Faculty Bibliography

OBJECTIVE: The purpose of this study was to determine the effect of physician gender and specialty on the utilization of hysterectomy and alternatives to hysterectomy. STUDY DESIGN: The database of Empire Blue Cross Blue Shield was abstracted for all claims relating to a hysterectomy procedure or a hysterectomy-associated diagnosis during the 48 consecutive months May 2001-April 2005. Two hundred ninety-five thousand, one hundred forty-eight claim lines were abstracted and analyzed by CPT and diagnostic grouping codes. RESULTS: One thousand nine hundred seventy-two hysterectomies were performed during the time analyzed, as well as 5077 hysterectomy alternatives. These 7049 procedures represented 2.4% of all coded physician encounters. Male physicians utilize hysterectomy and hysterectomy alternatives at the same rate as female physicians. Physicians who practice gynecology-only or gynecologic oncology utilize laparoscopically assisted vaginal hysterectomy more often than their counterparts who practice obstetrics as well as gynecology. CONCLUSION: Gender does not influence the rate of hysterectomy for similar clinical diagnoses. Subspecialty physicians utilize laparoscopic assisted vaginal hysterectomies more frequently than general obstetricians and gynecologists.

BACKGROUND AND OBJECTIVES: To compare intraoperative, pathologic and postoperative outcomes of robotic radical hysterectomy (RRH) to total laparoscopic radical hysterectomy (TLRH) in patients with early stage cervical carcinoma. METHODS: We prospectively analyzed cases of TLRH or RRH with pelvic lymphadenectomy performed for treatment of early cervical cancer between 2000 and 2008. RESULTS: Thirty patients underwent TLRH and pelvic lymphadenectomy for cervical cancer from August 2000 to June 2006. Thirteen patients underwent RRH and pelvic lymphadenectomy for cervical cancer from April 2006 to January 2008. There were no differences between groups for age, tumor histology, stage, lymphovascular space involvement or nodal status. No statistical differences were observed regarding operative time (323 vs 318 min), estimated blood loss (157 vs 200 mL), or hospital stay (2.7 vs 3.8 days). Mean pelvic lymph node count was similar in the two groups (25 vs 31). None of the robotic or laparoscopic procedures required conversion to laparotomy. The differences in major operative and postoperative complications between the two groups were not significant. All patients in both groups are alive and free of disease at the time of last follow up. CONCLUSION: Based on our experience, robotic radical hysterectomy appears to be equivalent to total laparoscopic radical hysterectomy with respect to operative time, blood loss, hospital stay, and oncological outcome. We feel the intuitive nature of the robotic approach, magnification, dexterity, and flexibility combined with significant reduction in surgeon's fatigue offered by the robotic system will allow more surgeons to use a minimally invasive approach to radical hysterectomy.

STUDY OBJECTIVE: To assess the effect of laparoscopic surgery on the survival of women with early-stage endometrial cancer and to analyze the factors that affect survival. DESIGN: Retrospective cohort study (Canadian Task Force classification II-2). SETTING: Tertiary teaching hospital. PATIENTS: Women with clinical stage I and II endometrial cancer (International Federation of Gynecology and Obstetrics staging, 1971) from January 1993 through June 2003. INTERVENTION: Demographic, surgical, perioperative, and pathologic characteristics of women treated with laparoscopy or laparotomy were compared by use of Fisher's exact test or the Student t test. Recurrence-free and overall survival was calculated by use of the Kaplan-Meier method. Stratified analyses were performed with the log-rank test for factors affecting survival (surgical stage, histologic study, and grade). MEASUREMENTS AND MAIN RESULTS: Sixty-seven and 127 women were treated with laparoscopy and laparotomy, respectively. Median follow-up was 36.3 months for the laparoscopy group and 29.6 months for the laparotomy group. The complication rates in the 2 groups were comparable. Women undergoing laparoscopy had shorter hospital stay and less morbidity related to infection. The 2- and 5-year estimated recurrence-free survival rates for the laparoscopy and laparotomy groups (93 % vs 91.7% and 88.5% vs 85%, respectively), as well as the overall 2- and 5-year survival rates (100% vs 99.2% and 100% vs 97%, respectively) were similar. CONCLUSIONS: Laparoscopic surgery in women with early-stage endometrial carcinoma resulted in survival rates similar to laparotomy, although a small sample size precludes definitive conclusions. A larger randomized comparison of the 2 techniques is needed to validate these findings.

