. Retrorectal teratomas are resected to alleviate these symptoms and to rule out malignancy. Complete resection by one of the open abdominal or sacral approaches was traditionally advocated as the best treatment for either a benign or malignant presacral and retrorectal tumor. A 15-year-old girl had chronic, progressively worsening dull pelvic pain and was given the diagnosis of a retrorectal tumor during her first gynecologic examination. Computed tomography of the pelvis showed an encapsulated presacral and retrorectal tumor measuring 10x8.5x8 cm. The retrorectal teratoma was removed by laparoscopy. No complication was observed interoperation. In addition, no sensory or motoric dysfunction of the bladder or rectum was observed postoperatively. Laparoscopy can be used to surgically remove presacral teratomas.

Evaluation of the biocompatibility and mechanical properties of xenogeneic (porcine) extracellular matrix (ECM) scaffold for pelvic reconstruction

Introduction and hypothesisXenogeneic (porcine) extracellular matrix (ECM) scaffolds have been suggested as ideal biomaterials for regeneration medicine; however, ECM prepared from different tissue sources has shown distinctive biological properties. Therefore, a comprehensive understanding of biological characteristics of different tissue-derived ECM is essential in the design of scaffolds for pelvic reconstruction.MethodsWe compared the biological properties of ECM derived from different tissue sources of Bama miniature pigs as a pelvic biological patch in terms of histological structure, water absorption ability, biodegradation ability, mechanical properties, antimicrobial activity, and biocompatibility in vitro.ResultsDifferent ECM scaffolds have distinct structural differences, and all have good biocompatibility, and UBM exhibited better water uptake ability (above 500%), anti-biodegradation ability, mechanical properties, antimicrobial activity, and stem cell attachment properties than other tissue-derived ECM.ConclusionsPorcine UBM might serve as an ideal pelvic biological patch.

Laparoscopic nerve-sparing radical parametrectomy for occult early-stage invasive cervical cancer after simple hysterectomy.

Objective To investigate the feasibility and surgical outcomes of laparoscopic nerve-sparing radical parametrectomy (LNSRP) and lymphadenectomy for treatment of occult early-stage invasive cervical cancer after simple hysterectomy. Methods From 2006 to 2010, 28 patients who were discovered to have occult early-stage invasive cervical cancer after a simple hysterectomy underwent LNSRP, upper vaginal resection, and pelvic lymphadenectomy. A retrospective analysis of these cases was performed. Results All patients underwent successful LNSRP. There was no conversion to laparotomy. The mean ± SD operation time was 173.30 ± 56.20 minutes. The mean ± SD estimated blood loss was 230.00 ± 109.55 mL. Two intraoperative complications were recorded. The median number of extracted pelvic and para-aortic lymph nodes was 23 (range, 12–36) and 7 (range, 3–15), respectively. The mean ± SD time before Foley catheter removal was 5.6 ± 2.74 days (range, 3–14 days ), and bladder voiding function recovery to grade 0 to grade 1 was observed in 26 patients (92.9%). Of the 28 patients, 3 patients received further adjuvant therapy. The median follow-up period was 38 (range, 4–62) months for all patients. No recurrence case was found in this series. Conclusion Laparoscopic nerve-sparing radical parametrectomy is a therapeutic option for occult early-stage invasive cervical cancer discovered after hysterectomy. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function.

Endoscopic inguinal lymphadenectomy with a novel abdominal approach to vulvar cancer: description of technique and surgical outcome.

STUDY OBJECTIVE To evaluate the feasibility and surgical outcome of a novel technique of endoscopic inguinal lymphadenectomy to treat vulvar cancer. DESIGN Retrospective analysis performed by a single center over 2 years (Canadian Task Force classification II-2). SETTING Major university teaching hospital. PATIENTS The medical records for 17 consecutive patients who underwent endoscopic inguinal lymphadenectomy because of invasive vulvar cancer were retrospectively reviewed. INTERVENTION Endoscopic inguinal lymphadenectomy was performed using a novel abdominal approach. MEASUREMENTS AND MAIN RESULTS All patients underwent abdominal endoscopic inguinal lymphadenectomy without intraoperative complications. Median (range) operative time for the endoscopic procedure was 94 minutes, with estimated blood loss of approximately 137 mL (80-170 mL). A mean (range) of 16 (11-23) nodes were retrieved. In an additional 5 patients, pelvic node dissection was performed, with retrieval of 6 (3-11) nodes. Of the 17 patients, 2 demonstrated vulvar wound necrosis, and 1 exhibited lymphorrhea through the drain orifice. No other inguinal wound-related complications were observed. Mean postoperative hospital stay was 11 (8-19) days. All patients were followed up for more than 13 months, with no recurrence of cancer. CONCLUSIONS Endoscopic inguinal lymph node dissection using this novel abdominal approach in patients with vulvar cancer is a safe and feasible technique that may diminish the wound-related complications associated with the standard open approach.

