1
|
Capozzi VA, Monfardini L, Maglietta G, Barresi G, De Finis A, Rosati A, Vargiu V, Cosentino F, Sozzi G, Chiantera V, Bogani G, Carnelli M, Scambia G, Fanfani F, Ghi T, Berretta R. Pattern of recurrence in endometrial cancer. The murderer always returns to the scene of the crime. Eur J Surg Oncol 2024; 50:107985. [PMID: 38301532 DOI: 10.1016/j.ejso.2024.107985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/15/2023] [Accepted: 01/25/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Endometrial cancer recurrence occurs in about 18 % of patients. This study aims to analyze the pattern recurrence of endometrial cancer and the relationship between the initial site of primary disease and the relapse site in patients undergoing surgical treatment. METHODS We retrospectively reviewed all surgically treated patients with endometrial cancer selecting those with recurrence. We defined primary site disease as uterus, lymph nodes, or peritoneum according to pathology analysis of the surgical specimen. The site of recurrence was defined as vaginal cuff, lymph nodes, peritoneum, and parenchymatous organs. Our primary endpoint was to correlate the site of initial disease with the site of recurrence. RESULTS The study enrolled 1416 patients. The overall recurrence rate was 17,5 % with 248 relapses included in the study. An increase of 9.9, 5.7, and 5.7 times in the odds of relapse on the lymph node, peritoneum, and abdominal parenchymatous sites respectively was observed in case of nodal initial disease (p < 0.001). A not significant difference in odds was observed in terms of vaginal cuff relapse (OR 0.9) between lymph node ad uterine primary disease (p = 0.78). An increasing OR of 8.7 times for nodal recurrences, 46.6 times for peritoneum, and 23.3 times for parenchymatous abdominal recurrences were found in the case of primary peritoneal disease (p < 0.001). CONCLUSION Endometrial cancer tends to recur at the initial site of the disease. Intraoperative inspection of the adjacent sites of primary disease and targeted instrumental examination of the initial sites of disease during follow-up are strongly recommended.
Collapse
Affiliation(s)
- Vito Andrea Capozzi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| | - Luciano Monfardini
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| | - Giuseppe Maglietta
- Clinical and Epidemiological Research Unit, University Hospital of Parma, 43125, Parma, Italy.
| | - Giuseppe Barresi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| | - Alessandra De Finis
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| | - Andrea Rosati
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Virginia Vargiu
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Cosentino
- Department of Medicine and Health Sciences, University of Molise Studies, Campobasso, Italy; Department of Oncology, Gemelli Molise Spa, Campobasso, Italy
| | - Giulio Sozzi
- Department of Gynecologic Oncology, University of Palermo, 90127, Palermo, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, 90127, Palermo, Italy
| | - Giorgio Bogani
- Department of Gynecologic Oncology, IRCCS National Cancer Institute, Milan, Italy
| | - Marco Carnelli
- Division of Gynecology and Obstetrics, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Giovanni Scambia
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Fanfani
- Department of Woman, Child and Public Health, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Tullio Ghi
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| | - Roberto Berretta
- Department of Medicine and Surgery, University Hospital of Parma, Parma, 43125, Italy
| |
Collapse
|
2
|
Cipres DT, Shim JY, Grimstad FW. Postoperative Vaginal Bleeding Concerns after Gender-Affirming Hysterectomy in Transgender Adolescents and Young Adults on Testosterone. J Pediatr Adolesc Gynecol 2023; 36:33-38. [PMID: 36089115 DOI: 10.1016/j.jpag.2022.09.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 08/05/2022] [Accepted: 09/02/2022] [Indexed: 01/18/2023]
Abstract
STUDY OBJECTIVE This study aimed to characterize the incidence and management of postoperative vaginal bleeding concerns experienced by transgender adolescents and young adults (AYA) on testosterone hormone therapy after gender-affirming hysterectomy (GAH). METHODS This was a retrospective cohort of transgender AYA, 18 years and older, using testosterone therapy who underwent a GAH between July 2020 and September 2021 at a tertiary care children's hospital. The incidence of patient-reported postoperative vaginal bleeding concerns and management of bleeding are described. RESULTS Patient ages ranged between 18 and 33 years. Among 25 patients who met the inclusion criteria, 13 (52.0%) reported vaginal bleeding concerns. No modifiable patient or operative characteristics reached statistical significance in association with postoperative bleeding concerns. Among patients with bleeding concerns, 10 (76.9%) experienced such concerns during the first 2 weeks after surgery, and 6 (46.2%) had resolution of bleeding without intervention. Among 11 patients who underwent an exam for evaluation of bleeding, findings included granulation tissue (n = 5, 45.5%), vaginal atrophy (n = 4, 36.4%), bleeding vessel (n = 1, 9.1%), mucosal separation (n = 1, 9.1%), or no cause of bleeding identified (n = 4, 36.4%). CONCLUSIONS Over half of transgender AYA on testosterone therapy in this cohort reported postoperative vaginal bleeding concerns that were most often secondary to atrophy and granulation tissue, suggesting possible susceptibility to vaginal tissue trauma at the time of GAH and granulation-susceptible healing in patients on testosterone. As vaginal bleeding could worsen gender dysphoria, these findings support the need for patient counseling on postoperative bleeding expectations and identification of interventions to reduce vaginal bleeding after GAH.
