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Nguyen KH, Joo H, Manuel S, Chen LM, Chen LL. Incorporating low haemoglobin into a risk prediction model for conversion in minimally invasive gynaecologic oncology surgeries. J OBSTET GYNAECOL 2024; 44:2349960. [PMID: 38783693 DOI: 10.1080/01443615.2024.2349960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND A well-known complication of laparoscopic management of gynaecologic masses and cancers is the need to perform an intraoperative conversion to laparotomy. The purpose of this study was to identify novel patient risk factors for conversion from minimally invasive to open surgeries for gynaecologic oncology operations. METHODS This was a retrospective cohort study of 1356 patients ≥18 years of age who underwent surgeries for gynaecologic masses or malignancies between February 2015 and May 2020 at a single academic medical centre. Multivariable logistic regression was used to study the effects of older age, higher body mass index (BMI), higher American Society of Anaesthesiologist (ASA) physical status, and lower preoperative haemoglobin (Hb) on odds of converting from minimally invasive to open surgery. Receiver operating characteristic (ROC) curve analysis assessed the discriminatory ability of a risk prediction model for conversion. RESULTS A total of 704 planned minimally invasive surgeries were included with an overall conversion rate of 6.1% (43/704). Preoperative Hb was lowest for conversion cases, compared to minimally invasive and open cases (11.6 ± 1.9 vs 12.8 ± 1.5 vs 11.8 ± 1.9 g/dL, p<.001). Patients with preoperative Hb <10 g/dL had an adjusted odds ratio (OR) of 3.94 (CI: 1.65-9.41, p=.002) for conversion while patients with BMI ≥30 kg/m2 had an adjusted OR of 2.86 (CI: 1.50-5.46, p=.001) for conversion. ROC curve analysis using predictive variables of age >50 years, BMI ≥30 kg/m2, ASA physical status >2, and preoperative haemoglobin <10 g/dL resulted in an area under the ROC curve of 0.71. Patients with 2 or more risk factors were at highest risk of requiring an intraoperative conversion (12.0%). CONCLUSIONS Lower preoperative haemoglobin is a novel risk factor for conversion from minimally invasive to open gynaecologic oncology surgeries and stratifying patients based on conversion risk may be helpful for preoperative planning.
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Affiliation(s)
- Kevin H Nguyen
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford Medicine, Palo Alto, CA, USA
| | - Hyundeok Joo
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Solmaz Manuel
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
| | - Lee-May Chen
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California, San Francisco, CA, USA
| | - Lee-Lynn Chen
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, CA, USA
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Pavone M, Lecointre L, Seeliger B, Oliva R, Akladios C, Querleu D, Scambia G, Marescaux J, Forgione A. The vaginal route for minimally invasive surgery: a practical guide for general surgeons. MINIM INVASIV THER 2024:1-10. [PMID: 38850263 DOI: 10.1080/13645706.2024.2359707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/21/2024] [Indexed: 06/10/2024]
Abstract
INTRODUCTION Vaginal approaches have become routine in the field of gynecologic surgery, whereas in general surgery vaginal wall transection is an infrequent practice typically reserved for extensive tumor resections. Approximately two decades ago, natural orifice transluminal endoscopic surgery (NOTES) revolutionized conventional boundaries by accessing the peritoneal cavity transorally, transrectally, or transvaginally, enabling general surgery without visible scars. Although transvaginal approaches have been successfully used for various abdominal procedures by general surgeons, a gap remains in comprehensive training to fully exploit the potential of this route. MATERIAL AND METHODS PubMed, Google Scholar, and Scopus databases were searched to retrieve relevant articles illustrating how general surgeons can adeptly manage vaginal approaches. RESULTS The article presents a practical framework for general surgeons to execute a complete vaginal approach, addressing the management of vaginal specimen extraction and vaginal cuff closure, even in the absence of an experienced gynecologist. CONCLUSION The evolution of abdominal surgery is moving towards less invasive techniques, emphasizing the importance of understanding the nuances and challenges associated with the vaginal route. This approach is linked to minimal oncological, sexual, and infective complications, and to the absence of pregnancy-related complications. Such knowledge becomes increasingly crucial, particularly with the renewed demand for transvaginal access in robot-assisted NOTES procedures.
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Affiliation(s)
- Matteo Pavone
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Lise Lecointre
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Barbara Seeliger
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
- Department of Digestive and Endocrine Surgery, University Hospitals of Strasbourg, Strasbourg, France
| | - Riccardo Oliva
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Cherif Akladios
- Department of Gynecologic Surgery, University Hospital of Strasbourg, Strasbourg, France
| | - Denis Querleu
- IHU Strasbourg, Institute of Image-Guided Surgery, Strasbourg, France
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
- ICube, UMR 7357 CNRS, University of Strasbourg, Strasbourg, France
| | - Giovanni Scambia
- Dipartimento di Scienze per la salute della Donna e del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario A. Gemelli, IRCCS, UOC Ginecologia Oncologica, Rome, Italy
| | - Jacques Marescaux
- IRCAD, Research Institute Against Digestive Cancer, Strasbourg, France
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Durán-Martínez M, Gómez-Dueñas G, Rodriguez-Ortíz L, Sanchez-Hidalgo JM, Gordón-Suárez A, Casado-Adam Á, Rufián-Peña S, Valenzuela-Molina F, Rufián-Andujar B, Vázquez-Borrego MC, Romero-Ruiz A, Briceño-Delgado J, Arjona-Sánchez Á. Laparoscopic versus open approach for interval cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC) in advanced epithelial ovarian cancer: a matched comparative study. Surg Endosc 2024; 38:66-74. [PMID: 37903884 DOI: 10.1007/s00464-023-10508-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 10/01/2023] [Indexed: 11/01/2023]
Abstract
BACKGROUND The use of the laparoscopic approach for the treatment of carcinomatosis from epithelial ovarian cancer (EOC) is controversial. The aim of this study was to compare the short-term outcomes of both laparoscopic and open approach for interval CRS+HIPEC in a matched cohort of patients with advanced EOC. METHODS A retrospective analysis of a prospectively maintained database including 254 patients treated with interval CRS-HIPEC between January 2016 and December 2021 was performed. Patients with primary disease and limited carcinomatosis (PCI ≤ 10) were selected. A comparative analysis of patients treated by either open (O-CRS-HIPEC) or the laparoscopic (L-CRS-HIPEC) approach was conducted. Overall survival (OS), disease-free survival (DFS), and perioperative outcomes were analysed. RESULTS Fifty-three patients were finally selected and enrolled into two comparable groups in this study. Of these, 14 patients were treated by interval L-CRS-HIPEC and 39 by interval O-CRS-HIPEC. The L-CRS-HIPEC group had a shorter hospital stay (5.6 ± 1.9 vs. 9.7 ± 9.8 days; p < 0.001) and a shorter time to return to systemic chemotherapy (4.3 ± 1.9 vs. 10.3 ± 16.8 weeks; p = 0.003). There were no significant differences in postoperative complications between both groups. The 2-year OS and DFS was 100% and 62% in the L-CRS-HIPEC group versus 92% and 60% in the O-CRS-HIPEC group, respectively (p = 0.96; p = 0.786). CONCLUSION This study suggests that the use of interval L-CRS-HIPEC for primary advanced EOC is associated with shorter hospital stay and return to systemic treatment while obtaining similar oncological results compared to the open approach. Further prospective research is needed to recommend this new approach for these strictly selected patients.
