The role of laparoscopy in the management of gynecologic malignancy.

With the advent of minimally invasive laparoscopic techniques, most gynecologic procedures for benign conditions can be performed in an outpatient setting. However, the role of such techniques in gynecologic oncology is not well defined. By reviewing the literature and presenting some new data, we attempt to elucidate the applications of operative videolaparoscopy in gynecologic oncology. Advanced laparoscopic techniques are utilized for the management of cervical cancer as well as the staging and treatment of endometrial and ovarian cancers. Such techniques are used in performing radical hysterectomy for early stage cervical cancer, pelvic and paraaortic lymphadenectomy, and second look laparoscopy following chemotherapy for ovarian cancer. Even though preliminary data are encouraging, large prospective controlled studies with long-term follow-up are necessary to better define the role and limitations of laparoscopy in the treatment of gynecologic malignancies.

Laparoscopic radical hysterectomy and laparoscopically assisted vaginal radical hysterectomy with pelvic and paraaortic node dissection.

Nineteen women underwent laparoscopic radical hysterectomy or laparoscopically assisted vaginal radical hysterectomy, with pelvic node dissection and paraaortic node dissection when indicated. One procedure was converted to laparotomy due to equipment failure (at The University of Puerto Rico). There were two minor postoperative complications. The first, febrile morbidity resulting from a urinary tract infection, responded to medical therapy. The second was incisional bleeding, which was controlled with sutures applied using a local anesthetic. No major postoperative complications were noted, there have been no incidents of recurrence, and the follow-up results are encouraging.

Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection.

We report the first case of a laparoscopic radical hysterectomy and paraaortic and pelvic lymphadenectomy to treat a stage IA2 carcinoma of the cervix. To our knowledge, a laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy has not been previously described.

The modified radical vulvectomy with groin dissection: an eight-year experience.

Fifty-one patients were admitted to a single practice at St. Joseph's Hospital between April 1, 1978, and April 1, 1986 with a diagnosis of squamous cell carcinoma of the vulva greater than 1 mm in depth. Five advanced lesions were treated with combinations of radiation and surgery. Four patients had recurrent squamous cell carcinoma. Of 42 patients treated surgically with intention of cure, 14 were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated with complete radical vulvectomy and bilateral inguinofemoral lymphadenectomies, and 28 patients were treated in 26 instances with bilateral inguinofemoral lymphadenectomies in one of five different excision patterns individualized to the site of primary tumor. None of the 28 patients have had a recurrence. Five had positive nodes. Eight have died of unrelated causes. Lesions in 25 cases were stage I or II and in three cases they were stage III. Modified radical vulvectomy and bilateral groin dissection is a safe approach for most patients with stage I or II and occasionally even stage III lesions.

Intraperitoneal radioactive chromic phosphate P 32 in the treatment of ovarian cancer.

The use of intraperitoneal radioisotopes in the management of women with ovarian cancer is controversial. We analyzed the experience with intraperitoneal chromic phosphate P 32 at our institution, from October 1979 to February 1983, in 22 patients with various stages and grades of ovarian malignancy. Survival in stage I is 87.5% and in stage II, 50%. Survival is 88.9% among patients with grade 1 tumors and 33.3% for those with grade 3 lesions. Morbidity related to chromic phosphate P 32 was minimal; small bowel obstruction occurred in only one patient who had also received external pelvic irradiation. Our results suggest that chromic phosphate P 32 is a safe, well tolerated, inexpensive, and effective adjuvant to surgery in the management of selected patients with ovarian malignancy.

Extramammary Paget's disease of the vulva and anus: use of intraoperative frozen-section margins.