Collapse
Affiliation(s)
- Danielle T Cipres
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts.
| | - Jessica Y Shim
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| | - Frances W Grimstad
- Division of Gynecology, Department of Surgery, Boston Children's Hospital, Boston, Massachusetts; Department of Obstetrics, Gynecology, and Reproductive Biology, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
3
|
Ronsini C, Köhler C, De Franciscis P, La Verde M, Mosca L, Solazzo MC, Colacurci N. Laparo-assisted vaginal radical hysterectomy as a safe option for Minimal Invasive Surgery in early stage cervical cancer: A systematic review and meta-analysis. Gynecol Oncol 2022; 166:188-195. [PMID: 35513934 DOI: 10.1016/j.ygyno.2022.04.010] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Revised: 04/05/2022] [Accepted: 04/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery has been debated after the publication of a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC trial). It demonstrated poorer oncological outcomes for Minimal Invasive Surgery in ECC. However, the reasons are still an open debate. Laparo-Assisted Vaginal Hysterectomy (LAVRH) seems to be a logical option to Abdominal Radical Hysterectomy (ARH). This meta-analysis has the aim to prove it. METHODS Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the Pubmed database and Scopus database were systematically searched in January 2022 since early first publications. No limitation of the country was made. Only English article were considered. The studies containing data about Disease-free Survival (DFS) and/or Overall Survival (OS) and/or Recurrence Rate (RcR) were included. RESULTS 19 studies fulfilled inclusion criteria. 9 comparative studies were enrolled in meta-analysis. Patients were analyzed concerning surgical approach (Laparo-Assisted Vaginal Radical Hysterectomy) and compared with ARH Oncological outcomes such as DFS and OS were considered. 3196 patiets were included for the review. Meta-analysis of 1988 0f them highlighted a non-statistic significant difference between LARVH and ARH (RR 0.8 [95% CI 0.55-1.16] p = 0.24; I2 = 0%; p = 0.98). OS was feasible only for 4 studies (RR 0.84 [95% CI 0.23-3.02] p = 0.79; I2 = 0 p = 0.44). Sub-analysis for tumor with a maximum diameter greater than 2 cm was performed. Data about the type of recurrences (loco-regional vs distant) were collected. CONCLUSION LARVH does not appear to affect DFS and OS in ECC patients. The proposed results seem to be comparable with the open approach group of the LACC trial, which today represents the reference standard for the treatment of this pathology. More studies will be needed to test the safety and efficacy of LARVH in the ECC.
