Health-related quality of life after interval cytoreductive surgery with or without hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with stage III ovarian cancer.

INTRODUCTION: The addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) improves recurrence-free (RFS) and overall survival (OS) in patients with FIGO stage III ovarian cancer. We evaluated the effect of HIPEC on patient's health-related quality of life (HRQoL) in the OVHIPEC trial. MATERIALS AND METHODS: OVHIPEC was a multicentre, open-label, randomized phase III trial for patients with stage III ovarian cancer. Patients were randomly assigned (1:1) to receive interval CRS with or without HIPEC with cisplatin. HRQoL was assessed using the EORTC QLQ-C30, and the ovarian (QLQ-OV28) and colorectal cancer (QLQ-CR38) modules. HRQoL questionnaires were administered at baseline, after surgery, after end of treatment, and every three months thereafter. HRQoL was a secondary endpoint, with the prespecified focus on the QLQ-C30 summary score and symptom scores on fatigue, neuropathy and gastro-intestinal symptoms. HRQoL was analysed using linear and non-linear mixed effect models. RESULTS: In total, 245 patients were randomized. One-hundred-ninety-seven patients (80%) completed at least one questionnaire. No significant difference over time in the QLQ-C30 summary scores was observed between the study arms (p-values for linear and non-linear growth: p > 0.133). The pattern over time for fatigue, neuropathy and gastro-intestinal symptoms did not significantly differ between treatment arms. CONCLUSION: The addition of HIPEC to interval CRS does not negatively impact HRQoL in patients with stage III ovarian cancer who are treated with interval CRS due to the extent of disease. These HRQoL results, together with the improvement in RFS and OS, support the viability of HIPEC as an important treatment option in this patient population. CLINICALTRIALS. GOV NUMBER: NCT00426257. EUDRACT NUMBER: 2006-003466-34.

Vaginal delivery after hemipelvectomy and pelvic radiotherapy for chondrosarcoma.

Chondosarcoma of the proximal femur is a rare malignant disorder in women of (pre-) childbearing age, for which a radical resection through a hemipelvectomy could be indicated. We describe a case of a 36-year-old primigravida with a hemipelvectomy (2004) who had a history of radiotherapy of the pelvic and uterine regions after an atypical cartilaginous tumour. After an uncomplicated pregnancy, she had a spontaneous rupture of the membranes at 41+2 weeks and an uncomplicated vaginal delivery with physiological development of the infant. On the basis of the literature review, vaginal delivery after hemipelvectomy should be advocated and discussed with the patient and involved care providers. Women with radiotherapy in the pelvic and uterine areas have an increased risk of stillbirth, placental attachment disorders, impaired fetal growth, fetal malposition and preterm labour, but no association with prolonged rupture of the membranes has been described.

CT, MRI and laparoscopy findings of a retroperitoneally herniated ovary causing acute abdominal pain.

We report a case of a young woman presenting with abdominal pain due to a rare and recurrent herniation of the ovary, to a retroperitoneal location lateral to the external iliac artery and directly dorsal to the iliopsoas muscle. Correlation between computed tomography, magnetic resonance imaging and laparoscopy is presented. The patient's complaints subsided after right oophoropexy. When aware, this diagnosis is easy to make and may allow symptomatic patients to be treated with laparoscopic oophoropexy.

Clinical and radiologic signs of relapsed ovarian germ cell tumor: tissue is the issue.

Malignant ovarian germ cell tumor is a rare disease, but with current treatment strategies including surgery and platinum based chemotherapy survival is excellent. After treatment, intensive followup is indicated to encounter tumor relapse at an early stage. This case describes a 22-year-old female with a history of common variable immune deficiency (CVID) who underwent a resection of a large ovarian germ cell tumor followed by 4 cycles of cisplatin and etoposide resulting in clinical complete remission. During followup, she developed a mass at the umbilicus and ascites. Initially, the cytology of the ascites was interpreted as tumor positive, suspicious of relapse of the disease, but tumor markers remained negative. However, during laparoscopy it turned out to be a mature teratoma, which can develop after chemotherapy, the so called growing teratoma syndrome. In retrospect, the ascites was false positive. This case shows that current diagnostic tools are not sufficient to distinguish between vital tumor and mature teratoma and can be misleading. Tumor biopsy and/or laparoscopic inspection are therefore indicated.

Training and learning robotic surgery, time for a more structured approach: a systematic review.