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Affiliation(s)
| | | | - Lidia Rodriguez-Ortíz
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Juan Manuel Sanchez-Hidalgo
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Antonio Gordón-Suárez
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Ángela Casado-Adam
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Sebastián Rufián-Peña
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Francisca Valenzuela-Molina
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Blanca Rufián-Andujar
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - María Carmen Vázquez-Borrego
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | - Antonio Romero-Ruiz
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain
| | | | - Álvaro Arjona-Sánchez
- Surgical Oncology Unit, Reina Sofia University Hospital, Cordoba, Spain.
- GE09 Research in Peritoneal and Retroperitoneal Oncological Surgery, Reina Sofia University Hospital, Maimonides Biomedical Research Institute of Cordoba (IMIBIC), University of Cordoba, Av. Menendez Pidal, 14004, Cordoba, Spain.
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Melamed A, Eisenhauer EL. Minimally invasive interval cytoreductive surgery for advanced ovarian cancer. J Surg Oncol 2024; 129:126-127. [PMID: 38073159 DOI: 10.1002/jso.27553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 12/17/2023]
Abstract
With the increasing use of neoadjuvant chemotherapy, it has also become apparent that some patients will require a less extensive interval cytoreductive surgery which could be performed as a minimally invasive procedure. This observation, and expertise with minimally invasive surgery for other indications in gynecologic oncology, has driven surgeons in the United States and other countries to perform an increasing portion of interval cytoreductive surgery using minimally invasive techniques. Further observational and trial data will continue to inform which patients are best suited for this approach.
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Affiliation(s)
- Alexander Melamed
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, USA
| | - Eric L Eisenhauer
- Department of Obstetrics & Gynecology, Massachusetts General Hospital, Boston, USA
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5
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Finch L, Chi DS. An overview of the current debate between using minimally invasive surgery versus laparotomy for interval cytoreductive surgery in epithelial ovarian cancer. J Gynecol Oncol 2023; 34:e84. [PMID: 37545363 PMCID: PMC10482582 DOI: 10.3802/jgo.2023.34.e84] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 07/22/2023] [Indexed: 08/08/2023] Open
Abstract
The standard of care for treatment of advanced-stage epithelial ovarian cancer is primarily surgery followed by platinum-based chemotherapy, with the operative goal to achieve complete gross resection. Cytoreductive surgeries for epithelial ovarian cancer historically were performed via open laparotomy; however, as minimally invasive techniques became more widely accepted within gynecologic oncology, interest in employing this approach in the setting of cytoreductive surgery for epithelial ovarian cancer has grown. The purpose of this review was to examine the current debate between the use of minimally invasive surgery versus laparotomy as an approach to interval cytoreductive surgery in advanced epithelial ovarian cancer. While numerous retrospective and feasibility studies have found comparable outcomes with respect to complete gross residual disease, progression-free survival, and overall survival between minimally invasive and laparotomy approaches to interval cytoreductive surgery for epithelial ovarian cancer, methodological challenges limit the utility of these data. Given potential risks of underestimating disease burden and failing to achieve complete resection using a minimally invasive approach, further rigorous studies are needed to evaluate the safety and efficacy of minimally invasive surgery in this setting and to better define the subset of patients who would receive the greatest benefit from a minimally invasive approach.
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Affiliation(s)
- Lindsey Finch
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Dennis S Chi
- Gynecology Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Obstetrics and Gynecology, Weill Cornell Medical College, New York, NY, USA.
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6
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Jorgensen K, Melamed A, Wu CF, Nitecki R, Pareja R, Fagotti A, Schorge JO, Ramirez PT, Rauh-Hain JA. Minimally invasive interval debulking surgery for advanced ovarian cancer after neoadjuvant chemotherapy. Gynecol Oncol 2023; 172:130-137. [PMID: 36977622 PMCID: PMC10192032 DOI: 10.1016/j.ygyno.2023.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 01/12/2023] [Accepted: 01/16/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE Assess outcomes of interval debulking surgery (IDS) after neoadjuvant chemotherapy via minimally invasive surgery (MIS) compared with laparotomy in patients with advanced epithelial ovarian cancer. METHODS Patients diagnosed with stage IIIC or IV epithelial ovarian cancer between 2013 and 2018 who received neoadjuvant chemotherapy and IDS were identified in the National Cancer Database. Primary outcome was overall survival. Secondary outcomes were 5-year survival, 30- and 90-day postoperative mortality, extent of surgery, residual disease, hospitalization duration, surgical conversions, and unplanned readmissions. Propensity score matching was used to compare MIS and laparotomy for IDS. Association of treatment approach with overall survival was assessed using Kaplan-Meier method and Cox regression. Sensitivity analysis was conducted for effect of unmeasured confounders. RESULTS A total of 7897 patients met inclusion criteria; 2021 (25.6%) underwent MIS. Percentage undergoing MIS increased from 20.3%-29.0% over the study period. After propensity score matching, median overall survival was 46.7 months in the MIS group versus 41.0 months in the laparotomy group [hazard ratio (HR) 0.86 (95%CI 0.79-0.94)]. Five-year survival probability was higher in MIS versus laparotomy (38.3% vs 34.8%, p < 0.01). There was lower 30- and 90-day mortality (0.3% vs 0.7% [p = 0.04] and 1.4% vs 2.5% [p = 0.01], respectively), shorter length of stay (median 3 vs 5 days, p < 0.01), lower residual disease (23.9% vs 26.7%, p < 0.01), and lower additional cytoreductive procedures (59.3% vs 70.8%, p < 0.01) in MIS compared to laparotomy, with similar rates of unplanned readmission (2.7% vs 3.1%, p = 0.39). CONCLUSIONS Patients who undergo IDS by MIS have similar overall survival and decreased morbidity compared with laparotomy.
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Affiliation(s)
- Kirsten Jorgensen
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States.
