Surgical Anatomical Structure of Uterine Artery Caudal Space for Robot-Assisted Extrafascial Hysterectomy With Ureterohypogastric Nerve Fascia Preservation: A Case Description.

A surgical technique has been developed using a robot-assisted system to create the surgical anatomical structure of the uterine artery caudal space (UACS), a landmark for performing extrafascial hysterectomy, enabling a safe and easy parametrial resection to prevent ureteral injury and cervical sidewall bleeding at hysterectomy. UACS is created to preserve the ureterohypogastric nerve fascia (UHNF), which envelopes the ureter and the hypogastric nerve, and the vesicohypogastric fascia (VF), which wraps the uterine artery and veins. The boundaries of UACS are UHNF laterally, the uterine cervix medially, and VF cranially. VF is penetrated between UACS and the medial pararectal space under the uterine vessels and transected. We present a case of early-stage uterine cancer and describe the new surgical technique in detail, using UACS as a surgical landmark. This surgical technique could be applied not only to early-stage uterine cancer but also to benign uterine tumors using a robot-assisted surgical system.

HPV genotyping for triage of women with abnormal cervical cancer screening results: a multicenter prospective study.

BACKGROUND: In cervical cancer screening programs, women with abnormal cytology are referred for colposcopy for histological evaluation. We examined whether a human papillomavirus (HPV) genotyping assay could be used to identify women who do not need immediate colposcopy and biopsy because of low risk of cervical intraepithelial neoplasia grade 3 or worse (CIN3+). METHODS: We prospectively evaluated test performance for 2 carcinogenic HPV genotypes (HPV16/18), for 8 types (HPV16/18/31/33/35/45/52/58), and for 13 types (HPV16/18/31/33/35/45/51/52/56/58/59/68) for prediction of histological CIN3+ results among 427 screen-positive women referred for colposcopy. The study subjects consisted of 214 women with low-grade squamous intraepithelial lesion (LSIL), 184 with high-grade squamous intraepithelial lesion (HSIL), and 29 with atypical squamous cells, cannot exclude HSIL (ASC-H). RESULTS: Among women with LSIL cytology, HPV16/18 positivity was 29.4 % and increased to 58.9 % for 8 types and to 74.8 % for 13 types (P < 0.001). The risk of CIN3+ biopsy results was still 7.9 % for women testing negative for HPV16/18, but decreased to 0.0 % for those testing negative for at least eight types of HPV (HPV16/18/31/33/35/45/52/58). Although HPV genotyping results enabled additional risk stratification among women with HSIL/ASC-H cytology, the risk of histological CIN3+ diagnosis among women testing negative for eight types or more was still sufficiently high (>35 %) to warrant immediate colposcopy referral. CONCLUSIONS: Of women with LSIL cytology, those testing negative for at least eight of the highest-risk types of HPV (HPV16/18/31/33/35/45/52/58) may not need immediate colposcopy and biopsy. This would reduce the number of colposcopy referrals by approximately 40 %. However, the HPV genotyping assay is not likely to alter the clinical management of women with HSIL/ASC-H.

Optimizing biopsy procedures during colposcopy for women with abnormal cervical cancer screening results: a multicenter prospective study.

BACKGROUND: In cervical cancer screening programs, women with abnormal cytology results are referred to colposcopy for histological diagnosis. This study was designed to evaluate the sensitivity of colposcopic procedures for detecting cervical cancer and its precursor, cervical intraepithelial neoplasia (CIN). METHODS: Women referred to colposcopy for abnormal cytology were enrolled from four hospitals. Gynecologists were required to take a colposcopy-guided biopsy from the worst of the abnormal-looking areas as a first biopsy. They were also asked to take ≥ 3 cervical specimens including by endocervical curettage (ECC). Random biopsies were performed at the gynecologist's discretion. We analyzed 827 biopsy results from 255 women who were diagnosed by central pathologists as having histology of CIN or cancer. RESULTS: In this study, 78.1% of diagnoses of CIN grade 2 or worse (CIN2+) (the threshold that would trigger intensive management) were obtained from a first colposcopy-guided biopsy. The additional diagnostic utility of second and third colposcopy-guided biopsies was 16.4 and 1.8%, respectively. The combined sensitivity of two colposcopy-directed biopsies for CIN2+ detection was >90%, regardless of the colposcopist. Random biopsies and ECC increased the diagnostic yield of CIN2+ lesions otherwise missed by colposcopy-guided biopsies alone, but only by 1.2 and 2.4%, respectively. Random biopsies were more useful for women referred after low-grade abnormal cytology (P = 0.01). The utility of ECC was greatest among women with unsatisfactory colposcopy (P = 0.03) or aged ≥ 40 years (P = 0.02). CONCLUSIONS: Our data suggest that at least two colposcopy-directed biopsies should be taken for histological diagnosis. Random biopsies and ECC are recommended for special populations.