Should indications for laterally extended endopelvic resection (LEER) exclude patients with sciatica?

Hiroyuki Kanao,Yoichi Aoki,Atsushi Fusegi,Nobuhiro Takeshima 대한부인종양학회 2020 Journal of Gynecologic Oncology Vol.31 No.5

Objective: Previously, indications for laterally extended endopelvic resection (LEER) haveexcluded patients with sciatica because R0 resection has not been deemed possible [1]. Because laparoscopy optimizes visualization and thus provides for meticulous dissection, wehypothesized that R0 resection can be achieved by means of laparoscopic LEER in patientswith sciatica. This video article aimed to clarify the technical feasibility of laparoscopic LEERperformed for laterally recurrent previously irradiated cervical cancer with concomitant sciatica. Methods: We investigated technical feasibility of laparoscopic LEER performed as a salvagetherapy following abdominal radical hysterectomy and concurrent chemoradiotherapy ina patient suffering laterally recurrent cervical carcinoma with concomitant sciatica. Therecurrent tumor involved the right external and internal iliac artery and vein, ileocecum,rectosigmoid colon, right ureter, right obturator nerve, and right sciatic nerve, with aresulting fistula between the tumor and the rectosigmoid colon, and severe sciatica. Resection of all these structures was essential for achievement of R0 status, and suchresection means concomitant femoral bypass with prosthetic graft interposition andgastrointestinal/urinary tract resection. Results: Laparoscopic LEER with femoral-femoral artery bypass could be conductedwithout any postoperative complications. Pathological R0 resection could be achieved, andlocal recurrence could have been controlled. However, the patient died from liver and lungmetastasis at 1 year after this resection surgery. Conclusion: Laparoscopic LEER for a laterally recurrent previously irradiated cervical cancerwith concomitant sciatica was technically feasible, however, further study involving a greaternumber of patients and longer follow-up period is warranted to determine the stringentindications.

Transvaginal cervical tumor-concealing no-look no-touch technique in minimally invasive radical hysterectomy for early-stage cervical cancer: a novel operation technique

Hiroyuki Kanao,Atsushi Fusegi,Makiko Omi,Ariane C. Youssefzadeh,Hidetaka Nomura,Koji Matsuo 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.3

The Laparoscopic Approach to Cervical Cancer (LACC) trial demonstrated that minimally invasive radical hysterectomy was inferior to the open approach [1]; this unexpected result could be attributed to the spillage of cancer cells [2]. Following the LACC trial, laparoscopic radical hysterectomy without an intrauterine manipulator upon completion of a vaginal cuff closure became the new standard treatment method [3]. However, the lack of intrauterine manipulator results in poor visualization and inadequate paracervical tissue resection. This study describes the no-look no-touch technique to address this difficulty. The core procedures in our no-look, no-touch laparoscopic radical hysterectomy are: (Step 1) Creation and closure of a vaginal cuff; (Step 2) Manipulation of the uterus without an intra-uterine manipulator; and (Step 3) Exposure of the paracervical tissues by the suspension technique. The patient eligibility for our procedure is as follows: 1) previously untreated cervical cancer (those who underwent diagnostic conization could be included); 2) clinical stage IA2, IB1, IB2, and IIA1 based on the 2018 International Federation of Gynecology and Obstetrics staging system; 3) histologically confirmed cervical cancer, including squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. The important indication for this procedure is in cases where the tumor is less than 4 cm in diameter. We previously reported that our no-look no-touch technique enables smooth performance of laparoscopic radical hysterectomy without worsening oncologic outcomes [4]. According to a recent systematic review and meta-analysis [5], minimally invasive radical hysterectomy with vaginal cuff closure is a safe treatment option; however, it involves a steep learning curve, which has impeded its increased application. This video will hopefully make minimally invasive radical hysterectomy with protective maneuvers against cancer cell spillage more accessible. Based on our experiences, we propose that our transvaginal cervical tumor-concealing no-look no-touch technique will mitigate the risk of surgical spill of tumor cells during minimally invasive radical hysterectomy. The informed consent for use of this video was taken from the patient.

