Nerve sparing radical hysterectomy in early stage cervical cancer. Latest developments and review of the literature.

BACKGROUND: Cervical cancer is the second most common malignancy of the female genital tract worldwide. Radical hysterectomy with pelvic lymphadenectomy exemplifies the treatment of choice for early stage disease, whereas even if it is performed by gynaecologist-oncologist, still has the drawback of significant postoperative morbidity, especially for urinary bladder function. Nerve-sparing radical hysterectomy (NSRH) is a technique in which the neural part of the cardinal ligament which encloses the inferior hypogastric plexus, as well as the bladder branch (distal part of the plexus), remains intact. By this way, the bladder's innervation is safe and its functional recovery is more rapid. There is sufficient data to support the feasibility of the technique via laparotomy and laparoscopy, as well as the effectiveness related to the postoperative bladder dysfunction compared to conventional radical hysterectomy. On the other hand, the evidence related to survival outcomes is weak and derives from non-randomized trials. However, the low rate of local relapses after NSRH in early stage disease (IA2-IB1) with tumor diameter less than two cm makes the procedure suitable for this group of patients. CONCLUSION: According to the current evidence NSRH seems to be a suitable technique for gynaecologist-oncologist familiar with the method in early stage cervical cancer. It is a technique which improves significantly postoperative bladder recovery and the patients' quality of life (QoL), without compromising the oncological standard.

Laparoscopic myomectomy of a giant myoma.

We present the case of an infertile woman with a giant myoma which was laparoscopically removed. A 34-year-old patient was referred to our department with a large abdominal mass. Ultrasound revealed an 18 cm uterine myoma. Diagnostic laparoscopy showed a giant uterine myoma and with the help of a bent angle camera we started myoma enucleation. The myoma was totally enucleated and removed without disturbing the endometrial cavity. The uterine defect was closed with an absorbable suture in two layers. The myoma was removed using a PK (Gyrus) morcelator, without tissue or blood spillage in the abdomen. The operation time was 165 minutes and the myoma's weight was 1,200 g. The patient recovered uneventfully. Laparoscopic myomectomy can be an option even for giant myomas, with the condition of an expert surgeon and appropriate surgical instruments.

Laparoscopic para-aortic and pelvic lymphadenectomy and radical hysterectomy in a patient with cervical cancer, six months after primary chemoradiation.

Treatment of Stage IB-IIA cervical carcinoma is controversial. The choice to perform surgery or chemoradiation depends on the FIGO Stage, which does not include evaluation of lymph node involvement, although the prognosis of the patients depends on this evaluation. There is no method however, to safely evaluate preoperative lymph nodes metastasis, as both magnetic resonance imaging (MRI) and computed tomography (CT) have poor sensitivity and high specificity. As a result, inaccurate preoperative lymph node assessment can lead to suboptimal treatment. The authors report the case of a 42-year-old patient with cervical cancer Stage IB2, who was primary treated with chemoradiation. Although at the time of diagnosis no lymph node metastasis was detected, six months after treatment, an enlarged five-cm lymph node was found in the area of left iliac vein. The patient underwent laparoscopic pelvic and para-aortic lymphadenectomy and nerve sparing radical hysterectomy. Pathologic examination revealed one positive lymph node out of the 41 removed and no cancer cells in the uteral structures. There are cases of cervical cancer in which chemoradiation seems to be insufficient. Laparoscopic nerve-sparing radical hysterectomy can be the treatment in patients with lymph node metastasis after primary chemoradiation. It offers oncological safety combining the advantages of laparoscopy and the nerve-sparing technique. Furthermore, adjuvant chemotherapy or radiation can be initiated immediately, offering the best therapeutical choice in the authors' opinion.

Retromesenteric para-aortic lymphadenectomy in gynecologic malignancy.