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, MA, United States
| | - Chi-Fang Wu
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Roni Nitecki
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Rene Pareja
- Gynecologic Oncology, Instituto Nacional de Cancerología, Bogota, Colombia
| | - Anna Fagotti
- Department of Woman's and Child Health and Public Health Sciences, Gynecologic Oncology, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Catholic University of the Sacred Heart, Rome, Italy
| | - John O Schorge
- Department of Obstetrics and Gynecology, The University of Tennessee Health Science Center, Memphis, TN, United States
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jose Alejandro Rauh-Hain
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
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Kamei Y, Kobayashi E, Nakatani E, Shiomi M, Sawada M, Kakuda M, Toda A, Nakagawa S, Hiramatsu K, Kinose Y, Takiuchi T, Miyoshi A, Kodama M, Hashimoto K, Kimura T, Ueda Y, Sawada K, Kimura T. A single institution's experience with minimally invasive surgery for ovarian cancer, and a systematic meta-analysis of the literature. Int J Clin Oncol 2023; 28:794-803. [PMID: 37115425 DOI: 10.1007/s10147-023-02320-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/20/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND This study assesses the feasibility of minimally invasive surgery (MIS) for well-selected epithelial ovarian cancer (EOC) patients. METHODS We performed a review of data prospectively collected from a single center from 2017 to 2022. Only patients with histologically confirmed EOC, with a tumor diameter of less than 10 cm, were eligible. We also performed a meta-analysis of similar studies comparing the outcomes of laparoscopy and laparotomy. We used MINORS (Methodological Index for Non-Randomized Studies) to assess the risk of bias and calculated the odds ratio or mean difference. RESULTS Eighteen patients were included; 13 in re-staging group, four in PDS group, and one in IDS group. All achieved complete cytoreduction. One case was converted to laparotomy. The median number of removed pelvic lymph nodes was 25 (range 16-34), and 32 (range 19-44) for para-aortic nodes. There were two (15.4%) intraoperative urinary tract injuries. The median follow-up was 35 months (range 1-53). Recurrence was observed in one case (7.7%). Thirteen articles for early-stage ovarian cancer were included in our meta-analysis. Analysis of the pooled results found that MIS had a higher frequency of spillage (OR, 2.15; 95% CI 1.27-3.64). No differences were observed in recurrence, complications, or up-staging. CONCLUSIONS Our experience supports the possibility of conducting MIS for EOC in well-selected patients. Except for spillage, our meta-analysis findings are consistent with previous reports, the majority of which were also retrospective. Ultimately, randomized clinical trials will be needed to authenticate the safety.
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Affiliation(s)
- Yuji Kamei
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Eiji Kobayashi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan.
- Department of Obstetrics and Gynecology, Oita University Graduate School of Medicine, 1-1, Hasamamachiidaigaoka Yufu, Oita, 879-5503, Japan.
| | - Eiji Nakatani
- Division of Statistical Analysis, Research Support Center, Shizuoka General Hospital, Shizuoka, Japan
| | - Mayu Shiomi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Masaaki Sawada
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Mamoru Kakuda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Aska Toda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Satoshi Nakagawa
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Kosuke Hiramatsu
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Yasuto Kinose
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Tsuyoshi Takiuchi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Ai Miyoshi
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Michiko Kodama
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Kae Hashimoto
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Toshihiro Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Yutaka Ueda
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Kenjiro Sawada
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
| | - Tadashi Kimura
- Department of Obstetrics and Gynecology, Osaka University Graduate School of Medicine, 2-2, Yamadaoka Suita, Osaka, 567-0871, Japan
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Uterine allograft removal by total laparoscopic hysterectomy after successful cesarean delivery in a living-donor uterus recipient with uterovaginal agenesis (MRKHS). Arch Gynecol Obstet 2023; 307:827-840. [PMID: 36342536 PMCID: PMC9984324 DOI: 10.1007/s00404-022-06796-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 09/15/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE To limit the burden of long-term immunosuppression (IS) after uterus transplantation (UTx), removal of the uterine allograft is indicated after maximum two pregnancies. Hitherto this has required graft hysterectomy by laparotomy. Our objective was to demonstrate, as a proof of concept, the feasibility of less traumatic transplantectomy by total laparoscopic hysterectomy (TLH). PATIENT A 37-year-old woman with uterovaginal agenesis due to Mayer-Rokitansky-Küster-Hauser syndrome (MRKHS) who had undergone neovaginoplasty at age 19 years prior to living-donor (LD) UTx in 10/2019 at age 35 years gave birth to a healthy boy by primary cesarean section in 06/2021. During pregnancy, she developed impaired renal function, with bilateral hydronephrosis, necessitating early allograft removal in 09/2021 to prevent chronic kidney disease, particularly during a potential second pregnancy. METHODS Transplantectomy by TLH essentially followed standard TLH procedures. We paid meticulous attention to removing as much donor tissue as possible to prevent postoperative complications from residual donor tissue after stopping IS, as well as long-term vascular damage. RESULTS TLH was performed successfully without the need to convert to open surgery. Surgical time was 90 min with minimal blood loss. No major complications occurred intra- or postoperatively and during the subsequent 9-month follow-up period. Kidney function normalized. CONCLUSIONS To our knowledge, we report the first successful TLH-based removal of a uterine allograft in a primipara after LD UTx, thus demonstrating the feasibility of TLH in uterus recipients with MRKHS.
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Effects of Laparoscopic Hyperthermic Perfusion Therapy Combined with Adjuvant Treatment of Compound Yew Capsule on Ovarian Blood Flow Parameters and Immune Function in Patients with Ovarian Cancer. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2022; 2022:9603492. [PMID: 35873625 PMCID: PMC9300267 DOI: 10.1155/2022/9603492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 06/27/2022] [Accepted: 06/29/2022] [Indexed: 11/28/2022]
Abstract
Objective To determine the effects of laparoscopic hyperthermic perfusion therapy combined with adjuvant compound yew capsules on ovarian blood flow parameters and immune function in patients with ovarian cancer (OC). Methods A total of 90 OC patients enrolled in our hospital between January 2019 and January 2020 were randomly distributed into the control (Con group) and experimental group (Exp group) based on the sealed envelope method. The Con group was administered laparoscopic hyperthermic perfusion therapy. On this basis, the Exp group was subjected to compound yew capsules; the ovarian blood flow parameters and immune function indexes were compared between the two groups. Results The Exp group was reported to perform better than the Con group regarding ovarian blood flow parameters and immune indexes after treatment (p < 0.001). Conclusion Laparoscopic hyperthermic perfusion therapy combined with adjuvant compound yew capsules for patients with OC can substantially improve the clinical indexes and immune function. Furthermore, research and adequate promotion are needed to elicit the evidence beyond preclinical studies to understand the intricacies of its implementation.