Reconstruction of the diaphragm with autologous fascia lata during cytoreduction in patients with advanced ovarian cancer

Hiroyuki Kanao,Shiho Tsumura 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.4

Cytoreductive surgery for patients with advanced ovarian cancer often requires full-thickness resection of the diaphragm [1]. In most cases, the diaphragm can be closed directly; however, when the defect is wide and simple closure is difficult, reconstruction using a synthetic mesh is usually performed [2]. However, the use of this type of mesh is contraindicated in the presence of concomitant intestinal resections because of the risk of bacterial contamination [3]. Autologous tissue shows a higher resistance to infection than artificial materials [4]; thus, we introduce diaphragm reconstruction using autologous fascia lata during cytoreduction for advanced ovarian cancer. A patient with advanced ovarian cancer underwent right diaphragmatic full-thickness resection with concomitant resection of the rectosigmoid colon, and complete resection was achieved. The defect of the right diaphragm measured 12×8 cm, and direct closure was impossible. A section of the right fascia lata measuring 10×5 cm was harvested and sutured to the diaphragmatic defect with a 2-0 proline continuous suture. The harvesting of the fascia lata required only 20 minutes, with little blood loss. No intraoperative or postoperative complications were experienced, and adjuvant chemotherapy was initiated without any delay. Diaphragm reconstruction with the fascia lata is a safe and simple method, and we propose this reconstruction technique especially for patients with advanced ovarian cancer who undergo concomitant intestinal resections. The informed consent for use of this video was taken from the patient.

Unexpected result of minimally invasive surgery for cervical cancer

Hiroyuki Kanao,Yoichi Aoki,Nobuhiro Takeshima 대한부인종양학회 2018 Journal of Gynecologic Oncology Vol.29 No.4

.

Laparoscopic resection surgery for malignant transformation of extragonadal endometriosis by the “pincer” approach

Hiroyuki Kanao,Mai Nishimura,Atsushi Murakami 대한부인종양학회 2022 Journal of Gynecologic Oncology Vol.33 No.3

Up to 1% of women with endometriosis develop endometriosis-associated neoplasms [1]. Most endometriosis-associated malignant tumors develop from the ovarian endometriomas, whereas those developing from extragonadal lesions are extremely rare, estimated at 0.2% [2]. Because they are uncommon, a treatment protocol for the malignant transformation of extragonadal endometriosis lesions has not been clearly defined. When the lesion is confined to the site of origin and R0 resection is achieved, the 5-year survival rate is between 82% and 100%; therefore, complete resection should be performed [3]. The patient inthis video had previously undergone hysterectomy, bilateral salpingo-oophorectomy, left nephrectomy, and low-anterior resection of the rectum due to severe endometriosis. Ten years after the surgery, the patient had a 6 cm endometrioid adenocarcinoma developing from the residual endometriosis lesion at the left uterosacral ligament that involved the bladder, left ureter, and rectum. In this case, the tumor was attached to the pelvis due to infiltration of the left sacrospinous ligament. To completely remove the tumor, we used laterally extended endopelvic resection with abdominoperineal resection of the rectum. We used the laparoscopic-perineal-laparoscopic approach (pincer approach) because improved visualization of the left sacrospinous ligament increases the probability of achieving complete resection [4]. Pathological R0 resection was achieved without intraoperative or postoperative complications. Thus, for tumors that are firmly attached to the pelvic floor, the pincer approach can be useful for achieving R0 resection. The informed consent for use of this video was taken from the patient.

Various types of total laparoscopic nerve-sparing radical hysterectomies and their effects on bladder function

Hiroyuki Kanao,Kazuko Fujiwara,Keiko Ebisawa,Tomonori Hada,Yoshiaki Ota,Masaaki Andou 대한부인종양학회 2014 Journal of Gynecologic Oncology Vol.25 No.3

Objective: This study was conducted to ascertain the correlation between preserved pelvic nerve networks and bladder function after laparoscopic nerve-sparing radical hysterectomy. Methods: Between 2009 and 2011, 53 patients underwent total laparoscopic radical hysterectomies. They were categorized into groups A, B, and C based on the status of preserved pelvic nerve networks: complete preservation of the pelvic nerve plexus (group A, 27 cases); partial preservation (group B, 13 cases); and complete sacrifice (group C, 13 cases). To evaluate bladder function, urodynamic studies were conducted preoperatively and postoperatively at 1, 3, 6, and 12 months after surgery. Results: No significant difference in sensory function was found between groups A and B. However, the sensory function of group C was significantly lower than that of the other groups. Group A had significantly better motor function than groups B and C. No significant difference in motor function was found between groups B and C. Results showed that the sensory nerve is distributed predominantly at the dorsal half of the pelvic nerve networks, but the motor nerve is predominantly distributed at the ventral half. Conclusion: Various types of total laparoscopic nerve-sparing radical hysterectomies can be tailored to patients with cervical carcinomas.