UNLABELLED: In gynecologic oncology lymphadenectomy is of prognostic and therapeutic importance because recurrence-free time and survival depend on the metastatic involvement of lymph nodes. Lymphadenectomies are not performed to such an extent as they are indicated. This might be due to a laborious or problematic preparation. The authors therefore report their experience in a seldom taught preparation of the left para-aortic compartment in the form of a learning curve. MATERIALS AND METHODS: To access the left para-aortic area, the descending colon is lifted to open the retroperitoneum along the line of Toldt. The mesentery of the descending colon was separated from the kidney along the fascia of Gerota by blunt preparation. Time was measured from the incision of the peritoneum until the renal vein was clearly visible. RESULTS: The authors collected the data from the first 25 preparations. Mean duration for the left para-aortic preparation was 7.8 minutes compared to 5.9 minutes for the right side. Duration of preparation of the left area dropped from 11.0 minutes within the first patients (#1 to #5) to 3.8 minutes in the last patients (#20 to #25). No complications were observed in the study group linked to the retromesenteric approach described. CONCLUSION: Retromesenteric para-aortic lymphadenectomy is quick to learn. The authors needed 20 preparations to observe a significant drop in the time needed for preparation. Retromesenteric para-aortic lymphadenectomy offers an excellent overview that lightens lymphadenectomy and therefore reduces the risks for patients.

Follow-up of dysfunctional bladder and rectum after surgery of a deep infiltrating rectovaginal endometriosis.

PURPOSE: The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. Major goal of this review article is to compare different surgical techniques of deep infiltrating endometriosis and their follow-up results. METHODS: The research strategy included the online search of databases [MEDLINE, EMBASE, SCOPUS] for the diagnosis of deep infiltrating endometriosis with the indication of an operative resection. The outcome of the follow-up terms were noticed and compared. RESULTS: All in all, 16 trials could be identified with included follow-up. In all patients at least single-sided resection of the uterosacral ligaments were performed. Follow-up was heterogeneous in all trials ranging from 1 to 92 months. Postoperative symptoms, such as dysmenorrhoea, pelvic pain, and dyspareunia were commonly described in the majority of trials. Nevertheless, a tendency towards lower comorbidity after nerve sparing resection of endometriosis could be observed. CONCLUSION: Identification of the inferior hypogastric nerve and plexus was feasible in the minority of trials. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Laparoscopic nerve-sparing surgery of deep infiltrating endometriosis: description of the technique and patients' outcome.

INTRODUCTION: The radical surgery of the deep infiltrating endometriosis of the rectovaginal septum and the uterosacral ligaments with or without bowel resection can cause a serious damage of the pelvic autonomic nerves with urinary retention and the need of self-catheterization. PATIENTS AND METHODS: We introduce a case series report of 16 patients with laparoscopic nerve-sparing surgery of deep infiltrating endometriosis. We describe the technique step by step and compare the patients' outcome with patients who had undergone a non-nerve-sparing surgical technique. In 12 patients, a double-sided and in four patients, a single-sided identification of the inferior hypogastric nerve and plexus were performed. RESULTS: In all patients at least single-sided resection of the uterosacral ligaments were performed. Postoperatively dysmenorrhoea, pelvic pain, and dyspareunia disappeared in all patients. The average operating time was 82 min (range 45-185). Postoperatively, the overall time to resume voiding function was 2 days. The residual urine volume was in all patients <50 ml at two ultrasound measurements. DISCUSSION: Identification of the inferior hypogastric nerve and plexus was feasible. In comparison with non-nerve-sparing surgical technique, no cases of bladder self-catheterization for a long or even life time was observed, confirming the importance of the nerve-sparing surgical procedure.

Seasonality of spina bifida in Northern Germany.

PURPOSE: To verify a seasonal variation in the incidence of spina bifida and thus to identify possible environmental triggers leading to its developement. METHODS: An interdisciplinary approach has been taken to develop a better understanding of spina bifida through collaborative efforts from investigators specializing in genetics, fetal pathology, paediatrics, neuro-surgery and prenatal ultrasonographic diagnosis. All pregnancies with fetal spina bifida were retrospectively analyzed from May 1 1993 through May 1 2010 at Luebeck University Fetal Health Center. Results were used to construct a model to predict the occurrence of fetal spina bifida based on seasonal variation and environmental influence reflected by climatic changes and environmental pollution. Furthermore, data were categorized in respect to the date of conception and subdivided into date of conception during summer (April-September) and winter months (October-March). RESULTS: Neither a seasonal distribution of conception for fetuses with spina bifida in the defined time frame could be verified nor a relevant influence of the analyzed environmental factors on the prevalence of spina bifida could be proved. The incidence of spina bifida has remained relatively stable within the last 17 years at 2.5 per 1,000 screened pregnancies. CONCLUSION: Since we were unable to demonstrate a relationship between seasonal variation and certain environmental factors on the incidence of fetal spina bifida, other factors should be investigated for a possible association with the onset of fetal spina bifida.