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Does MIS Play a Role in the Treatment of Advanced Ovarian Cancer? Cancers (Basel) 2022; 14:cancers14153579. [PMID: 35892837 PMCID: PMC9331315 DOI: 10.3390/cancers14153579] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/12/2022] [Accepted: 07/20/2022] [Indexed: 02/06/2023] Open
Abstract
Neoadjuvant chemotherapy allows a minimally invasive approach for interval debulking in patients with ovarian cancer considered unresectable to no residual disease by laparotomy at diagnosis. The aim of the study was to evaluate the type of surgical approach at interval debulking (ID) after three courses of carboplatin and taxol in patients with unresectable ovarian cancer at diagnosis compared with the type of surgical approach at primary debulking (PD). A secondary objective was to compare the perioperative outcomes of MIS vs. laparotomy at ID. A retrospective review of the type of surgical approach at ID following three courses of carboplatin and taxol was compared with the surgical approach at PD, and a review of the perioperative outcomes of MIS vs. open at ID was performed during the period from 21 January 2012, through 21 February 2013, for stage IIIC > 2 cm or IV epithelial ovarian cancer (EOC) unresectable at diagnosis and the surgical approach at PD. During the study period, 127 patients with stage IIIC or IV EOC met the inclusion criteria. Minimally invasive surgery (MIS), laparoscopic or robotic, was used in 21.6% of patients at ID and in 23.3% of patients at PD. At ID, MIS patients had a shorter hospital stay as compared to laparotomy (2 vs. 8 days; p < 0.001). At 5 year follow-up, 31.5% of EOC patients were alive (ID MIS: 47.5% vs. ID open: 30%; PD MIS: 41% vs. PD open: 28%), while 24.4% had no evidence of disease (ID MIS: 39% vs. ID open: 19.5%; PD MIS: 32% vs. PD open: 22%). Among living patients, 22% had evidence of disease. Neoadjuvant chemotherapy is a form of chemo-debulking and allows a minimally invasive approach at interval debulking in about one-fifth of the patients, with initial disease deemed unresectable to no residual tumor at initial diagnosis.
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11
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Zeng S, Yu Y, Cui Y, Liu B, Jin X, Li Z, Liu L. Efficacy and Safety of Minimally Invasive Surgery Versus Open Laparotomy for Interval Debulking Surgery of Advanced Ovarian Cancer After Neoadjuvant Chemotherapy: A Systematic Review and A Meta-Analysis. Front Oncol 2022; 12:900256. [PMID: 35924170 PMCID: PMC9341245 DOI: 10.3389/fonc.2022.900256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Accepted: 06/22/2022] [Indexed: 12/24/2022] Open
Abstract
Objective The selection of minimally invasive surgery (MIS) or open laparotomy for ovarian cancer (OC) after neoadjuvant chemotherapy still remains controversial. This study aimed to assess the efficacy and safety of MIS versus open laparotomy following neoadjuvant chemotherapy for advanced OC, so as to provide another option to select optimal surgical procedures for patients with OC. Methods Relevant literature studies about the risks of progression or mortality between women receiving MIS and open laparotomy for interval debulking surgery (IDS) were searched in the online databases, including PubMed, Embase, and the Cochrane Library with the following keywords: “ovarian neoplasms”, “minimally invasive surgical procedures”, “laparotomy”, and “neoadjuvant therapy”. Eligible studies were screened out for further meta-analysis. Results Six eligible literature studies, with 643 patients in the MIS group and 2,885 patients in the open laparotomy group, were included in this meta-analysis. No significant differences were detected in the overall survival (OS) of patients with OC who were treated with MIS or open laparotomy [hazard ratio (HR) = 0.85; 95% confidence interval (CI) = 0.59–1.23; heterogeneity: P = 0.051, I2 = 57.6%]. However, the progression-free survival (PFS) was significantly higher in patients with OC treated with MIS than those treated with laparotomy (HR = 0.73; 95% CI = 0.57 to 0.92; heterogeneity: P = 0.276, I2 = 22.4%). The completeness of debulking removal (R0 rate) in the open laparotomy group was not statistically higher compared with the control group (RR = 1.07; 95% CI = 0.93 to 1.23; heterogeneity: P = 0.098, I2 = 52.3%), and no significant differences in residual disease of ≤1 cm (R1) (RR = 1.08; 95% CI = 0.91 to 1.28; heterogeneity: P = 0.330, I2 = 12.6%) and postoperative complications were found between the two groups (RR = 0.72; 95% CI = 0.34 to 1.54; heterogeneity: P = 0.055, I2 = 60.6%). Furthermore, the length of stays in hospital was significantly shorter in patients with OC treated with MIS than those treated with open laparotomy (Standard Mean Difference (SMD) = −1.21; 95% CI = −1.78 to −0.64; heterogeneity: P < 0.001, I2 = 92.7%]. Conclusions For IDS after NACT in patients with advanced OC, complete cytoreductive surgery with MIS is another feasible and effective choice Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022298519, identifier CRD42022298519
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Affiliation(s)
- Siyuan Zeng
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
- Dalian municipal Central Hospital, China Medical University, Shenyang, China
| | - Yongai Yu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Yuemei Cui
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Bing Liu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Xianyu Jin
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Zhengyan Li
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
| | - Lifeng Liu
- Department of Obstetrics and Gynecology, Dalian Municipal Central Hospital, Dalian, China
- Dalian municipal Central Hospital, China Medical University, Shenyang, China
- *Correspondence: Lifeng Liu,
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Wang Y, Yin J, Li Y, Shan Y, Gu Y, Jin Y. Laparoscopic and Laparotomic Restaging in Patients With Apparent Stage I Epithelial Ovarian Cancer: A Comparison of Surgical and Oncological Outcomes. Front Oncol 2022; 12:913034. [PMID: 35795058 PMCID: PMC9251109 DOI: 10.3389/fonc.2022.913034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 05/16/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To assess the surgical and oncological outcomes of laparoscopic restaging compared with laparotomy for apparent early-stage epithelial ovarian cancer. Methods A retrospective chart review was undertaken of patients who underwent laparoscopic (laparoscopy group) or laparotomic (laparotomy group) restaging at the Peking Union Medical College Hospital, China, between January 2012 and December 2017. All patients had apparent stage I epithelial ovarian cancer that was incompletely staged at the initial surgery. Results A total of 157 patients were included, with 50 in the laparoscopy group and 107 in the laparotomy group. Baseline characteristics were similar between the groups. No cases were converted from laparoscopy to laparotomy. The laparoscopy group had a significantly shorter operating time (p<0.001), less estimated blood loss (p<0.001), and a shorter postoperative hospitalization duration (p<0.001) than the laparotomy group. Transfusions were required in only eight laparotomy patients. No significant differences in postoperative complications were observed between the two groups (p=0.55). Eighteen (11.5%) patients were upstaged to stage II or stage III after surgery. A total of 123 (78.3%) patients received postoperative platinum-based chemotherapy. During the follow-up period, 15 (9.6%) patients experienced disease recurrence, and 3 patients died of disease progression. Five-year disease-free survival (p = 0.242, log-rank test) and overall survival (p = 0.236, log-rank test) were not affected by the surgical approach. Conclusions Laparoscopic restaging showed more favorable operative outcomes than laparotomy. Surgical restaging via laparoscopy versus laparotomy was not associated with worse survival in women with apparent stage I epithelial ovarian cancer.