Collapse
Affiliation(s)
- Carlo Ronsini
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy.
| | - Christhardt Köhler
- Department of Gynecology, Medical Faculty of the University of Cologne, Koln, Germany; Department of Special Operative and Oncologic Gynecology, Asklepios Klinik Altona, Hamburg, Germany.
| | - Pasquale De Franciscis
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marco La Verde
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Lavinia Mosca
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Maria Cristina Solazzo
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Nicola Colacurci
- Department of Woman, Child and General and Specialized Surgery, University of Campania "Luigi Vanvitelli", Naples, Italy
| |
Collapse
|
4
|
Walton E, Wolner Z, Hammett J. Vaginal cuff pyoderma gangrenosum with associated ureteral stricture: A case report. Urol Case Rep 2021; 39:101826. [PMID: 34522619 PMCID: PMC8424502 DOI: 10.1016/j.eucr.2021.101826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 08/24/2021] [Accepted: 08/26/2021] [Indexed: 11/18/2022] Open
Abstract
Pyoderma gangrenosum is a sterile inflammatory disease of unknown etiology characterized by recurrent cutaneous ulcers. It can occur in extracutaneous locations, especially at operative sites, and has been reported following gynecologic surgery. This report is the first case of pyoderma gangrenosum as a remote complication of pelvic surgery with associated ureteral stricture. It demonstrates the diagnostic challenge of this rare disease and the importance of broadening the differential diagnosis when apparent infections do not respond to treatment to minimize the morbidity of ineffective antibiotic and surgical interventions.
Collapse
Affiliation(s)
- Eric Walton
- Department of Urology, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite B 1400, Atlanta, GA, 30322, USA
| | - Zachary Wolner
- Department of Dermatology, Emory University School of Medicine, 1525 Clifton Rd #3, Atlanta, GA, 30322, USA
| | - Jessica Hammett
- Department of Urology, Emory University School of Medicine, 1365 Clifton Road NE, Building B, Suite B 1400, Atlanta, GA, 30322, USA
| |
Collapse
|
5
|
Miller H, Matsuo K, Roman LD, Yessaian AA, Pham HQ, Hom M, Castaneda A, Pham A, Ragab O, Muderspach L, Ciccone M, Brunette LL. Adjuvant hysterectomy following primary chemoradiation for stage IB2 and IIA2 cervical cancer: a retrospective comparison of complications for open versus minimally invasive surgery. Radiat Oncol 2021; 16:123. [PMID: 34187504 PMCID: PMC8244186 DOI: 10.1186/s13014-021-01843-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 06/15/2021] [Indexed: 11/25/2022] Open
Abstract
Background Adjuvant hysterectomy following chemoradiation for bulky, early stage cervical cancer has been shown to decrease local relapse rate. The objective of this study is to compare complications and recurrences between minimally invasive and open adjuvant hysterectomy for early stage cervical cancer. Methods Patients were identified who had undergone adjuvant hysterectomy following chemoradiation for 2009 FIGO stage IB2 and IIA2 cervical cancer from August 2006 to June 2018. Demographic information, treatment course, complications, recurrence data were retrospectively extracted from the medical record. Frequency of complications was compared with Fisher exact test or chi-square test as appropriate and inverse probability of treatment propensity score weighting was used to calculate the disease-free survival. Results Fifty-four patients met inclusion criteria with a median follow up time of 60.4 months (interquartile range 28.0–98.1 months). There were 24 (44%) open versus 30 (56%) minimally invasive hysterectomies performed. The overall grade 2 or worse complication rate was 43%. There were 8 (27%) patients with complications in the minimally invasive group compared to 4 (17%) in the open group (OR 1.82 (95% CI 0.5–7.0)). There were 9 vaginal cuff defects, dehiscences and/or fistulas in the minimally invasive group compared to 3 in the open group (OR 3.0 (95% CI 0.8–11.2)). There was no statistically significant difference between disease free survival and overall survival among the two groups, however there was a trend towards decreased disease-free survival in the minimally invasive group. Conclusions Among women undergoing adjuvant hysterectomy following chemoradiation for bulky, early stage cervical cancer, there was no difference in complication rates between an open or minimally invasive surgical approach. However, the overall complication rate was high, including a high rate of vaginal cuff defect, dehiscence and/or fistulas. Our findings suggest that an adjuvant hysterectomy should be reserved for patients in which chemoradiation is not anticipated to successfully treat the primary tumor and, if performed, an open approach should be considered.
