Prospective multicenter study on urologic complications after radical surgery with or without radiotherapy in the treatment of stage IB-IIA cervical cancer.

A national collaborative group has conducted a multicenter prospective study on the use of a specific glossary for the complications associated with the treatment of cervical cancer, which were analytically described in 1989. This report analyzes the urologic complications with particular reference to radical surgery in stage IB-IIA cancer cases. In the prospective multicenter clinical study 2024 patients with frankly invasive cervical cancer were enrolled (IB = 1041; IIA = 308; IIB = 384; IIIA-B = 237; IV = 54). This report considers 1349 patients with stage IB-IIA disease. Treatment modalities in this group of patients were: type III radical surgery in 21.9%; type III radical surgery followed by radiotherapy in 20.8%; type III radical surgery preceded by radiotherapy in 7.3%; type II radical surgery in 3.1%; type II radical surgery followed by radiotherapy in 8.4%; type II radical surgery preceded by radiotherapy in 18.8%; surgery plus chemotherapy plus radiotherapy in 3.5%; radiotherapy alone in 16%. In this case series 873 complications were registered, and among these 341 (39.1%) were described in the urinary tract. Among 277 bladder complications 47.3% were grade 1; 47.3% grade 2, and 5.4% grade 3. Among 64 ureter complications 59.4% were grade 1; 17.2% grade 2, and 23.4% grade 3. Distribution of severe urinary complications was different according to site (bladder or ureter) and treatment modalities (radical surgery alone: bladder 1.3%, ureter 1.3%; radical surgery followed by radiotherapy: 1.4% bladder, 2.8% ureter; radical surgery preceded by radiotherapy: 3% bladder, 0% ureter). Different distributions of severe urinary complication were also observed in respect to stage (IB vs IIA); treatment: elective vs nonelective. In 673 patients treated with radical surgery plus or minus radiotherapy 123 relapses were registered (18.2%). Incidence of relapse was not different in patients suffering from mild/severe complications vs patients without complications. Disease-free survival, death from tumor, and death from other causes were not different in the group with complications in comparison to the group without complications.

Risk factors for complicating infections after cesarean section.

In this study of 906 women who underwent Cesarean Section without the use of an antibiotic prophylactic it has been confirmed that age, labour in course and the premature rupture of the membrane are clinical parameters that are statistically significant for unspecified fever/endometritis or for infections of the wound and that hemoglobin and hematocrit values below 9 gr/dl and at 35% post-operation are significant for infections of the wound. 13.2% women had complicating infections of which 1.3% were infections of the wound, 0.6% were endometritis, 7.2% were unspecified fever and 4.1% were urinary infections. The Authors show that preventive measures in some areas could be as effective as chemoprophylaxis.

Clinical experience in gynecological cancer management. d). Ovarian tumors--1) Epithelial: report from the Gynaecological Institutes of Padua University (1963-1990).

A complete review of case series from 1963 to 1990 allows some considerations and conclusions on the clinical management of epithelial ovarian cancer. In the aim of early diagnosis, the ovarian condition must be evaluated also by ultrasound scans, in every woman, at every gynaecological control, and every ovarian or pelvic mass must be carefully examined and removed. Staging is generally recognized as reliable only by surgical pathological evaluation, (SPS) as in post-surgical FIGO staging. Therapy is based on adequate chemosurgical strategy. Surgery, performed in maximum effort, must aim at radicality or adequate debulking, avoiding, however too heavy mutilations, almost always useless for prognosis. Lymphadenectomy, in advanced cases, should be selectively and not systematically performed. Cyclophosphamide and Cis-Platinum appear to be, today too, the most effective regimens as first line chemotherapy. Neoadjuvant chemotherapy must still be well evaluated in its cost-benefit balance and personalized in particular cases. Second laparotomic look must be personalized in respect to residual disease after primary surgery and tumoral aggressiveness factors.

Clinical experience in gynecological cancer management. c). Cervical cancer: report from the Gynecologic Institutes of Padua University (1963-1989).

