Faculty Bibliography

To determine whether total laparoscopic radical hysterectomy (TLRH) is a feasible alternative to an abdominal radical hysterectomy (ARH) in a gynecologic oncology fellowship training program. We prospectively collected cases of all of the patients with cervical cancer treated with TLRH and pelvic lymphadenectomy by our division from 2000 to 2006. All of the patients from the TLRH group were matched 1:1 with the patients who had ARH during the same period based on stage, age, histological subtype, and nodal status. Thirty patients were treated with TLRH with a mean age of 48.3 years (range, 29-78 years). The mean pelvic lymph node count was 31 (range, 10-61) in the TLRH group versus 21.8 (range, 8-42) (P < 0.01) in the ARH group. Mean estimated blood loss was 200 cc (range, 100-600 cc) in the TLRH with no transfusions compared to 520 cc in the ARH group (P < 0.01), in which five patients required transfusions. Mean operating time was 318.5 min (range, 200-464 min) compared to 242.5 min in the ARH group (P < 0.01), and mean hospital stay was 3.8 days (range, 2-11 days) compared to 5.6 days in the ARH group (P < 0.01). All TLRH cases were completed laparoscopically. All patients in the TLRH group are disease free at the time of this report. In conclusion, it is feasible to incorporate TLRH training into the surgical curriculum of gynecologic oncology fellows without increasing perioperative morbidity. Standardization of TLRH technique and consistent guidance by experienced faculty is imperative.

Serous cystadenoma arising from ovarian remnant has not been reported in the literature. We report 3 cases with ovarian remnant syndrome that were treated with laparoscopic excision and were proven to be benign serous neoplasia with ovarian origin on final pathologic examination. We review the current evidence for malignant transformation potential of ovarian serous cystadenoma and discuss laparoscopic techniques for management of ovarian remnant syndrome.

We report a case of primary vaginal leiomyosarcoma occurring in a patient with a unicornuate uterus and pelvic kidney. The patient was treated with radical partial vaginectomy, unilateral groin dissection, total laparoscopic hysterectomy, and left pelvic laparoscopic lymphadenectomy, followed by adjuvant chemotherapy. Twenty-five months after her original procedure, the patient is alive and free of disease. The exact association between mullerian anomalies and primary malignancies of the genitourinary tract is unclear. It is nonetheless important to be aware of the close embryonic association between the genital and urinary tracts when evaluating such patients and choosing the appropriate surgical and therapeutic approach.

BACKGROUND:Endometrial cancer recurrences in the vagina after surgery and radiation therapy are traditionally treated with pelvic exenteration. However, this operation is associated with significant morbidity and mortality, and thus alternative surgical options should be explored. CASE/METHODS:We present a case of laparoscopic resection of recurrent endometrial cancer at the vaginal apex in the setting of prior brachytherapy and 32P intraperitoneal therapy. CONCLUSION/CONCLUSIONS:Laparoscopic radical parametrectomy and partial vaginectomy may be an option for patients with small central recurrences of endometrial cancer.

OBJECTIVES/OBJECTIVE:We compared the perioperative morbidity of laparoscopic hysterectomy for gynecologic oncologic (group A) and benign gynecologic (group B) indications at a single institution. METHODS:This is a retrospective analysis of 159 consecutive cases of laparoscopic hysterectomy at a tertiary care university hospital. It includes 74 women with gynecologic cancers and 85 women with benign gynecologic conditions. RESULTS:Patients in group A were significantly older and had higher body mass index (P < or = 0.001). The differences in mean blood loss (A, 201.1 mL; B, 183.6 mL, P=0.504), conversion to laparotomy (2 for each group), and wound infection (none) were not significant in the 2 groups. The mean operating time (253.2 and 188.2 minutes, P<0.001) and the mean length of hospital stay (3.5 days and 2.5 days, P<0.001) were significantly longer in group A. Transfusion was required for 2 patients in group A and 4 in group B. One intraoperative injury to the bladder occurred in group A. CONCLUSIONS:In spite of older age and longer operative time in cancer patients, there was no difference in perioperative complications associated with laparoscopic hysterectomy for gynecologic malignancies compared with benign gynecologic conditions.