Collapse
Affiliation(s)
- Heather Miller
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Koji Matsuo
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Lynda D Roman
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Annie A Yessaian
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Huyen Q Pham
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Marianne Hom
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Antonio Castaneda
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Anthony Pham
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, 90033, USA
| | - Omar Ragab
- Department of Radiation Oncology, University of Southern California, Los Angeles, CA, 90033, USA
| | - Laila Muderspach
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Marcia Ciccone
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA
| | - Laurie L Brunette
- Division of Gynecologic Oncology, University of Southern California, 2020 Zonal Ave, IRD 526, Los Angeles, CA, 90033, USA.
| |
Collapse
|
6
|
Dubuisson J, Claver M, Constantin F. [Transvaginal Natural Orifice Transluminal Endoscopic Surgery (vNOTES) for high uterosacral ligament suspension of the vaginal cuff (with video)]. ACTA ACUST UNITED AC 2021; 49:941-942. [PMID: 33640534 DOI: 10.1016/j.gofs.2021.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Indexed: 11/24/2022]
Affiliation(s)
- J Dubuisson
- Service de gynécologie, département de la femme, de l'enfant et de l'adolescent, hôpitaux universitaires de Genève, Genève, Suisse.
| | - M Claver
- Service de gynécologie, département de la femme, de l'enfant et de l'adolescent, hôpitaux universitaires de Genève, Genève, Suisse
| | - F Constantin
- Service de gynécologie, département de la femme, de l'enfant et de l'adolescent, hôpitaux universitaires de Genève, Genève, Suisse
| |
Collapse
|
7
|
Guy CL, Fields EC, Quinn BA, Fisher CM, Ladbury CJ, Romano KD, Todor D. The vaginal cylinder: Misunderstood, misused, or trivial? An in-depth dosimetric and multiinstitutional outcome investigation. Brachytherapy 2019; 18:763-770. [PMID: 31558353 DOI: 10.1016/j.brachy.2019.08.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 08/06/2019] [Accepted: 08/13/2019] [Indexed: 01/30/2023]
Abstract
PURPOSE The purpose of the study was to investigate the impact on dose distribution and radiobiological metrics of common high-dose-rate vaginal brachytherapy treatment parameters and to analyze multiinstitutional data for clinically significant impact on outcomes in early-stage endometrial cancer. METHODS AND MATERIALS Treatment plans were created for all combinations of prescription parameters and used to quantify the dosimetric impact of each parameter and to estimate the dose delivered using common voxel-integrated radiobiological metrics. A rating system, based on risk grouping from GOG and PORTEC trials, was used to consolidate staging information into a cancer "aggressiveness" measure. Correlations between the rating, toxicity, disease recurrence, and plan parameters were investigated. RESULTS When prescribing to 5 mm depth, the variation caused by the diameter was very large across all dose metrics, ranging from 51% to 175% increase with the most divergence in BEDmax. For surface prescription, changing the cylinder diameter from 4 cm to 2 cm caused the dose metrics of BEDmin, Dmin, and gBEUD (a = -3) to increase by 117%, 67%, and 52%, respectively. Prescription to 5-mm depth caused changes across all dose metrics of 260% compared with surface prescription for a 2-cm cylinder. Deeper prescription point (p = 0.005) and longer treatment length (p = 0.01) were correlated with increased stenosis rates. No correlation between recurrence and any plan parameter was found. CONCLUSIONS Dramatic differences in dose distributions arise by small variations of plan parameters, with large impact on rates of vaginal stenosis, but no clear relation with local recurrence. To help radiation oncologists interpret the magnitude of these effects for their patients, we created a tool that allows comparison between dose and fractionation parameters.
Collapse
Affiliation(s)
- Christopher L Guy
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Emma C Fields
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | - Bridget A Quinn
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA
| | | | - Colton J Ladbury
- Department of Radiation Oncology, University of Colorado, Aurora, CO
| | - Kara D Romano
- Department of Radiation Oncology, University of Virginia, Charlottesville, VA
| | - Dorin Todor
- Department of Radiation Oncology, Virginia Commonwealth University, Richmond, VA.