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Perioperative and Survival Outcomes of Robotic-Assisted Surgery, Comparison with Laparoscopy and Laparotomy, for Ovarian Cancer: A Network Meta-Analysis. JOURNAL OF ONCOLOGY 2022; 2022:2084774. [PMID: 35535312 PMCID: PMC9078848 DOI: 10.1155/2022/2084774] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 04/04/2022] [Indexed: 02/08/2023]
Abstract
Objective We aimed to compare the perioperative and survival outcomes of robotic-assisted surgery, traditional laparoscopy, and laparotomy approaches in ovarian cancer. Methods PubMed, Cochrane Library, Embase, Web of Science, and Chinese National Knowledge Infrastructure (CNKI) were searched using multiple terms for ovarian cancer surgeries, including comparative studies in Chinese and English. Literatures are published before August 31, 2021. The outcomes include operating time, estimated blood loss, length of hospital stay, postoperative/intraoperative/total complications, pelvic/para-aortic/total lymph nodes, transfusion, and five-year overall survival rate. The dichotomous data, continuous data, and OS data were pooled and reported as relative risk, standardized mean differences, and hazard ratio HRs with 95% confidence intervals, respectively. The Newcastle–Ottawa Scale was used to evaluate the risk of bias of included studies. Results Thirty-eight studies, including 8,367 patients and three different surgical approaches (robotic-assisted laparoscopy surgery, traditional laparoscopy, or laparotomy approaches), were included in this network meta-analysis. Our analysis shows that the operating time of laparotomy was shorter than laparoscopy. The robotic-assisted laparoscopy has the least estimated blood loss during the surgery, followed by laparoscopy, and finally laparotomy. Compared with laparotomy, the incidence of blood transfusion was lower in the robotic-assisted laparoscopy and laparoscopy groups, and the length of hospital stay is shorter. Laparotomy had a significantly higher incidence of total complications than robotic-assisted laparoscopy and laparoscopy and higher postoperative complications than laparoscopy. For the number of pelvic/para-aortic/total lymph nodes removed by different surgical approaches, our analysis revealed no statistical difference. Our analysis also revealed no significant differences in intraoperative complications and 5-year OS among the three surgical approaches. Conclusion Compared with laparotomy, robotic-assisted laparoscopy and laparoscopy had a shorter hospital stay, decreased blood loss, fewer complications, and transfusion happened. The 5-year OS of ovarian cancer patients has no difference between robotic-assisted laparoscopy, laparoscopy, and laparotomy groups.
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Survival and Surgical Approach among Women with Advanced Ovarian Cancer Treated with Neoadjuvant Chemotherapy. J Minim Invasive Gynecol 2022; 29:375-384. [PMID: 34648931 PMCID: PMC8918010 DOI: 10.1016/j.jmig.2021.09.716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 09/28/2021] [Accepted: 09/29/2021] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To evaluate the effect of surgical approach on overall survival (OS) for women with advanced, epithelial ovarian cancer (EOC) after neoadjuvant chemotherapy (NACT) and determine the sociodemographic and clinical factors associated with surgical approach. DESIGN The primary exposure was surgical approach to interval cytoreduction, minimally invasive versus open, and was evaluated by intention to treat. Primary outcome was OS. Associations were examined using Chi-squared tests, Wilcoxon rank sum tests, and multivariate logistic regression. Survival analysis was performed with Kaplan-Meier methods and Cox proportional hazards. SETTING The National Cander Database was used to identify eligible patients. PATIENTS Women diagnosed with stage IIIC/IV EOC from 2010-2016. INTERVENTIONS Patients were included if they were treated with NACT within 90 days of diagnosis before interval cytoreductive surgery (CRS). MEASUREMENTS AND MAIN RESULTS A total of 8085 women were identified; 6713 (83%) underwent open interval CRS, and 1372 (17%) underwent minimally invasive interval CRS. The proportion undergoing minimally invasive CRS after NACT increased from 2% in 2010 to 11% in 2016, a nearly 6-fold increase. There was no difference in OS between women who underwent minimally invasive and open interval CRS (median OS 36.5 vs 35.2 months, HR 0.94, 95% CI, 0.86-1.04). After adjusting for demographic and clinical variables, including age, race, ethnicity, income, and Charlson/Deyo score, no difference in OS was observed (HR 0.95, 95% CI, 0.86-1.04). Women of older age (OR 1.35, 95% CI, 1.05-1.74) and Hispanic ethnicity (OR 1.46, 95% CI, 1.14-1.88) had increased odds of receiving minimally invasive CRS after NACT, whereas low income (<$38000/year) women had decreased odds (OR 0.76, 95% CI, 0.60-0.97, p = .03). Length of stay differed for patients undergoing minimally invasive versus open interval CRS (3 vs 5 days, p <.01), but there was no difference in need for postoperative readmission. CONCLUSIONS Minimally invasive CRS has similar survival outcomes to open CRS among women with EOC who have undergone NACT.
