Introduction

Optimal Cytoreduction CCO is the only sure Prognostic marker of good DFS and OS thats avaialble with Gynecological oncologist in advanced Ovarian cancer. But its not what we do in Pelvis alone that matters, but what we do and how we handle upper abdomen and diagpragm and Pontis hepatis and upper abdomen disease that translates to good OS. This video shows systematiclaly the surgical technqiue of Peritonecotmy and upper abdomen Optimal CRS quadrant wise to achieve Optimal CRS with HIPEC

Description

Optimal Cytoreduction CCO is the only sure Prognostic marker of good DFS and OS thats avaialble with Gynecological oncologist in advanced Ovarian cancer. But its not what we do in Pelvis alone that matters, but what we do and how we handle upper abdomen and diagpragm and Pontis hepatis and upper abdomen disease that translates to good OS. This video shows systematiclaly the surgical technqiue of Peritonecotmy and upper abdomen Optimal CRS quadrant wise to achieve Optimal CRS. the Glisson capusulectomy with Diaphragem resection and Mesentric stripping and managing Pontis Hepaticus and Pouch of Douglosectomy and retro grade hystrecotmy. and then HIPEC

Conclusion/Implications

We have done over 500 advanced ultra radiical surgery with HIEPC and 1100 ultra radical upper abdominal CRS without HIEPC and morbidity and and mortlaity is standardisesd aftet learning curve of 70 cases with these technqiue of Ball Point caurgery with 90 setting spray mode and systematic quadrant wise approach to high PCI ca ovarian cases.

this video shares this technqiue in this

Introduction

SLNB is standard of care in Early Breast cancer. Tradationally dual technique, using Radiocolloid and hand held gamma probe and Blue dye is used. Disadvantage is its expensive and cumbersome and need for mandatory dependency on nuclear medicine department is requiree and its not dynamic imaging but static. so Low energy resourse setting countries cannot use it . So hand held ICG flourescence imaging probe and ICG SLNB for breast cancer is cost economical and easy and no need for nuclear medicine department and easy to replicate and dynamic imaging per op LYMPHA surgery to prevent lymphodedmea

Description

SLNB is standard of care in Early Breast cancer. Tradationally dual technique, using Radiocolloid and hand held gamma probe and Blue dye is used. Disadvantage is its expensive and cumbersome and need for mandatory dependency on nuclear medicine department is requiree and its not dynamic imaging but static. so Low energy resourse setting countries cannot use it . So hand held ICG flourescence imaging probe and ICG SLNB for breast cancer is cost economical and easy and no need for nuclear medicine department and easy to replicate and dynamic imaging per op LYMPHA primary LVA surgery using ICG hand held probe to prevent Lymphoedema

Conclusion/Implications

This video shows technique of ICG fluorescence SLNB for breast cancer and primary LVA Lympho venous anastamosis LYMPHA using hand held ICG probe

Introduction

Report regarding single-site laparoscopic radical trachelectomy (RT) is still absent at the present stage, for which the feasibility and safety of this surgery remains a question. We herein introduce the single-site laparoscopic RT without a uterine manipulator for a nulligravida patient with early-stage cervical cancer to preserve fertility without compromising the oncology outcomes.

Description

A 29-year-old woman who was diagnosed with stage IB1 (FIGO 2018) cervical cancer underwent the single-site laparoscopic (RT) plus pelvic lymphadenectomy without the manipulator. We used our expertise with single-site laparoscopic technique to perform space development as much as possible before the ligaments were resected. First, the bilateral round ligaments were sutured to form a coil, and the uterus was suspended by sutures from different directions according to the different operative requirements. Second, prior to colpotomy, a vagino-purse-string suture was formed to avoid spreading of tumor cells. The operative time was 300 minutes, and blood loss was 20 mL. No perioperative complications occurred and the residual cervix and vagina were restored to its original anatomy after 6 months. Postoperative pathological results suggested that the patient did not need radiotherapy or chemotherapy. So far, the surgical scar becomes invisible and the patient has resumed normal menstruation and sexual life.

Conclusion/Implications

Single-site laparoscopic RT plus pelvic lymphadenectomy without the manipulator should be deemed as a safe and feasible therapeutic option for patients with early-stage cervical cancer for fertility preservation. More cases shall be in place to better evaluate the postoperative efficacy and pregnancy outcomes of such procedure to a further step.

Objectives

To evaluate the feasibility of uterine transposition (UT) as a method of preserving ovarian and uterine function after pelvic radiation.