High levels of circulating CD34+/VEGFR3+ lymphatic/vascular endothelial progenitor cells is correlated with lymph node metastasis in patients with epithelial ovarian cancer.

Lymph node metastasis is one of the predictive factors associated with poor prognosis of epithelial ovarian cancer. To clarify the role of CD34 and vascular endothelial growth factor receptor‐3‐positive (CD34+/VEGFR3+) lymphatic/vascular endothelial progenitor cells (LVEPC) in patients with lymph node metastasis and epithelial ovarian cancer progression, the levels of circulating CD34+/VEGFR3+ LVEPC in epithelial ovarian cancer patients were detected. We also tested the plasma protein levels of VEGF and stromal cell‐derived factor to find out their possible relationships with lymph node metastasis in our epithelial ovarian cancer cohort.

Inhibition of Fibroblast Differentiation of Muscle-Derived Stem Cells in Cell Implantation Treatment of Stress Urinary Incontinence

The aim of this study was to investigate the effects of transforming growth factor-β1 (TGF-β1) stimulation and the blocking of the TGF-β1/Smad3 signaling pathway by vector-mediated Smad3 shRNA on muscle-derived stem cells (MDSCs) in cell implantation treatment of stress urinary incontinence (SUI) of the rat. MDSCs were infected with the GC-shSmad3 lentivirus vector. Five days after infection, the cells were treated with TGF-β1. The expression levels of desmin (a marker of muscle differentiation) and vimentin (a marker of fibroblast differentiation) were tested by real-time PCR and Western blot. GC-shSmad3 lentivirus-infected MDSCs were injected into the bladder neck and proximal urethra of SUI rats. Urodynamic test was used to measure leak point pressure (LPP) at 2 weeks and 4 weeks after MDSC transplantation. Upregulated expression of vimentin and downregulated expression of desmin were found in MDSCs after culture with TGF-β1 in vitro. GC-shSmad3 lentivirus infection inhibited fibroblast differentiation of MDSCs but allowed muscle differentiation with desmin expression. In vivo experiments showed that GC-shSmad3 lentivirus infection could improve MDSC-mediated repairing of urethra sphincter function. In conclusion, blocking Smad3 expression inhibits the fibroblast differentiation of MDSCs induced by TGF-β1 in vitro and improves the repairing of urethral sphincter function by inhibiting the fibroblast differentiation of MDSCs in a rat model of SUI in vivo.

Laparoscopic Nerve-Sparing Radical Vaginectomy in Patients With Vaginal Carcinoma: Surgical Technique and Operative Outcomes

STUDY OBJECTIVES To describe our technique for laparoscopic nerve-sparing radical vaginectomy and to assess the feasibility and safety of the procedure via operative outcomes. DESIGN Retrospective study (Canadian Task Force classification II-2). SETTING Major university teaching hospital in Chongqing, China. PATIENTS Twelve consecutive patients with early stage vaginal carcinoma. INTERVENTIONS Laparoscopic radical parametrectomy/vaginectomy with pelvic/paraaortic lymphadenectomy. MEASUREMENTS AND MAIN RESULTS Nerve-sparing radical vaginectomy was completed laparoscopically without conversion to laparotomy in 12 patients with early stage vaginal cancer. Mean (SD) operative time was 158.5 (36.7) minutes, and estimated blood loss was 135.2 (62.8) mL. No intraoperative complications occurred, and no patients required blood transfusion. The number of pelvic nodes obtained was 21.2 (9.8), and of para-aortic nodes was 13. All nodes were negative for malignancy. Histologic analysis confirmed the absence of any residual cancer tissue in the margins of the parametrial tissue and vagina. The median (range) time before Foley catheter removal was 9.76 (3-14) days, and bladder void function recovery to grade 0-I was observed in 11 patients (91.7%). Neither long-term bladder voiding dysfunction nor any other long-term complications were reported. The median duration of follow-up was 28 months. One patient with stage II vaginal cancer received pelvic regional radiation therapy; the other patients did not require adjuvant therapy after the operation. All patients were included in the follow-up protocol, and there was no recurrence of disease in any patients. CONCLUSIONS Laparoscopic radical parametrectomy/vaginectomy with pelvic/para-aortic lymphadenectomy is a therapeutic option for early stage vaginal carcinoma. Nerve-sparing radical surgery in indicated patients may lead to optimal preservation of bladder function. The technique described in this preliminary study seems to be safe and feasible, and was relatively easy to perform in our study population.