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Conte C, Rosati A, Marchetti C, Iacobelli V, Quagliozzi L, Gallucci V, Gueli Alletti S, Scambia G, Fagotti A. Nomogram to predict feasibility of minimally invasive interval debulking surgery in advanced ovarian cancer. Int J Gynecol Cancer 2022; 32:532-539. [PMID: 35022309 DOI: 10.1136/ijgc-2021-002908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE Currently, there is no clear guidance defining the ideal candidate for minimally invasive interval debulking surgery. This study aimed to identify predictive factors for a minimally invasive approach in patients with advanced ovarian cancer who are candidates for interval debulking surgery after neoadjuvant chemotherapy. METHODS This was a single institution retrospective study conducted between January 2014 and June 2020 Perioperative variables were used to predict the likelihood of minimally invasive interval debulking surgery using multivariable models. A nomogram was developed, and internal validation was performed using the bootstrapping correction technique. This nomogram was built to visualize the effect of perioperative variables on the estimated probability of minimally invasive interval debulking surgery in patients with a clinical response after neoadjuvant chemotherapy. We used the four significant perioperative variables according to logistic regression. RESULTS A total of 108 (28.4%) and 272 (71.6%) patients underwent interval debulking surgery by a minimally invasive or open approach, respectively. Absence of omental cake (odds ratio (OR) 9.15, 95% confidence interval (CI) 4.26 to 19.64, p<0.001), high volume surgeon (OR 5.43, 95% CI 2.75 to 10.71, p<0.001), less than two peritoneal sites involved (OR 2.94, 95% CI 1.34 to 6.43, p=0.007), and CA125 normalization (OR 1.79, 95% CI 1.05 to 3.36, p=0.049) correlated with the feasibility of minimally invasive interval debulking surgery at multivariate analysis. The calibration plot demonstrated good agreement between the predicted and actual probability of minimally invasive interval debulking surgery (p=0.93, Hosmer-Lemeshow test). CONCLUSIONS Our nomogram may serve as a useful tool to choose the surgical approach in patients with advanced ovarian cancer undergoing interval debulking surgery.
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Affiliation(s)
- Carmine Conte
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Andrea Rosati
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Claudia Marchetti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Valentina Iacobelli
- Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lorena Quagliozzi
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Valeria Gallucci
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Salvatore Gueli Alletti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy .,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Anna Fagotti
- Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy.,Dipartimento Scienze della Vita e Sanità Pubblica, Università Cattolica del Sacro Cuore, Roma, Italy
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16
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[Epithelial ovarian cancers and minimally invasive cytoreductive surgery after neoadjuvant chemotherapy: A systematic review]. ACTA ACUST UNITED AC 2021; 49:736-743. [PMID: 33636412 DOI: 10.1016/j.gofs.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Advanced epithelial ovarian cancer (EOC) is associated with high mortality and often managed first with neoadjuvant chemotherapy (NACT) followed by debulking surgery. Laparoscopic surgery with or without robotic assistance (Minimally Invasive Surgery (MIS)) may represent a beneficial option for these patients. The objective of this literature review is to clarify the place of MIS in the management of advanced EOC for selected patients. METHOD Pubmed, Cochrane and Clinicaltrials.gov online databases were used for this review, to select English or French published articles. RESULTS We selected 11 original articles published between 2015 and 2020, 6 of which compared MIS and laparotomy. Among these 11 studies, 8 were retrospective cohorts, 2 were phase II trials, and one was a case-control study. In total, there were 3721 patients, of which 854 (23%) were treated with MIS. The robotic assistance was used with 224 patients (26%) of those MIS patients. Looking specifically at MIS patients, the laparoconversion rate was 9.5%, the rate of complete resection (CC-0) was 83.4%. Finally, the MIS complication rate was 1% intraoperatively and 12% postoperatively. The rate of complete resection, postoperative complication, as well as overall survival (OS) were comparable between patients treated with MIS or laparotomy. One study found an improved disease-free survival (DFS) in MIS versus laparotomy (18 months versus 12 months; P=0.027). CONCLUSION MIS seems feasible, effective, and reliable in comparison to laparotomy for the completion of cytoreductive surgery after NACT without compromising oncological safety. Prospective randomized controlled trials are needed to confirm the role of MIS in advanced EOC.
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Zhang Y, Grant MS, Zhang X, Paraghamian SE, Tan X, Clark LH. Comparing Laparotomy with Robot-assisted Interval Debulking Surgery for Patients with Advanced Epithelial Ovarian Cancer Receiving Neoadjuvant Chemotherapy. J Minim Invasive Gynecol 2020; 28:1237-1243. [PMID: 33248314 DOI: 10.1016/j.jmig.2020.11.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/17/2020] [Indexed: 10/22/2022]
Abstract
STUDY OBJECTIVE Compare survival of patients with advanced epithelial ovarian cancer (EOC) undergoing interval debulking surgery (IDS) with either robot-assisted (R-IDS) or open (O-IDS) approach. Second, we assessed the impact of adjuvant and neoadjuvant chemotherapy (NACT) cycles as independent variables associated with survival in this patient population. DESIGN Retrospective cohort study. SETTING Single tertiary care center. PATIENTS Total of 93 patients diagnosed with advanced EOC who underwent NACT before primary debulking surgery after consultation with a gynecologic oncologist. INTERVENTIONS All patients underwent IDS after completion of NACT with either R-IDS or O-IDS between 2011 and 2018 at a single tertiary care center. Exclusion criteria included receiving fewer than 3 or more than 6 cycles of NACT or having concurrent diagnoses of other malignancies during the treatment period. MEASUREMENTS AND MAIN RESULTS A total of 93 patients were identified (n = 43 R-IDS; n = 50 O-IDS). Median age (63.0 vs 66.2 years) did not differ between the 2 groups (p = .1). Of the total patients, 91% were optimally cytoreduced (57% R0 and 34% R1), and R0 rate was not influenced by surgical modality (52% O-IDS vs 63% R-IDS, p = .4). Progression-free survival (PFS) and overall survival (OS) did not differ between patients undergoing O-IDS and those undergoing R-IDS (PFS 15.4 vs 16.7 months, p = .7; OS 38.2 vs 35.6 months, p = .7). Cytoreduction to R0 improved both PFS and OS independent of surgical approach. Subgroup analysis showed that, specifically in patients undergoing R-IDS, receiving >6 total cycles of chemotherapy was independently associated with both decreased PFS (hazard ratio 3.85; 95% confidence interval, 1.52-9.73) and OS (hazard ratio 3.97; 95% confidence interval, 1.08-14.59). When analyzed separately, neither NACT nor adjuvant cycle numbers had any effect on survival. CONCLUSION In this retrospective study of patients with advanced EOC undergoing IDS after NACT, the use of robot-assisted surgery did not affect debulking success or oncologic survival indices. Receiving >6 total cycles of chemotherapy before IDS was associated with a decrease in both PFS and OS in patients undergoing R-IDS in this cohort and warrants further investigation.
