Relevance of Laparoscopic Surgery for Ovarian Cancer in Well-selected Patients: A Propensity-matched Comparison With Laparotomy.

BACKGROUND/AIM: This study aimed to evaluate the relevance of laparoscopy in comparison with laparotomy in the management of ovarian cancer in well-selected patients. PATIENTS AND METHODS: Data of consecutive ovarian cancer patients treated by laparoscopy were matched 1:1 to a cohort of patients operated by laparotomy using a propensity score matching. The inclusion criteria included patients who underwent a complete staging procedure in the early stages and optimal upfront or interval debulking surgery for advanced ovarian cancer. RESULTS: In total, 153 patients were included. Propensity score matching led to the analysis of 41 well-balanced pairs of patients. For a median follow-up of 34.0 [19.0-64.0] months and 38.0 [24.5-75.0] months, respectively, no difference was found between the two groups in regards to overall survival (p=0.28) and disease-free survival (p=0.89). CONCLUSION: In well-selected patients, laparoscopic surgery may be a safe and effective alternative to laparotomy.

Augmented reality in gynecologic laparoscopic surgery: development, evaluation of accuracy and clinical relevance of a device useful to identify ureters during surgery.

OBJECTIVE: To develop and evaluate a non-invasive surgical assistance based on augmented reality (AR) in the detection of ureters on animal model. METHOD: After an experimental prototyping step on two pigs to determine the optimal conditions for visualization of the ureter in AR, three pigs were operated three times at 1 week intervals. The intervention consisted of an identification of the ureter, with and without the assistance of AR. At the end of the intervention, a clip was placed on the AR-proposed ureter to evaluate its accuracy. By doing a cone beam computed tomography, we measured the distance between the contrasted ureter and the clips in the acquired volume. Thirteen videos were recorded, allowing subsequent evaluation of the clinical relevance of the device. RESULTS: The feasibility of the technique has been confirmed. The margin of error was 1.77 mm (± 1.56 mm) for ureter localization accuracy. In order to evaluate the perceived relevance and accuracy in the detection of AR-assisted ureter, 58 gynecological surgeons were shown the videos then questioned. Of the 754 responses obtained (13 videos × 58 surgeons), the ureter was identified in direct vision in 31.2% of cases versus 81.7% in AR (p value 3.62 × 10-7). When looking at pigs that had already had one or two operations, the ureter was identified in only 16% of cases with direct vision compared to 76.1% with AR (p-value 5.48 × 10-19). In addition, 67% of surgeons felt that AR allowed them to better identify the ureters and 61% that AR reconstruction was accurate. CONCLUSION: This first AR device showed a satisfactory precision in the detection of ureters with a favorable opinion of surgeons. This surgical assistance system could be helpful in the performance of difficult procedures, for example in the case of patients, which have undergone multiple surgeries in the past.

Laparoscopic Transperitoneal Para-Aortic Lymphadenectomy in 10 Steps.

STUDY OBJECTIVE: Laparoscopic transperitoneal lymphadenectomy has a few advantages. First, it is a minimally invasive approach, and the transperitoneal approach is also the best option when intra-abdominal surgery is indicated. Although the procedure was described more than 2 decades ago, there is a lack of diffusion of the technique. The main objective of this video is standardization and a simple description of the technique. We described this procedure in 10 logical steps, which should help to understand and perform this procedure. METHODS: This video presents a systematic approach to transperitoneal lumboaortic lymphadenectomy, which is clearly divided in 10 steps ordered in a counterclockwise direction. RESULTS: The 10 steps are as follows: step 1, retroperitoneal access; step 2, creating a space for subsequent lymphadenectomy and identification of anatomic landmarks; step 3, left common iliac lymph node dissection; step 4, right common iliac lymph node dissection; step 5, presacral lymph node dissection; step 6, lateroaortal lymph node dissection; step 7, laterocaval lymph node dissection; step 8, aortocaval lymph node dissection; step 9, vaginal extraction of bags with specimens; and step 10, vaginal suture. CONCLUSIONS: Laparoscopic transperitoneal access to lumboaortic lymph nodes is an effective method of lymphadenectomy, which may bring benefits to a patient and physician. The presented 10 steps help to perform each part of surgery in a logical sequence, making the procedure ergonomic and easier to adopt and learn. Standardization of laparoscopic techniques could help to reduce the learning curve.

Risk of malignancy on suspicion of polyps in menopausal women.