Thirteen consecutive cases of vulvar Paget's disease treated by us between 1975 and 1984 underwent pathologic retrospective review. In the first group of eight patients having Paget's disease not involving the anal mucosa, the extent of disease was completely defined by frozen-section margins. Additional intraoperative resections were necessary in five of the eight. None had residual involvement on permanent sections and none had recurrences in 3 to 8 years of follow-up, although two died of unrelated causes. A second group of two patients early in the series had frozen sections to define some but not all of the margins. Both had positive perineal margins on permanent sections. One has required two subsequent revisions after 3 years of follow-up and the other has been free of disease during 9 years of follow-up. A third group of three patients all had anal mucosal involvement and all had associated mucinous adenocarcinoma of the rectum. Frozen sections actually discovered the presence of one of the three carcinomas. After appropriate radical operations, all three are alive and free of disease between 2 and 9 years of follow-up. It is concluded: patients with vulvar Paget's disease can reduce the need for subsequent operations with the use of frozen sections to define surgical margins; anal mucosal involvement of Paget's disease represents an ominous sign of underlying carcinoma.

Radical hysterectomy and pelvic lymphadenectomy.

In recent years there has been an increasing awareness that radical hysterectomy and pelvic lymphadenectomy can play an important role in the management of early invasive cervical cancer. We present a series of 255 patients who had radical hysterectomy for gynecologic malignancy over a nine-year period. The incidence of ureteral fistulas was 0.8% and of vesical fistulas 1.6%. The operative mortality was 0.78%, which compares favorably with the rates in most larger centers in which radical pelvic operations are common. With proper patient selection and excellent operative technique, survival rates of well over 90%, with minimal complications, can be obtained.

A deliberate hypotensive technique for decreasing blood loss during radical hysterectomy and pelvic lymphadenectomy.

Nitroglycerin was utilized in combination with general anesthesia in order to reduce mean arterial blood pressure with the objective of reducing operative blood loss in 26 consecutive patients undergoing radical hysterectomy and pelvic lymphadenectomy. This deliberate hypotensive technique added no morbidity and compared to a control group decreased the blood loss by 70%, shortened operating time by 29.5%, and decreased the percentage of patients requiring blood transfusions from 81% to 11.5%. The indications for controlled hypotension are still controversial and somewhat dependent upon the expertise of the anesthesia and surgery teams, availability of blood, and the risk of transfusion hepatitis. Cerebrovascular disease, myocardial ischemia, peripheral vascular disease, severe renal or hepatic disease, and hypovolemia are relative contraindications to deliberate hypotension.

Endometrial cancer: evaluation of spread and follow-up one hundred eighty-nine patients with Stage I or Stage II disease.

A retrospective study was undertaken of 189 patients with Stage I or Stage II endometrial cancer in whom selective lymphadenectomy had been performed between the years 1974 and 1981. Pelvic and para-aortic nodal involvement increased with increasing stage, grade, and depth of myometrial invasion. The incidences of pelvic and para-aortic node metastases in Stage I were 1.4% and 3.8%, respectively, while 17.6% of Stage II patients had para-aortic metastases. Mortality was significantly greater for Stage I adenosquamous carcinoma (10.5%) and papillary serous adenocarcinoma (37.5%) than for Stage I adenocarcinoma (2.2%). In Stage I, grade 3 nonrandomized cases of endometrial cancer, no significant difference in survival or morbidity occurred between those patients treated with external radiation and those who were not. Intraperitoneal or adnexal spread occurred in 12 of the 189 patients, and lymph nodes were diseased in two of these. Sixteen of 17 recurrences developed at extrapelvic sites, indicating the need for effective systemic chemotherapy in high-risk patients. The overall 5-year survival rates for Stage I and II patients were 88.0% and 83.3%, respectively.

Reconstructive techniques in radical pelvic surgery.

The use of reconstructive surgical techniques accelerates recovery from radical pelvic surgery. It also allows the surgeon greater latitude in the type of procedure and the selection of patients for extended pelvic surgery. The techniques involved in three such reconstructive procedures are described, and their applicability is illustrated with care reports. The use of the compound myocutaneous flap, the axial cutaneous flap, and the omental island flap is discussed.