Laparoscopic nerve-sparing radical hysterectomy: description of the technique and patients' outcome.

OBJECTIVE: The radical hysterectomy type three can be accompanied by postoperative morbidity, such as dysfunction of the lower urinary tract with loss of bladder or rectum sensation. We describe the technique of laparoscopic nerve-sparing radical hysterectomy and patient's outcome. METHODS: Thirty-two patients underwent laparoscopic nerve-sparing radical hysterectomy with pelvic lymphadenectomy. Both the hypogastric and the splanchnic nerves were identified bilaterally during pelvic lymphadenectomy. RESULTS: The median age of the patients was 52 years, and the average operating time was 221 min. There were no intraoperative or postoperative complications considering the nerve-spring radical hysterectomy. Postoperatively, in all patients spontaneous voiding was possible on the third postoperative day with a median residual urine volume of <50 ml. CONCLUSIONS: Laparoscopic identification (neurolysis) of the inferior hypogastric nerve and inferior hypogastric plexus is a feasible procedure for trained laparoscopic surgeons who have a good knowledge not only of the retroperitoneal anatomy but also of the pelvic neuro-anatomy as this qualification could prohibit long-term bladder and voiding dysfunction during nerve-sparing radical hysterectomy.

Treatment of endometriosis of uterosacral ligament and rectum through the vagina: description of a modified technique.

BACKGROUND: Endometriosis is common in women of childbearing age, whereas involvement of the rectosigmoid requiring resection is rare. Laparoscopy has become a standard procedure in the management of endometriosis. The optimum way to diagnose endometriosis is by direct visualization of the implants. Usually for the removal of the specimen, an additional larger abdominal incision is needed. METHODS: Here we report on cases of four patients with a uterosacral ligament and rectal endometriosis who were successfully treated with combined laparovaginal resection, using a modification of an existing technique. They had been complaining of rectal bleeding and lower abdominal pain in relation to their menstrual cycle. The aim of this technique is to achieve a careful and margin-free resection of the area involved. This can be done without any large incisions of the abdominal wall. The hypogastric nerves remain preserved on both sides. RESULTS: The intra- and post-operative courses were uneventful. No blood transfusions were needed. Haemoglobin decrease was usually < or =1 mmol/l. The average tumour diameter was 3.5 cm. CONCLUSIONS: Our technique circumvents a larger abdominal incision. This combined laparoscopic-transvaginal approach, avoiding the extension of port-site incisions, represents a viable option for the treatment of bowel endometriosis.

Histopathological extent of rectal invasion by rectovaginal endometriosis.

BACKGROUND: We aimed to evaluate the microscopic extent of endometriosis in surgical en-bloc specimens of vaginal skin, rectovaginal septum, cul-de-sac, and part of the rectosigmoid bowel. METHODS: From December, 1997 to October, 2001, 50 patients with the trias of intestinal pain, palpable disease in the rectovaginal septum, and laparoscopic diagnosis of endometriosis of the cul-de-sac and/or rectosigmoid colon underwent combined laparoscopic-vaginal en-bloc resection of the cul-de-sac with partial resection of the posterior vaginal wall and rectum with reanastomosis by minilaparotomy. All surgical specimens were histopathologically evaluated in a standardized fashion. RESULTS: The mean length of the bowel specimen was 7.48 cm. Endometriosis involved the serosa and muscularis propria in all patients, the submucosa in 17 patients (34%), and the mucosa in five patients (10%). After a mean follow-up of 32 months, 90% of patients reported a considerable improvement or were completely free of symptoms and the rate of recurrence was 4% (two patients). CONCLUSIONS: Partial bowel resection indicates the depth and multifocality of endometriosis affecting the recto-sigmoid colon. Such extensive surgery appears justified by the extent of the lesions and the long-term relief of symptoms achieved.