Improved performances in gynaecological ultrasonography have enabled an increasing number of often asymptomatic endometrial polyps to be detected. Most of these polyps are removed surgically, as a precautionary measure, so as not to miss a case of endometrial cancer. Nonetheless, this management strategy is based solely on the sonographer's judgement and a number of these operations, which are probably of no benefit, could be avoided. In order to do so, risk factors for malignancy need to be identified. OBJECTIVE: Estimate the prevalence of lesions in menopausal patients with a pre-operative diagnosis of endometrial polyp. Establish risk factors for malignancy. STUDY DESIGN: This is a single-centre retrospective study. Enrolment criteria were menopausal patients aged over 45 who had undergone hysteroscopic resection of a polyp. Pre-op diagnosis was made either by ultrasonography or diagnostic hysteroscopy. Malignant lesions included cancers and atypical hyperplasia. Benign lesions consisted of simple polyps, non-atypical simple hyperplasia and non-atypical complex hyperplasia. Risk factors studied were existing abnormal uterine bleeding, endometrial thickness, personal or first-degree family history of gynaecological cancer (breast, cervix, endometrium, ovary) and age on diagnosis. RESULTS: 631 patients were enrolled of whom 30 presented a malignant disorder (4.75%); 579 patients (91.76%) presented a simple polyp, 11 a non-atypical simple hyperplasia (1.74%) and 11 a non-atypical complex hyperplasia (1.74%). On univariate analysis age alone proved to be statistically significant (OR 1.05; 95%CI=[1.02-1.09] p<0.01), with a threshold of 59 years of age on the ROC curve. On multivariate analysis, factors predictive of a malignant lesion were age (OR=1.06; 95%CI [1.02-1.10]), existence of AUB (OR=2.4; 95% CI [1.07-5.42]) and family history (OR=2.88; 95%CI [1.08-7.67]). Neither the univariate nor multivariate model was able to demonstrate a statistically significant relationship with respect to endometrial thickness. The risk of malignancy was 12.3% in patients aged over 59 presenting AUB. For all other subgroups, the risk varied between 2.31 and 3.78%. CONCLUSION: The risk of a malignant lesion appears to be high (12%) in menopausal patients aged over 59 presenting an endometrial polyp detected when there is pre-existing AUB. In this situation, hysteroscopic resection of endometrial polyps should therefore be routinely proposed. For other patients, the risk of a malignant lesion is low but not insignificant, standing at about 3%. Each patient record should therefore be discussed on an individual case basis, taking into consideration the patient's pre-existing conditions, after providing clear and appropriate information.

Type B Laparoscopic Radical Trachelectomy With Pelvic Lymphadenectomy for Early Cervical Cancer.

STUDY OBJECTIVE: To demonstrate the technique of laparoscopic radical trachelectomy (LRT) and laparoscopic pelvic lymphadenectomy for early cervical cancer. DESIGN: Case report (Canadian Task Force Classification Study design III). SETTING: Tertiary referral centre in Strasbourg, France. BACKGROUND: Over the past 15 years, gynecologic oncologists have sought ways to preserve female fertility when treating invasive cervical cancer. Many cases of cervical cancer have been diagnosed in young women with a desire to preserve their fertility. As more women are delaying childbearing, fertility preservation has become an important consideration. Radical hysterectomy and bilateral pelvic lymphadenectomy represent the standard surgical treatment for stage IA2-IB1 cervical cancer. In some women with small localized invasive cervical cancer, there is hope for a pregnancy after treatment. Vaginal radical trachelectomy (VRT) is a fertilitypreserving surgical procedure for early-stage cervical cancers. The National Comprehensive Cancer Network has published guidelines stating that radical trachelectomy is part of the standard of care for women desiring to preserve their future fertility. VRTwas introduced in 1987 with its first reported use in 1994, and since then more than 1000 cases of VRT have been reported involving more than 250 live births. The tumor recurrence rate is between 4.2% and 5.3%, and the mortality rate is between 2.5% and 3.2%. However, VRT has several limitations despite results demonstrating the safety of the procedure. One limitation is that it is an inadequate procedure for nulliparous patients and those with history of previous conization with adverse vaginal anatomy. In addition, it is difficult to learn the techniques involved in radical vaginal surgery. PATIENTS: A 26 year-old nulliparous women with a FIGO Stage IB1 squamous cell tumor of the cervix. A first conisation was performed with no safe resection margins. INTERVENTION: In this video we show a type B laparoscopic radical trachelectomy with round ligament and uterine artery preservation. A laparoscopic pelvic lymphadenectomy was also performed. Our institutional review board approved this study. MEASUREMENTS AND MAIN RESULTS: Operative time was 240 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathological findings demonstrated the presence of a cervical intraepithelial neoplasia 2 on the anterior lips from an 11 o'clock to a 1 o'clock position. Resection margins were safe. The surgical specimen did not show any residual invasive carcinoma. Twenty one lymph nodes were removed, 7 on the right side, and 14 on the left side. No metastatic adenopathy was found. The patient was discharged on day 11. After 5 months, no late complications or recurrence was detected. CONCLUSIONS: LRT appears to be a safe option for women who intend to maintain their desire for a future pregnancy.