PURPOSE OF REVIEW: To review the recent literature regarding modifications of abdominal radical hysterectomy as well as development of new approaches including laparoscopic, vaginal, and robotic radical hysterectomy. RECENT FINDINGS: Nerve-sparing radical hysterectomy technique allows for significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates with absence of abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to a traditional abdominal radical hysterectomy approach that yields comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers and larger series describing successful treatment of cervical cancer with robotic radical hysterectomy are soon to be published. SUMMARY: There are a number of approaches to performing radical hysterectomy. The feasibility and safety of these techniques have been well established. Preliminary oncologic outcome data are encouraging. The decision to utilize newer techniques depends on the patient and type of practice, as well as the surgeon's comfort level with laparoscopy, robotics, or vaginal surgery.

OBJECTIVES: Isothiocyanates (ITC) from broccoli and other cruciferous vegetables have long been shown to have chemopreventive properties, as demonstrated in cancer models in rodents. Sulforaphane (SFN) is a major ITC present in broccoli. We examined the effects of SFN on the growth of the OVCAR-3 and SKOV-3 ovarian carcinoma cell lines. METHODS: Cell cycle phase determination was performed using a Coulter flow cytometer. DNA strand breaks in apoptotic cells were measured by terminal deoxynucleotidyl transferase-mediated biotinylated UTP nick end-labelling (TUNEL). RESULTS: There was a concentration dependent decrease in cell density. Approximately 50% decrease was observed after 48 h of incubation with SFN (2 muM). Analysis of cell cycle phase progression revealed a decrease in the cell populations in S and G2M phases, with an increase of G1 cell population, indicating a G1 cell cycle arrest. The degree of decrease in the replicating population was concentration and time dependent. Incubation of OVCAR-3 cells in cultures with concentrations of 2, 10 and 50 muM of SFN showed 6, 8 and 17% apoptosis, respectively. In addition, when OVCAR-3 cells were exposed to SFN for various time periods (1, 2 or 3 days), the percentage of cells undergoing apoptosis was directly proportional to the incubation period. In this regard, while 18% of the cells underwent apoptosis after 2 days, 42% of the cells showed apoptosis after 3 days of incubation. CONCLUSIONS: These results clearly demonstrated an effect of SFN in inducing growth arrest and apoptosis in ovarian carcinoma cell lines.

OBJECTIVE:To analyze clinicopathologic patterns of early ovarian carcinoma. DESIGN/METHODS:Retrospective chart and histopathology review. SETTING/METHODS:Mount Sinai School of Medicine, New York and the Centre Jean Perrin, Clermont Ferrand, France. PATIENT(S)/METHODS:Seventy-six consecutive cases of Fédération Internationale de Gynécologie et d'Obstétrique stage I ovarian carcinoma. INTERVENTION(S)/METHODS:Surgical staging. MAIN OUTCOME MEASURE(S)/METHODS:Symptomatology, pathology, and histology analysis. RESULT(S)/RESULTS:Twenty-two cases (29%) were serous papillary carcinomas and 54 were nonserous carcinomas (71%) (40 endometrioid, 10 clear cell, and 4 mixed endometrioid and clear cell carcinomas). Ninety-eight percent of ovarian endometriosis, 95% of endometrial carcinomas, and 83% of endometrial polyps and hyperplasias were associated with nonserous carcinomas. Most patients with serous papillary carcinoma presented with asymptomatic pelvic masses; patients with nonserous carcinomas presented with pelvic pain or abnormal vaginal bleeding with or without pelvic mass. CONCLUSION(S)/CONCLUSIONS:Over two thirds of stage I ovarian carcinomas were nonserous, and were diagnosed because of associated symptoms: pelvic pain with endometriosis and/or adnexal masses, or vaginal bleeding from endometrial pathology. Serous papillary carcinomas were often asymptomatic and diagnosed during follow-up evaluations in breast cancer patients. Stage I ovarian carcinoma has different clinical and pathologic patterns than advanced ovarian carcinoma. The risk of ovarian and endometrial malignancy should be taken into consideration during evaluation of patients with endometriosis and breast cancer histories.

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.