Methods

This was a prospective, non-randomized feasibility study of UT for patients with non-gynecologic pelvic cancers, who require radiation. UT to the upper abdomen was performed 7 to 14 days prior radiation. Frequent clinical examinations and doppler ultrasound were used to evaluate the gonadal vessels vasculature after surgery. The uterus was placed back to the pelvis 2 to 4 weeks after radiation and patients were followed with clinical examinations, pelvic ultrasound and laboratory tests to evaluate hormonal function. Menses were systematically recorded. Cancer treatment and follow-up were performed according to the standard guidelines and no modification were allowed.

Results

From June 2017 to June 2019, eleven patients were selected for the study. Eight patients were submitted to UT (median age of 30.5 yo). There were no transoperatory complications. Cervical stenosis was the most common postoperative complication. One patient had uterine necrosis 4 days after surgery, but the right ovary was preserved and kept normal hormonal function. One patient died from carcinomatosis 4 months after UT. All patients who preserved the uterus have normal hormonal levels, menses and sexual activity after treatment. Two patients have had spontaneous pregnancies, one baby was born at 37 weeks and the other patient is 20 weeks pregnant. One patient tried to get pregnant but did not succeed.

Conclusions

Uterine transposition is a feasible procedure to preserve the uterus and gonadal function. Spontaneous and healthy pregnancy is also possible.

Objectives

We report on a cohort of patients undergoing intrathoracic cytoreduction as part of primary debulking surgery (PDS), assessing safety and survival outcomes.

Methods

We conducted a single center, database review of patients with stage IIIB-IV ovarian carcinoma who underwent intrathoracic cytoreduction as part of PDS at our institution between 01/2001-12/2019. Patients were excluded if they received neoadjuvant chemotherapy.

Results

During the study, 179 patients had intrathoracic surgery as part of PDS. This represents 11% (179/1579) of patients who had a PDS at our institution during this time. Supradiaphragmatic/cardiophrenic lymph nodes were excised in 64% of patients (114/179); mediastinal (not cardiophrenic) nodes 13% (23/179); pleural nodules 7% (12/179); lung parenchyma 1% (2/179), and multiple intrathoracic areas 16% (28/179). Complete gross resection (CGR) was achieved in 73% of patients (127/179), 26% (44/179) had optimal cytoreduction (1-10 mm of residual disease (RD)), and 1% (2/179) underwent suboptimal cytoreduction (>10 mm of RD). Median length of follow-up among survivors was 55 months. Patients with an intrathoracic cytoreduction of carcinoma where CGR was achieved had a median OS of 97 months versus 54 months following an optimal cytoreduction with RD (p = 0.0036). Patients with an intrathoracic cytoreduction where CGR was achieved had a median PFS of 22.1 months versus 14.4 months following an optimal cytoreduction with RD (p = 0.04).

Conclusions

Intrathoracic cytoreduction during PDS for advanced ovarian cancer is safe and feasible. CGR can be obtained in patients with intrathoracic disease if properly selected. Resection of all gross RD including intrathoracic disease significantly improves both PFS and OS.

Introduction

Volume of residual disease following cytoreductive surgery for patients with advanced ovarian, fallopian tube, and peritoneal carcinoma is one of the most important factors for overall survival. Extensive upper abdominal resections was not initially part of the surgical armamentarium of advanced ovarian cancer management for Gynecologic Oncologists. Large-volume upper abdominal tumor involving the diaphragm, liver, and/or spleen was deemed “unresectable,” and the patient was left with suboptimal residual disease. The incorporation of upper abdominal comprehensive surgical techniques has led to a significant improvement in optimal cytoreduction rates, and ultimately improved progression-free and overall survival.

Description

In this film we demonstrate the steps of open abdominal radical debulking surgery for high-grade ovarian carcinoma including a splenectomy, pancreatectomy, and full thickness diaphragm resection with excision of a cardiophrenic lesion. We also demonstrate potential complications as well as strategies to repair and limit these.

Conclusion/Implications

This surgical film demonstrates the feasibility and techniques involved for performing a splenectomy, pancreatectomy, and full thickness diaphragm resection with excision of a cardiophrenic lesion. Additionally, we demonstrate strategies to limit and manage post-operative complications associated with these surgeries. We hope this video will provide physicians with tools to incorporate into their practice in order to improve outcomes for their patients.

Objectives

To assess the oncological safety of uterine manipulators in apparent early-stage (FIGO I-II) endometrial cancer treated by MIS.

