Surgical outcomes of robotic radical hysterectomy after neoadjuvant chemotherapy for locally advanced cervical cancer: comparison with early stage disease.

AIMS: To evaluate the feasibility and safety of robotic radical hysterectomy (RRH) with pelvic lymphadenectomy for locally advanced cervical cancer (LACC) after neoadjuvant chemotherapy (NACT). METHODS: Starting from 04/2009, consecutive patients with LACC were submitted to robotic surgical staging after NACT. Surgical outcomes were compared to those achieved by women undergoing robotic surgery for an early stage disease during the same temporal interval. RESULTS: Overall 25 (Group 1) and 21 (Group 2) patients had an early stage and a LACC, respectively. Among women with LACC, 18 achieved best tumor responses to NACT and therefore they were addressed to RRH. Outcomes resulted comparable between Groups in terms of operative time, blood loss, hospitalization and complications. No differences were found in terms of nodal yield, parametrial and vaginal cuff length. CONCLUSIONS: RRH is feasible and safe also in patients previously submitted to NACT for LACC. Larger series with longer follow-up are mandatory to establish survival outcomes.

Robotic radical parametrectomy with pelvic lymphadenectomy: our experience and review of the literature.

AIMS: To evaluate the feasibility and safety of robotic radical parametrectomy (RRP) and pelvic lymphadenectomy for the management of occult invasive cervical cancer or local recurrence of endometrial cancer and to compare our outcomes with the evidence available in the literature. METHODS: Starting from 07/2008 consecutive patients submitted to RRP have been included in this study. A comprehensive literature review of published papers about this subject was carried out. RESULTS: During the study period 11 patients were managed; 7 and 4 patients had an occult cervical cancer and a vaginal recurrence of endometrial cancer, respectively. One intra-operative and one post-operative complications were recorded. Neither conversion to laparotomy, nor blood transfusions occurred. Three women required further adjuvant therapies. After a median follow-up of 19 months (range 8-36) one recurrence has been detected. The outcomes of other 200 women from 15 different papers have been collected and compared to our findings. CONCLUSIONS: Robotic surgery represents an effective alternative to accomplish radical parametrectomy with comparable results of those reported in the literature in terms of feasibility and safety. RRP is certainly a demanding procedure which however avoids radiotherapy in more than 80% of cases.

Gynecological fertility-sparing surgery.

The implementation of early detection protocols and advanced treatment strategies has significantly improved survival outcomes for gynecologic cancer patients. The improvement of oncological outcomes has led to an increased attention toward Quality of Life issues, including the childbearing potential for young women. Traditionally the surgical treatment of cervical, endometrial and ovarian cancers involves the removal of the uterus and adnexa, irrespective of the impact on fertility and parenthood and regardless of patient desires. For young women affected by gynecological malignancies at an apparently early stage, fertility-sparing procedures could be offered. The aim of our review is to going through the available evidence in the Literature and to evaluate the current state of art regarding fertility-sparing procedures for women with gynecological malignancies in terms of oncological and fertility outcomes.

Total laparoscopic radical hysterectomy and pelvic lymphadenectomy in patients with Ib1 stage cervical cancer: analysis of surgical and oncological outcome.

AIM: To evaluate safety, feasibility and oncological outcome of total laparoscopic radical hysterectomy (TLRH) in patients with early invasive cervical cancer. METHODS: Data of patients with Ib1 cervical cancer who underwent TLRH were prospectively collected. Inclusion criteria were: good general condition, tumor size <3 cm, and no evidence of lymph node metastases in imaging study (MRI and/or CT and/or PET). Radical hysterectomy was performed with a PlasmaKinetic tissue management system. Adjuvant therapy was administered according to surgical risk factors. RESULTS: Between September 2001 and October 2007 107 patients underwent laparoscopic radical hysterectomy and pelvic lymphadenectomy. Conversion to laparotomy was necessary in 6 patients. Median number of resected pelvic lymph nodes was 26. Median blood loss was 200 ml and median duration of surgery was 305 min. Minor intraoperative complications were registered in two patients, while five patients needed a second surgery for postoperative complications. Thirteen patients had microscopic nodal metastasis. A total of 24 patients received adjuvant therapy. After a median follow-up of 30 months 11 patients had a recurrence; survival rate is 95%. CONCLUSION: Total laparoscopic radical hysterectomy, in experienced hands, has to be considerate an adequate and feasible surgical technique. Considering historical data the oncological outcome can be considered comparable to patients treated with laparotomy, as the relapse rate in our population was 11% and the overall survival good.

Randomised comparison of Burch colposuspension versus anterior colporrhaphy in women with stress urinary incontinence and anterior vaginal wall prolapse.

OBJECTIVE: To compare the Burch colposuspension and the anterior colporrhaphy in women with both stress urinary incontinence and advanced anterior vaginal wall prolapse (cystocele). DESIGN: Prospective randomised study. SETTING: Secondary referral centre, Urogynaecology Unit, San Gerardo Hospital, Monza, Italy. SAMPLE: Seventy-one women undergoing surgery for primary genuine stress incontinence and concurrent grade 2 or 3 cystocele (descending at or outside the vaginal introitus). METHODS: Full urodynamic investigation performed pre-operatively and repeated six months after surgery. Clinical follow up continued for 8 to 17 years. MAIN OUTCOME MEASURES: Subjective (patient history) and objective (negative stress test result) cure of stress incontinence. Assessment of cystocele recurrence. RESULTS: Thirty (86%) of the 35 evaluable women who had the Burch colposuspension and 17 (52%) of the 33 evaluable women who had the anterior colporrhaphy were subjectively cured (OR 5.6, 95% CI 1.6 to 21.6; P = 0.005). Objective cure rates were 74% (26 of 35) and 42% (14 of 33), respectively (OR 3.9, 95% CI 1.3 to 12.5; P = 0.02). A recurrent cystocele of grade 2 or 3 with or without prolapse at other vaginal sites was recorded in 34% (12 of 35) and 3% (1 of 33) of women, respectively (OR 16.7, 95% CI 2.0 to 368.1; P = 0.003). CONCLUSIONS: The Burch colposuspension was better in controlling stress incontinence but it lead to an unacceptable high rate of prolapse recurrence. The anterior colporrhaphy was more effective in restoring vaginal anatomy but it was accompanied by an unacceptable low cure rate of stress incontinence. Neither of the two operations is recommended for women who are suffering from a combination of stress incontinence and advanced cystocele.