| |
Collapse
|
8
|
Ajao MO, Larsen CR, Manoucheri E, Goggins ER, Rask MT, Cox MKB, Mushinski A, Gu X, Cohen SL, Rudnicki M, Einarsson JI. Two-dimensional (2D) versus three-dimensional (3D) laparoscopy for vaginal cuff closure by surgeons-in-training: a randomized controlled trial. Surg Endosc 2020; 34:1237-43. [PMID: 31172324 DOI: 10.1007/s00464-019-06886-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 05/31/2019] [Indexed: 12/29/2022]
Abstract
BACKGROUND Objective evidence is lacking as to the benefit of the addition of 3D vision to conventional laparoscopy in Gynecologic surgery. This study aims to compare 3-D visual system to traditional 2-D laparoscopic visualization for the laparoscopic closure of the vaginal cuff during total laparoscopic hysterectomy by surgeons-in-training [defined as senior OBGYN resident or Minimally Invasive Gynecologic Surgery (MIGS) fellow]. METHODS 51 patients undergoing total laparoscopic hysterectomy at two tertiary care academic hospitals were randomized to two-dimensional or three-dimensional vision system with cuff closure performed by surgeons-in-training. The primary outcome was the time taken for vaginal cuff closure. Secondary outcomes included peri-operative outcomes and assessment of surgeon's perception of ease of cuff closure. RESULTS 27 (52.9%) cases were allocated to cuff closure with the 2D system and 24 (47.1%) cases to closure with the 3D vision system. Patient baseline characteristics were similar between the vision systems. Mean vaginal cuff closure time was not significantly different between 2D and 3D vision (10.1 min for 2D versus 12 min for 3D, p = 0.31). An additional 24 s was added to cuff closure time with each 1 kg/m2 increase in BMI, after controlling for potential confounders (p = 0.003). There was no difference in the surgeon rating of ease of cuff closure between 2D and 3D. Peri-operative outcomes are similar among the two groups. CONCLUSION We did not demonstrate any benefits of 3D vision system over conventional 2D for the task of laparoscopic vaginal cuff suturing performed by surgeons-in-training. RCT Registration Number NCT02192606 https://clinicaltrials.gov/ct2/show/NCT02192606 (July 17, 2014).
Collapse
|
9
|
Pergialiotis V, Daskalakis G, Thomakos N, Haidopoulos D, Loutradis D, Rodolakis A. Impact of vertical versus horizontal vaginal cuff closure on vaginal length following hysterectomy: a meta-analysis of randomized trials. Int Urogynecol J 2019; 30:1239-1245. [PMID: 30694343 DOI: 10.1007/s00192-019-03881-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2018] [Accepted: 01/14/2019] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Posthysterectomy vaginal length has been previously associated with postoperative sexual dysfunction, but evidence for this in the literature is controversial. The purpose of this meta-analysis was to investigate whether vertical or horizontal closure of the vaginal cuff has a direct effect on posthysterectomy vaginal length and on postoperative sexual dysfunction. METHODS The study was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched Medline, Scopus, Clinicaltrials.gov , EMBASE, Cochrane Central Register of Controlled Trials, and Google Scholar databases. RESULTS Overall, five randomized trials were included in this meta-analysis with 223 patients. The results suggest that horizontal closure of the vaginal cuff results in a shorter vaginal length compared with vertical closure [mean difference (MD) -0.77 cm, 95% confidence interval (CI) -1.12 to -0.43]. Mean vaginal length significantly decreased when the horizontal method was used (MD -0.61 cm, 95% CI -0.97 to -0.24). The subgroup analysis revealed that vertical closure was associated with longer vaginal length only in cases treated with vaginal hysterectomy. Trial sequential analysis revealed that our meta-analysis had adequate power to support these results. Postoperative sexual function was evaluated in only one study; no differences were observed. CONCLUSIONS Findings of our meta-analysis suggest that horizontal closure of the vaginal vault results in shorter vaginal length in vaginal hysterectomies; thus, we suggest that this technique be avoided. Data concerning quality of life of patients and specifically sexual dysfunction remain extremely limited and should be studied in future trials.