Feasibility and outcome of total laparoscopic radical hysterectomy with no-look no-touch technique for FIGO IB1 cervical cancer

Hiroyuki Kanao,Koji Matsuo,Yoichi Aoki,Terumi Tanigawa,Hidetaka Nomura,Sanshiro Okamoto,Nobuhiro Takeshima 대한부인종양학회 2019 Journal of Gynecologic Oncology Vol.30 No.3

Objectives: Intraoperative tumor manipulation and dissemination may possibly compromise survival of women with early-stage cervical cancer who undergo minimally-invasive radical hysterectomy (RH). The objective of the study was to examine survival related to minimallyinvasive RH with a “no-look no-touch” technique for clinical stage IB1 cervical cancer. Methods: This retrospective study compared patients who underwent total laparoscopic radical hysterectomy (TLRH) with no-look no-touch technique (n=80) to those who underwent an abdominal radical hysterectomy (ARH; n=83) for stage IB1 (≤4 cm) cervical cancer. TLRH with no-look no-touch technique incorporates 4 specific measures to prevent tumor spillage: 1) creation of a vaginal cuff, 2) avoidance of a uterine manipulator, 3) minimal handling of the uterine cervix, and 4) bagging of the specimen. Results: Surgical outcomes of TLRH were significantly superior to ARH for operative time (294 vs. 376 minutes), estimated blood loss (185 vs. 500 mL), and length of hospital stay (14 vs. 18 days) (all, p<0.001). Oncologic outcomes were similar between the 2 groups, including disease-free survival (DFS) (p=0.591) and overall survival (p=0.188). When stratified by tumor size (<2 vs. ≥2 cm), DFS was similar between the 2 groups (p=0.897 and p=0.602, respectively). The loco-regional recurrence rate following TLRH was similar to the rate after ARH (6.3% vs. 9.6%, p=0.566). Multiple-pelvic recurrence was observed in only 1 patient in the TLRH group. Conclusion: Our study suggests that the no-look no-touch technique may be a useful surgical procedure to reduce recurrence risk via preventing intraoperative tumor spillage during TLRH for early-stage cervical cancer.

Minimally invasive radical hysterectomy and the importance of avoiding cancer cell spillage for early-stage cervical cancer: a narrative review

Atsushi Fusegi,Hiroyuki Kanao,Shiho Tsumura,Atsushi Murakami,Akiko Abe,Yoichi Aoki,Hidetaka Nomura 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.1

Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons’ skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons’ inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.

Efficacy of intra-abdominal cytoreductive surgery in advanced endometrial cancer with distant metastasis

Motoko Kanno,Mayu Yunokawa,Nozomi Kurihara,Yoichi Aoki,Makiko Omi,Terumi Tanigawa,Hiroyuki Kanao 대한부인종양학회 2023 Journal of Gynecologic Oncology Vol.34 No.6

Objective: The efficacy of intra-abdominal cytoreductive surgery in patients with endometrial cancer and distant metastasis is equivocal. We investigated the effectiveness of such surgical treatment and whether it should be performed before or after chemotherapy (CT). Methods: This study included patients with an International Federation of Gynecology and Obstetrics stage IVB endometrial cancer who received initial treatment at our hospital between January 2006 and December 2017. Results: We retrospectively reviewed 67 patients with stage IVB endometrial cancer with distant metastases and classified them into preceding surgery (PS, n=23), chemotherapy followed by a surgery (CS, n=27), and CT (n=17) groups. We examined the achievement of resection with [R (1)] or without [R (0)] intra-abdominal macroscopic residue and survival. The median survival time for R (0) was 44 (95% confidence interval [CI]=9–not available [NA]) months in the PS group and 27 (95% CI=11–NA) months in the CS group. The median survival time for R (1) was 9 (95% CI=0–24) months in the PS group and 12 (95% CI=7–19) months in the CS group. The similar prognosis in both groups was worse with R (1) than with R (0). The survival curve for R (1) in the resection groups was similar to that of the CT group. Conclusion: Achieving resection without intra-abdominal macroscopic residue for endometrial cancer with distant metastases, whether before or after CT, could extend patients’ survival.