Methods

This is a single center retrospective study including patients who underwent endometrial cancer surgery for apparent early stage disease by either laparoscopy, robotics or laparoscopic assisted vaginal hysterectomy from 11-2012 to 12-2020. Data on manipulator type, isolated tumor cells (ITC), cytology, LVSI, free cancer cells in fallopian tubes (floaters), stage, histology and grade were collected. Primary outcome was cancer recurrence. Secondary outcome was disease specific death. Kaplan-Meier curves and multivariate logistic regression were used for statistical analysis.

Results

935 women with early-stage endometrial cancer were included; 794 (85%) had hysterectomy with uterine manipulator and 141 (15%) without, with a mean follow-up of 44,6 months (range 3-118). 84,7% had endometrioid histology, 84,5 % were grade 1 or 2 and 97,2% had stage I disease. Uterine manipulators were not associated with recurrence on univariate (OR 3,178; 95% CI, 0.984-10,261; p=0,0531) and multivariate analysis (OR 2,536; 95% CI 0,770-8,349; p=0,1259) and for disease specific death on both univariate (OR 1,88; 95% CI, 0.436-8,127; p=0,3970) and multivariate analysis (OR 0,770; 95% CI 0,158-3,741; p=0,7455), even when adjusted with adjuvant treatments and tumor characteristics. They were not associated with higher rates of positive cytology, LVSI and ITC. Intra-uterine balloon manipulators were associated with higher risk of floaters (OR 2.47; 95% CI, 1.17-5,23; p=0,0001).

Conclusions

Uterine manipulators in endometrial cancer MIS were not associated with higher recurrence rate and disease specific death in early-stage disease. Prospective trials must confirm our data.

Objectives

This study was to evaluate the role of lymphadenectomy by comparing survival outcomes for patients with clinically early epithelial ovarian cancer (eEOC) who underwent lymphadenectomy versus those who did not.

Methods

We conducted a multicenter retrospective study of patients diagnosed with eEOC by imaging study from 2007 to 2021. Clinicopathological characteristics and oncologic outcomes were compared between the lymphadenectomy group and the no lymphadenectomy group.

Results

In this study, out of 586 clinical eEOC patients, 453 (77.3%) had lymphadenectomy and 133 (22.7%) did not. The upstaging was 4/133 (3.0%) in the no lymphadenectomy group 30/453 (6.6%) in the lymphadenectomy group; the upstaging by lymph node metastasis was 21/453 (4.6%). Compared to the no lymphadenectomy group, the lymphadenectomy group had a longer operating time (P = 0.000), a higher EBL (P = 0.000), and a higher rate of postoperative adverse events (P = 0.004). Among histological subtypes of eEOC, serous carcinoma showed more improved PFS in the lymphadenectomy group compared to no lymphadenectomy group (P = 0.048). There was no difference in PFS in mucinous (P = 0.67), endometrioid (P = 0.41), and clear cell (P = 0.89) carcinomas between the two groups.

Conclusions

This study showed that in patients with clinical eEOC, histological subtype is associated with a survival benefit for lymphadenectomy. In serous carcinoma, lymphadenectomy showed improvement in PFS, but other histological subtypes did not differ significantly. Considering the higher risk of perioperative adverse events in lymphadenectomy, lymphadenectomy in patients with clinically eEOC can be selectively performed according to histological subtype.

Objectives

The OVHIPEC-1 trial demonstrated improved recurrence-free and overall survival with the addition of hyperthermic intraperitoneal chemotherapy (HIPEC) to interval cytoreductive surgery (CRS) in patients with stage III epithelial ovarian cancer (EOC). In 2019, HIPEC for this patient population was implemented in ten Dutch HIPEC-centers. This study aimed to examine the use and early postoperative outcomes of HIPEC in a real-world setting.

Methods

This observational multicenter study used data from the Dutch Gynaecological Oncology Audit including all 668 Dutch patients with stage III EOC who underwent complete or optimal interval CRS between 2019-2021. We examined use of HIPEC and compared early postoperative outcomes with and without HIPEC while accounting for differences in baseline characteristics.

Results

During the study period, HIPEC use increased from 49% to 64%. Uptake varied between geographical regions from 40%-76%. Age, performance status, and result of CRS were associated with HIPEC use (Table 1). Early postoperative outcomes are shown in Table 2. In multivariable logistic regression analysis, HIPEC was associated with a prolonged length of hospital stay (>7 days) (OR 3.9, 95% CI 2.5-5.3, p<0.001) and increased complications (any complication) (OR 1.5, 95% CI 1.0-2.1, p=0.026). However, no effect was seen on incidence of severe complications (Clavien-Dindo ≥grade 3) (OR 0.7, 95% CI 0.3-1.5, p=0.378) and 30-day-mortality.