Collapse
Affiliation(s)
- Vasilios Pergialiotis
- Laboratory of Experimental Surgery and Surgical Research N.S Christeas, National and Kapodistrian University of Athens, 6, Danaidon str, 15232, Halandri, Greece.
| | - Georgios Daskalakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Nikolaos Thomakos
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Haidopoulos
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Dimitrios Loutradis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Alexandros Rodolakis
- 1st Department of Obstetrics and Gynecology, Alexandra Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
10
|
Abstract
BACKGROUND AND OBJECTIVES Vaginal cuff dehiscence may be a vascular-mediated event, and reports show a higher incidence after robot-assisted total laparoscopic hysterectomy (RATLH), when compared with other surgical routes. This study was conducted to determine the feasibility of using laser angiography to assess vaginal cuff perfusion during RATLH. METHODS This was a pilot feasibility trial incorporating 20 women who underwent RATLH for benign disease. Colpotomy was made with ultrasonic or monopolar instruments, whereas barbed or nonbarbed suture was used for cuff closure. Time of instrument activation during colpotomy was recorded. Images were captured of vaginal cuff perfusion before and after cuff closure. Reviewers evaluated these images and determined areas of adequate cuff perfusion. RESULTS Indocyanine green (ICG) was visible at the vaginal cuff in all participants. Optimal dosage was determined to be 7.5 mg of ICG per intravenous dose. Mean time to appearance for ICG was 18.4 ± 7.3 s (mean ± SD) before closure and 19.0 ± 8.7 s after closure. No significant difference (P = .19) was noted in judged perfusion in open cuffs after colpotomy with a monopolar (48.9 ± 26.0%; mean ± SD) or ultrasonic (40.2 ± 14.1%) device. No difference was seen after cuff closure (P = .36) when a monopolar (70.9 ± 21.1%) or ultrasonic (70.5 ± 20.5%) device was used. The use of barbed (74.1 ± 20.1%) or nonbarbed (66.4 ± 20.9%) sutures did not significantly affect estimated closed cuff perfusion (P = .19). Decreased cuff perfusion was observed with longer instrument activation times in open cuffs (R2 = 0.3175). CONCLUSION Laser angiography during RATLH allows visualization of vascular perfusion of the vaginal cuff. The technology remains limited by the lack of quantifiable fluorescence and knowledge of clinically significant levels of fluorescence.
Collapse
Affiliation(s)
- Benjamin D Beran
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Marie Shockley
- Department of Gynecology and Obstetrics, Gynecologic Specialties, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pamela Frazzini Padilla
- Department of Gynecology, Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Sara Farag
- Department of Gynecology, Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Pedro Escobar
- Department of Obstetrics and Gynecology, Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio, USA
| | - Stephen Zimberg
- Department of Gynecology, Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| | - Michael L Sprague
- Department of Gynecology, Section of Minimally Invasive Gynecologic Surgery, Cleveland Clinic Florida, Weston, Florida, USA
| |
Collapse
|
11
|
Houten JK, Smith S, Schwartz AY. Vaginal Migration of Ventriculoperitoneal Shunt Catheter and Cerebrospinal Fluid Leak as a Complication of Hysterectomy. World Neurosurg 2017; 104:1046.e13-1046.e14. [PMID: 28461282 DOI: 10.1016/j.wneu.2017.04.138] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/19/2017] [Accepted: 04/20/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Ventriculoperitoneal (VP) shunting is a common neurosurgical procedure to treat hydrocephalus that diverts cerebrospinal fluid from the cerebral ventricles to the peritoneal cavity for reabsorption. The distal catheter may potentially migrate through any potential or iatrogenic opening in the peritoneal cavity. Increasingly successfully management of childhood hydrocephalus and adult-onset conditions leading to hydrocephalus, such as subarachnoid hemorrhage, is leading many adult female patients harboring VP shunts needing to undergo hysterectomy. Hysterectomy creates a potential defect though which a VP shunt catheter may migrate. It is not known whether the hysterectomy cuff closure technique may affect the likelihood of distal catheter migration though the repair site. CASE DESCRIPTION We report the case of a 38-year-old woman with a VP shunt who underwent laparoscopic hysterectomy via an open vaginal cuff technique who subsequently presented with vaginal cerebrospinal fluid leakage secondary to migration of the distal shunt catheter through the hysterectomy cuff. CONCLUSIONS Vaginal migration of the distal VP shunt catheter is a possible complication of hysterectomy. The authors postulate that an open cuff hysterectomy closure technique may increase the risk of catheter migration, an issue that may be better understood with further investigation.