The retrospective analysis of 1876 cases of invasive cervical cancer allows some considerations and conclusions on the clinical management of this neoplasia. Always led by the Gynaecologist, in the aims of prophylaxis and early diagnosis, personalized screening are necessary, with regard to risk factors. Surgical Pathological Staging (SPS) is mandatory for adequate treatment and prognosis. By personalizing surgical radicality and avoiding the application, in all cases, of the routine and standard extended operations of the past, it may be possible to reduce the complication rate with 5 year survival rate unchanged. In early stages personalized radical operations with systemic pelvic lymphadenectomy allow the best results (94% 5 year survival rate). Integrated therapies must be planned only in lymph nodal positive or in vascular space invasion cases. In advanced cases, surgery must be personalized in enlarged operations and integrated with adjuvant treatments on the basis of surgical pathological findings. In very advanced stages, integrated therapies, even without surgery, are justified, due to the poor prognosis of these cases.

Clinical experience in gynecological cancer management. b) Vulvar cancer: report from the Gynecologic Institutes of Padua University (1963-1989).

A review of the case series of our Institute from 1963 to 1989 (197 patients) permits some considerations and conclusions on the clinical management of vulvar cancer. In the aim of prophylaxis, prevention and early detection, personalized screening must be systematically performed in clinical practice by the Gynecologist. Surgical Pathological Staging (post-surgical FIGO stages) is mandatory for the exact knowledge of local tumor spread, lymph nodal involvement, aggressiveness factors and possible neoplastic multicentricity. In our experience operability is now 93%, with pathological radicality in 93% of operated cases. In early stages lymph nodal involvement is low (8.6% in tumor less than 2 cm; post surgical FIGO stage I) but it is very high in advanced cases. Surgery is the treatment of choice both in early and advanced stages. The increasing incidence of early vulvar cancer in young women has obliged us to reduce the cost to the patient of the surgical strategy to avoid mutilation in order to improve the quality of life without endangering survival. With this aim, since 1975 we have been performing an enlarged non mutilant radical vulvectomy which allows a better post operative period, with a low rate of complications and the preservation of anatomo-functional integrity. Furthermore 5 year survival rate appears unchanged while the quality of life greatly improves in cases treated by non mutilant operation. In any case of invasive tumor bilateral systemic inguinal lymphadenectomy must be performed and frozen biopsies are useful for planning the best surgical strategy. Integrated therapies are useful in advanced cases and in lymph nodal involvement. Close follow-up is mandatory.

Clinical experience in gynecological cancer management. Endometrial cancer: report from the gynecological institutes of Padua university (1963-1989).

A complete review of case series from 1963 to 1969 (603 patients) permits some considerations and conclusions on the clinical management of endometrial cancer. In the aims of prophylaxis, prevention and early diagnosis, personalized, not routine mass screenings, are the best in clinical practice by gynecologists. Surgical Pathological Staging (SPS) is mandatory for adequate treatment and prognosis. Operability is now 96%, with surgical pathological radicality in 98% of operated patients. In early stages lymphnode involvement was low (5%), in advanced, high (31%). In uterine cancer the simple surgical exploration, when negative, is reliable in 90.9% for parametrial and 89.9% for lymphnodal status; consequently in early stages surgical exploration can lead to pelvic lymphadenectomy, or not. Simple surgical operations are almost always enough for good radicality, while enlarged operations must be personalized only in particular advanced cases. Five-year survival is better with surgery alone in the early stages (SPS A1-A2) rather than surgery plus integrated therapies. On the contrary, in advanced stages limited to the corpus uteri (SPS A3) surgery plus integrated therapies gives the best results in 5-year survival rates. In advanced cases growing outside the corpus uteri (SPS B) both surgery alone and surgery plus integrated therapy are disappointing, and the 5-year survival is the same. The incidence of vaginal cuff relapses is the same, with or without complementary radiotherapy, which we have abandoned. Close follow-up allows for the early treatment of relapses, improving quality of life and survival.