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Affiliation(s)
- Yingao Zhang
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine (Drs. Zhang, Paraghamian, Clark, and Ms. Grant).
| | - Megan S Grant
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine (Drs. Zhang, Paraghamian, Clark, and Ms. Grant)
| | - Xinyi Zhang
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health (Dr. Tan and Ms. Zhang), University of North Carolina, Chapel Hill, North Carolina
| | - Sarah E Paraghamian
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine (Drs. Zhang, Paraghamian, Clark, and Ms. Grant)
| | - Xianming Tan
- Department of Biostatistics, University of North Carolina Gillings School of Global Public Health (Dr. Tan and Ms. Zhang), University of North Carolina, Chapel Hill, North Carolina
| | - Leslie H Clark
- Gynecologic Oncology Division, Department of Obstetrics and Gynecology, University of North Carolina School of Medicine (Drs. Zhang, Paraghamian, Clark, and Ms. Grant)
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Knisely A, Gamble CR, St Clair CM, Hou JY, Khoury-Collado F, Gockley AA, Wright JD, Melamed A. The Role of Minimally Invasive Surgery in the Care of Women with Ovarian Cancer: A Systematic Review and Meta-analysis. J Minim Invasive Gynecol 2020; 28:537-543. [PMID: 33202311 DOI: 10.1016/j.jmig.2020.11.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/10/2020] [Accepted: 11/11/2020] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To synthesize evidence from studies investigating survival outcomes for patients with ovarian cancer undergoing minimally invasive surgery (traditional or robotic laparoscopy) compared with those for patients with ovarian cancer undergoing laparotomy. DATA SOURCES We searched Ovid MEDLINE and Embase (from inception to December 2019). METHODS OF STUDY SELECTION Observational cohort studies and randomized controlled trials that compared risk of recurrence or death between women undergoing minimally invasive and open procedures for staging (10), interval cytoreduction (4), secondary cytoreduction (2), and evaluation of resectability (1) were included. TABULATION, INTEGRATION, AND RESULTS Data on the number of participants, number of deaths and recurrences, and results of analyses of overall or progression-free survival were abstracted for all studies. A random-effects meta-analysis was used to pool the results of studies comparing minimally invasive staging and open staging. The surgical approach (minimally invasive versus open) was not significantly associated with hazard of death or recurrence (pooled hazard ratio 0.92; 95% confidence interval, 0.61-1.38) or all-cause mortality (pooled hazard ratio 0.96; 95% confidence interval, 0.49-1.89). One randomized trial demonstrated that diagnostic laparoscopy could triage patients to neoadjuvant chemotherapy and avoid suboptimal primary surgery, without affecting recurrence-free or overall survival. Most studies included in this review were observational and at high risk for bias, and few studies accounted for potential confounding. CONCLUSION Although existing studies do not demonstrate deleterious survival effects associated with minimally invasive surgery for ovarian cancer, these data must be viewed with caution given the significant methodologic shortcomings in the existing literature.
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Affiliation(s)
- Anne Knisely
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Charlotte R Gamble
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Caryn M St Clair
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - June Y Hou
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Fady Khoury-Collado
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Allison A Gockley
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Jason D Wright
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)
| | - Alexander Melamed
- Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, NewYork-Presbyterian/Columbia University Irving Medical Center, New York, New York (all authors)..
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Morton M, Chambers LM, Costales AB, Chichura A, Gruner M, Horowitz MP, Rose PG, Yao M, Debernardo R, Michener C. Assessing feasibility and perioperative outcomes with minimally invasive surgery compared with laparotomy for interval debulking surgery with hyperthermic intraperitoneal chemotherapy for advanced epithelial ovarian cancer. Gynecol Oncol 2020; 160:45-50. [PMID: 33067001 PMCID: PMC7553874 DOI: 10.1016/j.ygyno.2020.09.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 09/28/2020] [Indexed: 12/12/2022]
Abstract
Objective To determine peri-operative outcomes in women with advanced epithelial ovarian cancer (EOC) undergoing interval debulking surgery (IDS) with hyperthermic intraperitoneal chemotherapy (HIPEC) via minimally invasive interval debulking surgery (MIS) or laparotomy (LAP). Methods A single institution, retrospective cohort study was performed in women with EOC who underwent IDS with HIPEC from 2017 to 2019 via MIS or LAP. Peri-operative outcomes were compared using univariate analysis. Results In total, 50 eligible women were identified; ten (20.0%) underwent MIS + HIPEC and 40 (80.0%) LAP + HIPEC. The median age of patients in the MIS group was 71.1 vs. 64.2 years in LAP (p = 0.031). There was no significant difference in pre-operative complete radiographic response following NACT (p = 0.18). Notably, there was no difference in the rate of R0 resection (70.0% vs. 77.5%; p = 0.39). There was no significant difference in ICU admission, estimated blood loss, operative time, or use of vasopressors between the cohorts. Similarly, there was no difference in 30-day adverse events for MIS vs. LAP, but length of stay was decreased for those who underwent minimally invasive procedures (3 vs. 4 days, p = 0.016). Time to initiation of chemotherapy following surgery was not significantly different between groups (26.2 days vs 32.0 days, p = 0.090). With median follow-up of 15.1 months, there was no difference in recurrence free survival (median 15.0 vs 17.2 months log-rank, p = 0.30) for MIS vs. LAP. Conclusions In this retrospective cohort study, we demonstrate that in women with advanced EOC, HIPEC with MIS at the time of IDS following NACT is feasible. Our institutional experience demonstrates similar rates of R0 cytoreduction, compared to LAP. An MIS approach should not prevent surgeons from utilizing HIPEC where indicated for management of advanced EOC. When comparing MIS and LAP at time of HIPEC, no differences are observed in adverse perioperative outcomes. MIS was associated with shorter hospitalization and with no significant difference in the rate of R0 resections. Patient candidacy for an MIS IDS should not prevent surgeons from utilizing HIPEC in appropriate candidates.
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Affiliation(s)
- Molly Morton
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America.
| | - Laura M Chambers
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Anthony B Costales
- Division of Gynecologic Oncology, Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, 7200 Cambridge Street, Mailstop 660, Houston, TX 77030, United States of America
| | - Anna Chichura
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Morgan Gruner
- Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Max P Horowitz
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Peter G Rose
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Meng Yao
- Department of Quantitative Health Sciences, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Robert Debernardo
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
| | - Chad Michener
- Division of Gynecologic Oncology, Obstetrics, Gynecology and Women's Health Institute, Cleveland Clinic, Desk A81, 9500 Euclid Avenue, Cleveland, OH 44195, United States of America
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Jochum F, Vermel M, Faller E, Boisrame T, Lecointre L, Akladios C. Three and Five-Year Mortality in Ovarian Cancer after Minimally Invasive Compared to Open Surgery: A Systematic Review and Meta-Analysis. J Clin Med 2020; 9:E2507. [PMID: 32759715 PMCID: PMC7463583 DOI: 10.3390/jcm9082507] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/27/2020] [Accepted: 07/30/2020] [Indexed: 12/24/2022] Open
Abstract
As regards ovarian cancer, the use of minimally invasive surgery has steadily increased over the years. Reluctance persists, however, about its oncological outcomes. The main objective of this meta-analysis was to compare the three and five-year mortality of patients operated by minimally invasive surgery (MIS) for ovarian cancer to those operated by conventional open surgery (OPS), as well as their respective perioperative outcomes. PubMed, Cochrane library and CinicalTrials.gov were systematically searched, using the terms laparoscopy, laparoscopic or minimally invasive in combination with ovarian cancer or ovarian carcinoma. We finally included 19 observational studies with a total of 7213 patients. We found no statistically significant difference for five-year (relative risk (RR) = 0.89, 95% CI 0.53-1.49, p = 0.62)) and three-year mortality (RR = 0.95, 95% CI 0.80-1.12, p = 0.52) between the patients undergoing MIS and those operated by OPS. When five and three-year recurrences were analyzed, no statistically significant differences were also observed. Analysis in early and advanced stages subgroups showed no significant difference for survival outcomes, suggesting oncological safety of MIS in all stages. Whether the surgery was primary or interval debulking surgery in advanced ovarian cancer, did not influence the comparative results on mortality or recurrence. Although the available studies are retrospective, and mostly carry a high risk for bias and confounding, an overwhelming consistency of the evidence suggests the likely effectiveness of MIS in selected cases of ovarian cancer, even in advanced stages. To validate the use of MIS, the development of future randomized interventional studies should be a priority.