BACKGROUND: Robotic assisted laparoscopic surgery is growing rapidly and there is an increasing need for a structured approach to train future robotic surgeons. OBJECTIVES: To review the literature on training and learning strategies for robotic assisted laparoscopic surgery. SEARCH STRATEGY: A systematic search of MEDLINE, EMBASE, the Cochrane Library and the Journal of Robotic Surgery was performed. SELECTION CRITERIA: We included articles concerning training, learning, education and teaching of robotic assisted laparoscopic surgery in any specialism. DATA COLLECTION AND ANALYSIS: Two authors independently selected articles to be included. We categorised the included articles into: training modalities, learning curve, training future surgeons, curriculum design and implementation. MAIN RESULTS: We included 114 full text articles. Training modalities such as didactic training, skills training (dry lab, virtual reality, animal or cadaver models), case observation, bedside assisting, proctoring and the mentoring console can be used for training in robotic assisted laparoscopic surgery. Several training programmes in general and specific programmes designed for residents, fellows and surgeons are described in the literature. We provide guidelines for development of a structured training programme. AUTHORS' CONCLUSIONS: Robotic surgical training consists of system training and procedural training. System training should be formally organised and should be competence based, instead of time based. Virtual reality training will play an import role in the near future. Procedural training should be organised in a stepwise approach with objective assessment of each step. This review aims to facilitate and improve the implementation of structured robotic surgical training programmes.

Laparoscopic skills training using inexpensive box trainers: which exercises to choose when constructing a validated training course.

OBJECTIVE: To obtain face and construct validity for a new training course to be used in any type of box/video trainer and to give a comprehensive overview of validated exercises for box/video training. DESIGN: Cross-sectional study. SETTING: University Medical Centre. POPULATION: Students, residents and consultants. METHODS: Participants (n = 42) were divided into three groups according to their laparoscopic experience: 'Novices' (n = 18), 'Intermediates' (n = 14) and 'Experts' (n = 10). A laparoscopic training course consisting of six exercises was constructed. To emphasise precision, a penalty score was added. Every participant performed two repetitions of the exercises; total score per exercise was calculated. To determine face validity, participants filled in a questionnaire after completion of the exercises. An evidence-based literature search for validated box/video trainer exercises was performed. MAIN OUTCOME MEASURES: Face and construct validity. RESULTS: The mean score of the 'experts' was set as the training target. Total scores appeared to be positively correlated with individual's laparoscopic experience. The overall score and the score for each exercise were significantly higher in the intermediate and expert groups when compared with the novice group (P ≤ 0.001). All participants completed the questionnaire. The overall assessment of the exercises was considered to be good. The course was found to be most appropriate for training residents year 1-3. CONCLUSION: Face and construct validity for an inexpensive course for box/video training was established. A comprehensive and practical overview of all validated and published exercises for box/video trainers is provided to facilitate an inexpensive, but optimal and tailored selection for training purposes.

From open radical hysterectomy to robot-assisted laparoscopic radical hysterectomy for early stage cervical cancer: aspects of a single institution learning curve.

We analysed the introduction of the robot-assisted laparoscopic radical hysterectomy in patients with early-stage cervical cancer with respect to patient benefits and surgeon-related aspects of a surgical learning curve. A retrospective review of the first 14 robot-assisted laparoscopic radical hysterectomies and the last 14 open radical hysterectomies in a similar clinical setting with the same surgical team was conducted. Patients were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and open radical hysterectomy (RH) before August 2006 and were candidates for a laparoscopic sentinel node procedure, pelvic lymph node dissection and robot-assisted laparoscopic radical hysterectomy (RALRH) after August 2006. Overall, blood loss in the open cases was significantly more compared with the robot cases. Median hospital stay after RALRH was 5 days less than after RH. The median theatre time in the learning period for the robot procedure was reduced from 9 h to less that 4 h and compared well to the 3 h and 45 min for an open procedure. Three complications occurred in the open group and one in the robot group. RALRH is feasible and of benefit to the patient with early stage cervical cancer by a reduction of blood loss and reduced hospital stay. Introduction of this new technique requires a learning curve of less than 15 cases that will reduce the operating time to a level comparable to open surgery.

Robotic surgery.

Over the past decade, there has been an exponential growth of robot-assisted procedures and of publications concerning robotic-assisted laparoscopic surgery. From a review of the available literature, it becomes apparent that this technology is safe and allows more complex procedures in many fields of surgery, be it at relatively high costs. Although randomised controlled trials in gynaecology are lacking, available evidence suggests that particularly in gynaecology robotic surgery might not only reduce morbidity but also be cost effective if performed in high-volume centres. Training in robotic surgery and programs for safe and effective implementation are necessary.