Surgery for genitourinary prolapse and stress incontinence: a randomized trial of posterior pubourethral ligament plication and Pereyra suspension.

OBJECTIVE: Our purpose was to compare two antiincontinence procedures in patients with severe genitourinary prolapse and coexisting clinical or potential stress incontinence. STUDY DESIGN: In addition to cystopexy, 109 patients with a urethrocystocele of grade 2 or more and a positive stress test result with prolapse reduction received posterior pubourethral ligament plication or Pereyra suspension. RESULTS: Of 55 patients undergoing posterior pubourethral ligament plication, 15 were clinically and 40 potentially incontinent; the same figures were 21 and 33, respectively, among 54 patients undergoing the Pereyra procedure. Follow-up was for 3 to 9 years. Subjective (60% vs 71%, p = 0.72) and objective (27% vs 57%, p = 0.14) cure rates were not statistically different among patients who were clinically incontinent (posterior pubourethral ligament plication vs Pereyra suspension). Among potentially incontinent patients, subjective (85% vs 100%, p = 0.03) and objective (50% vs 76%, p = 0.04) continence rates were higher after the Pereyra procedure. Overall, the cotton swab test had negative results (maximum straining angle < or = 30 degrees) after successful surgery in 79% and 96%, respectively, of patients (p = 0.03). Four subjects (7%) underwent removal of one Pereyra suture because of urinary retention or suprapubic wound infection. CONCLUSION: Cystopexy with Pereyra suspension is recommended, particularly for patients with prolapse and potential stress incontinence.

A randomized comparison of Burch colposuspension and abdominal paravaginal defect repair for female stress urinary incontinence.

OBJECTIVE: Our aim was to compare Burch colposuspension and paravaginal repair for success rates, complications, and urodynamic effects when the procedures are used in the treatment of stress urinary incontinence. STUDY DESIGN: Thirty-six patients were enrolled. A full urodynamic evaluation was repeated 6 months postoperatively. RESULTS: Twelve (67%) and 17 (94%) subjects (Burch colposuspension vs paravaginal repair) voided spontaneously before discharge (p = 0.04). One patient receiving the Burch procedure underwent urethral dilation for urinary retention. Follow-up was for 1 to 3 years. Differences in subjective and objective cure rates favored the Burch colposuspension over the paravaginal repair: 100% versus 72% (p = 0.02) and 100% versus 61% (p = 0.004), respectively. The paravaginal repair did not produce significant modifications in profilometry. Postoperatively, cotton swab tests had negative results in all patients with the Burch operation and in 33% of those with the paravaginal repair (p = 0.01). CONCLUSION: Paravaginal repair is not recommended for the treatment of stress incontinence, although it was accompanied by a more immediate resumption of voiding.

The Burch colposuspension for women with and without detrusor overactivity.

OBJECTIVE: To compare the results of the Burch colposuspension in women with stress urinary incontinence and detrusor overactivity with those obtained in women with stress incontinence and stable bladders. Additionally, to analyse the value of two detrusor instability indexes and of standard cystometric parameters in predicting the surgical outcome. DESIGN: Retrospective cohort study. SETTING: Secondary referral centre Urodynamics Unit, San Gerardo Hospital, Monza. SAMPLE: Forty-four women with detrusor overactivity (21 with low compliance bladder and 23 with detrusor instability) and 44 with stable bladders. They were matched for age, parity, dystocia, menopause, body mass index, previous vaginal surgery, heavy work, urethral functional length and maximum urethral closure pressure. RESULTS: At two years follow up, the cure rate of stress incontinence was 95% in the control group (patients with stable bladders) and 75% in detrusor overactivity group (odds ratio 0.1, 95% confidence interval 0.01-0.9, P = 0.02). No significant differences were observed between cured and failed patients according to both detrusor instability indexes. Likewise, mean pre-operative standard cystometric values of cured and failed patients showed no differences. CONCLUSIONS: Although results were better in women with stable bladders, we believe that the success of the Burch colposuspension in cases with mixed incontinence should be considered satisfactory. No pre-operative cystometric parameter consistently predicting the surgical outcome on stress incontinence was identified.

Chromocystoscopy in the urological monitoring of patients with cancer of the cervix.

OBJECTIVE: To determine whether chromocystoscopy could be used for the urological monitoring of cervical carcinoma. METHODS: The absolute ejaculation time (AET, the interval of time between the intravenous injection of dye and the ejaculation of dyed urine in the bladder from either of the ureters) and the relative ejaculation time (RET, the difference of time between the two ejaculations) were retrospectively studied in relation to intravenous urography (IVU) and radionuclide renography (RR) in 141 patients. RESULTS: A significant probability of normal IVU and RR was found when the AET was < or = 7 min or the RET < or = 4 min and when no interval occurred between the two ejaculations. Pathological IVU and RR were found when there was no ejaculation from one or both ureters after 12 min. CONCLUSIONS: Chromocystoscopy could be used for monitoring cervical cancer patients. An abnormal chromocystoscopy could indicate the need for further radiological examinations.