BACKGROUND:Laparoscopic surgery has revolutionized the concept of minimally invasive surgery for the last 3 decades. Robotic-assisted surgery is one of the latest innovations in the field of minimally invasive surgery. Already, many procedures have been performed in urology, cardiac surgery, and general surgery. In this article, we attempt to report our preliminary experience with robotic-assisted laparoscopy in a variety of gynecological surgeries. We sought to evaluate the role of robotic-assisted laparoscopy in gynecological surgeries. METHODS:The study was a case series of 15 patients who underwent various gynecologic surgeries for combined laparoscopic and robotic-assisted laparoscopic surgery. The da Vinci robot was used in each case at a tertiary referral center for laparoscopic gynecologic surgery. An umbilicus, suprapubic, and 2 lateral ports were inserted. These surgeries were performed both using laparoscopic and robotic-assisted laparoscopic techniques. The assembly and disassembly time to switch from laparoscopy to robotic-assisted surgery was measured. Subjective advantages and disadvantages of using robotic-assisted laparoscopy in gynecological surgeries were evaluated. RESULTS:Fifteen patients underwent a variety of gynecologic surgeries, such as myomectomies, treatment of endometriosis, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, and Moskowitz procedure. The assembly time to switch from laparoscopy to robotic-assisted surgery was 18.9 minutes (range, 14 to 27), and the disassembly time was 2.1 minutes (range, 1 to 3). Robotic-assisted laparoscopy acts as a bridge between laparoscopy and laparotomy but has the disadvantage of being costly and bulky. CONCLUSION/CONCLUSIONS:Robotic-assisted laparoscopic surgeries have advantages in providing a 3-dimensional visualization of the operative field, decreasing fatigue and tension tremor of the surgeon, and added wrist motion for improved dexterity and greater surgical precision. The disadvantages include enormous cost and added operating time for assembly and disassembly and the bulkiness of the equipment.

Vaginal clear cell adenocarcinoma arising from pelvic endometriosis has not been reported in the literature. We report a case of a 50-year-old woman with stage I clear cell adenocarcinoma of the vagina who was found to have endometriosis adjacent to the vaginal tumor. She was treated with neoadjuvant chemoradiation, laparoscopically assisted radical vaginal hysterectomy, radical upper vaginectomy, and pelvic lymphadenectomy followed by combination chemotherapy.

OBJECTIVE:We evaluated the role of MRI as a preoperative diagnostic tool for leiomyoma and adenomyosis. METHOD/METHODS:This is a retrospective chart review at a university-based hospital. The study included 1517 women who underwent hysterectomy or myomectomy over a 5-year period, and 153 women with a preoperative pelvic MRI were included. Comparisons were made between the results of the MRI and postoperative pathology reports. RESULTS:The MRI and pathology report were the same for 136 of 144 women with leiomyoma and 12 of 31 women with adenomyosis. The MRI had 94% sensitivity and 33% specificity for leiomyoma and 38% sensitivity and 91% specificity for adenomyosis. Positive and negative predictive values of MRI for leiomyoma were 95% and 27% with 90% accuracy. Positive and negative predictive values of MRI for adenomyosis were 52% and 85%, respectively, with 80% accuracy. CONCLUSION/CONCLUSIONS:MRI has a high sensitivity and a low specificity for diagnosing leiomyoma and a high specificity and a low sensitivity for diagnosing adenomyosis. Due to the high cost and technical variations, we suggest using MRI only as an adjunctive diagnostic tool when ultrasound is not conclusive and differentiation between the 2 pathologies ultimately affects patient management.

OBJECTIVE:To critically examine the possible association between ovulation-inducing drugs and ovarian cancer. DESIGN/METHODS:Medline literature review and cross-reference of published data. RESULTS(S)/RESULTS:The studies that have adjusted for the effects of confounding factors such as duration of oral contraceptive use and number of pregnancies have noted an increased risk of ovarian cancer among infertile women who remain childless despite long periods of unprotected intercourse. Whether such women are at risk due to the primary basis for their infertility or factors such as ovulation-inducing drugs, has been the subject of several studies. Overall, the findings on ovarian cancer (especially invasive epithelial and non-epithelial) risk associated with fertility drug treatment are reassuring. However, a stronger association between fertility drug use and borderline tumors of the ovary has been observed. CONCLUSION(S)/CONCLUSIONS:Despite the overall reassuring findings of the available studies, there is a need for well-designed clinical trials to understand the possible carcinogenic effects of the ovulation-inducing drugs.