Collapse
Affiliation(s)
- John K Houten
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA; Department of Neurosurgery, Hofstra Northwell School of Medicine, Hempstead, New York, USA.
| | - Shiela Smith
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA
| | - Amit Y Schwartz
- Division of Neurosurgery, Maimonides Medical Center, Brooklyn, New York, USA
| |
Collapse
|
12
|
Harkenrider MM, Block AM, Alektiar KM, Gaffney DK, Jones E, Klopp A, Viswanathan AN, Small W. American Brachytherapy Task Group Report: Adjuvant vaginal brachytherapy for early-stage endometrial cancer: A comprehensive review. Brachytherapy 2017; 16:95-108. [PMID: 27260082 PMCID: PMC5612425 DOI: 10.1016/j.brachy.2016.04.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/30/2016] [Accepted: 04/08/2016] [Indexed: 11/29/2022]
Abstract
This article aims to review the risk stratification of endometrial cancer, treatment rationale, outcomes, treatment planning, and treatment recommendations of vaginal brachytherapy (VBT) in the postoperative management of endometrial cancer patients. The authors performed a thorough review of the literature and reference pertinent articles pertaining to the aims of this review. Adjuvant VBT for early-stage endometrial cancer patients results in very low rates of vaginal recurrence (0-3.1%) with low rates of late toxicity which are primarily vaginal in nature. Post-Operative Radiation Therapy in Endometrial Cancer 2 (PORTEC-2) supports that VBT results in noninferior rates of vaginal recurrence compared to external beam radiotherapy for the treatment of high-intermediate risk patients. VBT as a boost after external beam radiotherapy, in combination with chemotherapy, and for high-risk histologies have shown excellent results as well though randomized data do not exist supporting VBT boost. There are many different applicators, dose-fractionation schedules, and treatment planning techniques which all result in favorable clinical outcomes and low rates of toxicity. Recommendations have been published by the American Brachytherapy Society and the American Society of Radiation Oncology to help guide practitioners in the use of VBT. Data support that patients and physicians prefer joint decision making regarding the use of VBT, and patients often desire additional treatment for a marginal benefit in risk of recurrence. Discussions regarding adjuvant therapy for endometrial cancer are best performed in a multidisciplinary setting, and patients should be counseled properly regarding the risks and benefits of adjuvant therapy.
Collapse
MESH Headings
- Adenocarcinoma, Clear Cell/pathology
- Adenocarcinoma, Clear Cell/radiotherapy
- Advisory Committees
- Brachytherapy/methods
- Carcinoma, Endometrioid/pathology
- Carcinoma, Endometrioid/radiotherapy
- Carcinosarcoma/pathology
- Carcinosarcoma/radiotherapy
- Combined Modality Therapy
- Endometrial Neoplasms/pathology
- Endometrial Neoplasms/radiotherapy
- Female
- Humans
- Hysterectomy
- Neoplasm Recurrence, Local
- Neoplasm Staging
- Neoplasms, Cystic, Mucinous, and Serous/pathology
- Neoplasms, Cystic, Mucinous, and Serous/radiotherapy
- Radiotherapy, Adjuvant/methods
- Societies, Medical
- United States
- Vagina
Collapse
Affiliation(s)
- Matthew M Harkenrider
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL.