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Affiliation(s)
| | | | | | | | | | - Cherif Akladios
- Department of Gynecology, Strasbourg University Hospital, 67000 Strasbourg, France; (F.J.); (M.V.); (E.F.); (T.B.); (L.L.)
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Lehman A, Kemp EV, Brown J, Crane EK, Tait DL, Taylor VD, Naumann RW. Pre-emptive Non-narcotic Pain Medication before Minimally Invasive Surgery in Gynecologic Oncology. J Minim Invasive Gynecol 2020; 28:811-816. [PMID: 32730991 DOI: 10.1016/j.jmig.2020.07.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE To review the impact of enhanced recovery after surgery (ERAS) after minimally invasive surgery (MIS) with respect to perioperative narcotics, time in the recovery room, and total time in hospital. DESIGN Retrospective cohort. SETTING Teaching hospital. PATIENTS All patients having MIS in the division of gynecologic oncology during a 20-month period. INTERVENTION MIS cases were compared before and after the implementation of an ERAS protocol that incorporated orally administered acetaminophen, gabapentin, and celecoxib. MEASUREMENT AND MAIN RESULTS A total of 800 MIS cases were performed during the period (77% laparoscopy, 18% robotic, 5% mini-lap). Of these, 449 cases were treated without and 351 with the ERAS protocol. There were no significant differences between the groups with respect to age, BMI, surgery type, smoking, surgical indication, blood loss, or diagnosis. Total narcotic use in milligram intravenous equivalents of morphine (mg IV Eq) was significantly less in the ERAS patients (28.5-mg IV Eq vs 23.6-mg IV Eq; p <.001). There was a trend toward less narcotics in recovery (4.8-mg IV Eq vs 4.1-mg IV Eq; p = .08). Postoperative recovery room time was not different between the groups (129 minutes vs 131 minutes; p = .66). ERAS was associated with a higher rate of same day discharge (38.5% vs 49.0%; p = .003) and a shorter length of hospital stay (22.9 hours vs 18.5 hours; p = .008), with a hazard ratio for discharge of 0.82 (0.71-0.94). However, the same day discharge rate varied widely between treating physicians (20% to 56%). CONCLUSIONS Implementation of an ERAS protocol for MIS appears to reduce total perioperative narcotic use but does not reduce recovery room time. There was a reduction in total hospital time, but this may be dependent on practice patterns of individual physicians.
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Affiliation(s)
- Alanna Lehman
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - Erin V Kemp
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - Jubilee Brown
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - Erin K Crane
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - David L Tait
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - Valerie D Taylor
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors)
| | - R Wendel Naumann
- Levine Cancer Institute, Atrium Health, Charlotte, North Carolina (all authors).
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Robotic-assisted interval cytoreductive surgery in ovarian cancer: a feasibility study. Obstet Gynecol Sci 2020; 63:150-157. [PMID: 32206654 PMCID: PMC7073361 DOI: 10.5468/ogs.2020.63.2.150] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 11/01/2019] [Accepted: 12/11/2019] [Indexed: 01/06/2023] Open
Abstract
Objective The primary objective was to assess the feasibility of robotic-assisted interval cytoreductive surgery for achieving complete cytoreduction for patients with advanced-stage ovarian cancer. The secondary objective was to examine the perioperative outcomes. Methods A retrospective study of 12 patients with stage IIIC or IV ovarian, fallopian tube, and primary peritoneal carcinoma who underwent interval cytoreductive surgery after neo-adjuvant chemotherapy. Results Optimal cytoreduction was achieved in 100% of selected patients. Complete cytoreductive surgery was achieved in 75% of patients. The estimated mean blood loss was 100 mL. The median length of hospital stay was 2 days. Perioperative complication and 30-day readmission rates were 8.3% (1 patient). The median follow-up time was 9.5 months. Conclusion Robotic-assisted interval cytoreductive surgery in ovarian cancer is safe and feasible and may be an alternative to standard laparotomy in selected patients.
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Matsuo K, Klar M, Mandelbaum RS, Matsuzaki S, Matsushima K, Roman LD, Wright JD. Minimally invasive interval debulking surgery after neoadjuvant chemotherapy for metastatic ovarian cancer: a national study in the United States. Arch Gynecol Obstet 2020; 301:863-866. [PMID: 31980874 DOI: 10.1007/s00404-020-05442-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 01/13/2020] [Indexed: 01/25/2023]
Affiliation(s)
- Koji Matsuo
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue IRD520, Los Angeles, CA, 90033, USA. .,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA.
| | - Maximilian Klar
- Department of Obstetrics and Gynecology, University of Freiburg, Freiburg, Germany
| | - Rachel S Mandelbaum
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue IRD520, Los Angeles, CA, 90033, USA
| | - Shinya Matsuzaki
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue IRD520, Los Angeles, CA, 90033, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Southern California, 2020 Zonal Avenue IRD520, Los Angeles, CA, 90033, USA.,Norris Comprehensive Cancer Center, University of Southern California, Los Angeles, CA, USA
| | - Jason D Wright
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York, NY, USA
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24
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Bogani G, Ditto A, Raspagliesi F. Regarding “When Less Is More: Minimally Invasive Surgery Compared to Laparotomy for Interval Debulking after Neoadjuvant Chemotherapy in Women with Advanced Ovarian Cancer”. J Minim Invasive Gynecol 2019; 26:573-574. [DOI: 10.1016/j.jmig.2018.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/08/2018] [Indexed: 10/27/2022]
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