Conclusions

Use of HIPEC increased substantially in the Netherlands since its introduction in 2019. The effect of HIPEC on early postoperative outcomes in a real-world setting and clinical trial setting are comparable. Future analyses will show whether this also accounts for survival outcomes.

Introduction

The purpose of this study is to introduce robotic radical hysterectomy with tagged uterine suture instead of using a uterine manipulator or vaginal tube.

Description

A total of 4 ports were used; first port was located left at 8cm from umbilicus, second port was 20mm sized at umbilicus, third port was located right at 8cm from umbilicus, and fourth was located right at 8cm from the third port (near the right flank). Uterus was tied with needle-straightened multifilament Vicryl 2-0 and tagged uterus was manipulated by fourth arm of the robot. If additional traction is required, instrument was inserted though the umbilical trocar site.

During operation, the tagged uterus was successfully manipulated and appropriate parametrial space was exposed. Pathologically, all surgical margins were not involved with cancer. No tumor cells were seen in cytologic exam before and after the colpotomy.

Conclusion/Implications

Robotic radical hysterectomy can be easily and safely done with the traction of tagged uterine suture.

Introduction

A 65 year old female with BMI of 35 kg/m² presented with postmenopausal bleeding for 3 months. An endometrial biopsy revealed endometrial sarcoma. Her staging CT scan showed a 6.6cm endometrial mass distending the cavity. There was no lymphadenopathy or distant metastasis. She had a history of open umbilical hernia repair with a large mesh in 2019. In view of sarcoma on the histology, she was counselled for full surgical staging including total hysterectomy, bilateral salpingo-oophorectomy, pelvic lymphadenectomy and omentectomy.

Description

We needed to avoid disruption of the large mesh across the umbilicus during surgical staging of this patient, as well as avoid potential bowel adhesions in the central region. We wanted to perform this using a minimally invasive approach. Therefore, we decided to adopt an “outside-in” approach whereby we performed an extraperitoneal pelvic lymph node dissection first followed by completion hysterectomy bilateral salpingo-oophorectomy and omentectomy via the VNOTES route. The surgery took a total of 206 minutes with an estimated blood loss of 200 mls. The patient recovered well post-operatively with minimal pain and no complications. She was discharged on post-operative Day 3. Final histology revealed Stage 1B low grade adenosarcoma. 14 lymph nodes were harvested with no metastasis. She was recommended for close observation and surveillance.

Conclusion/Implications

This “outside-in” approach is a safe and novel minimally invasive method of surgical staging for gynaecological cancers. It confers an advantage for technically difficult cases, such as multiple previous midline abdominal surgeries and morbid obesity.

Objectives

The objective of this study was to evaluate the efficacy of the three-drug regimen topotecan, paclitaxel, and bevacizumab (TPB) in women with recurrent high-grade neuroendocrine cervical cancer (HGNECC).

Methods

This retrospective cohort study used data from the Neuroendocrine Cervical Tumor Registry (NeCTuR). The study compared women with recurrent HGNECC who received TPB as first- or second-line therapy for recurrence and women with recurrent HGNECC who received chemotherapy but not TPB. Progression-free survival from the start of treatment for recurrence to the next recurrence or death, overall survival from first recurrence, and response rates were evaluated.

Results

The study included 57 patients who received TPB as first- or second-line treatment for recurrence and 48 patients who received chemotherapy but not TPB for recurrence. Median progression-free survival was 8.2 months in the TPBgroup compared to 3.1 months in the non-TPBgroup, with a hazard ratio for progression of 0.23 (95% CI 0.14-0.40; P < 0.0001). In the TPB group, 16% had stable disease, 38% had a partial response, and 16% had a complete response. Significantly more patients in the TPB group than in the non-TPB group remained on treatment at 6 months (67% vs. 25%, P = 0.0002) and 1 year (24% vs. 6%, P = 0.03). Median overall survival was 16.9 months in the TPBgroup compared to 14.0 months in the non-TPB group, with a hazard ratio for death of 0.89 (95% CI 0.55-1.45).

Conclusions

TPB is an active regimen in women with recurrent HGNECC and improves progression-free survival while decreasing the hazard ratio for progression.