| | - Alec M Block
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| | - Kaled M Alektiar
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - David K Gaffney
- Department of Radiation Oncology, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT
| | - Ellen Jones
- Department of Radiation Oncology, Lineberger Comprehensive Cancer Center, University of North Carolina School of Medicine, Chapel Hill, NC
| | - Ann Klopp
- Department of Radiation Oncology, MD Anderson Cancer Center, University of Texas, Houston, TX
| | - Akila N Viswanathan
- Department of Radiation Oncology, Brigham & Women's Hospital/Dana-Farber Cancer Institute, Boston, MA
| | - William Small
- Department of Radiation Oncology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL
| |
Collapse
|
13
|
Shin SJ, Chung H, Kwon SH, Cha SD, Cho CH. New suturing technique for robotic-assisted vaginal cuff closure during single-site hysterectomy. J Robot Surg 2016; 11:139-143. [PMID: 27550318 DOI: 10.1007/s11701-016-0629-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Accepted: 07/24/2016] [Indexed: 10/21/2022]
Abstract
To describe a simple and efficient technique for suturing the vaginal cuff in robotic-assisted single-site hysterectomy using barbed suture and a straight needle. Consecutive patients undergoing robotic-assisted single-site hysterectomy from February 2014 to August 2015 at Dong San Hospital, Keimyung University were included. Surgeons used two barbed sutures in a running fashion to close the vaginal cuff. A barbed suture was exclusively used with a straightened needle in upward direction from posterior vaginal cuff to anterior vaginal cuff which played a pivotal role for closure. A total of 100 patients underwent robotic-assisted single-site hysterectomy. The total operation time was 132.5 min and vaginal cuff closure time was 12.0 min. There were no postoperative complications; vaginal cuff dehiscence, vaginal cuff infection, and vaginal bleeding that require surgical intervention or admission. The use of barbed suture with straightened needle to close the vaginal cuff in robotic-assisted single-site hysterectomy is easy to perform and demonstrates safety and efficacy. This technique offers secure, fast, and effective incision closure.
Collapse
Affiliation(s)
- So-Jin Shin
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, 56 Dalseong-Ro, Jung-Ku, Daegu, 41931, Republic of Korea
| | - Hyewon Chung
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, 56 Dalseong-Ro, Jung-Ku, Daegu, 41931, Republic of Korea
| | - Sang-Hoon Kwon
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, 56 Dalseong-Ro, Jung-Ku, Daegu, 41931, Republic of Korea
| | - Soon-Do Cha
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, 56 Dalseong-Ro, Jung-Ku, Daegu, 41931, Republic of Korea
| | - Chi-Heum Cho
- Department of Obstetrics and Gynecology, School of Medicine, Keimyung University, 56 Dalseong-Ro, Jung-Ku, Daegu, 41931, Republic of Korea.
| |
Collapse
|
14
|
Harkenrider MM, Grover S, Erickson BA, Viswanathan AN, Small C, Kliethermes S, Small W Jr. Vaginal brachytherapy for postoperative endometrial cancer: 2014 Survey of the American Brachytherapy Society. Brachytherapy 2016; 15:23-9. [PMID: 26620818 DOI: 10.1016/j.brachy.2015.09.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 09/25/2015] [Accepted: 09/30/2015] [Indexed: 11/23/2022]
Abstract
PURPOSE Report current practice patterns for postoperative endometrial cancer emphasizing vaginal brachytherapy (VBT). METHODS AND MATERIALS A 38-item survey was e-mailed to 1,598 American Brachytherapy Society (ABS) members and 4,329 US radiation oncologists in 2014 totaling 5,710 recipients. Responses of practitioners who had delivered VBT in the previous 12 months were included in the analysis. Responses were tabulated to determine relative frequency distributions. χ(2) analysis was used to compare current results with those from the 2003 ABS survey. RESULTS A total of 331 respondents initiated the VBT survey, of whom 289 (87.3%) administered VBT in the prior 12 months. Lymph node dissection and number of nodes removed influenced treatment decisions for 90.5% and 69.8%, respectively. High-dose-rate was used by 96.2%. The most common vaginal length treated was 4 cm (31.0%). Three-dimensional planning was used by 83.2% with 73.4% of those for the first fraction only. Doses to normal tissues were reported by 79.8%. About half optimized to the location of dose specification and/or normal tissues. As monotherapy, the most common prescriptions were 7 Gy for three fractions to 0.5-cm depth and 6 Gy for five fractions to the surface. As a boost, the most common prescriptions were 5 Gy for three fractions to 0.5-cm depth and 6 Gy for three fractions to the vaginal surface. Optimization points were placed at the apex and lateral vagina by 73.1%. Secondary quality assurance checks were performed by 98.9%. CONCLUSIONS VBT is a common adjuvant therapy for endometrial cancer patients, most commonly with HDR. Fractionation and planning processes are variable but generally align with ABS recommendations.
Collapse
|