Rectal mobilization for laparoscopic pelvic lymphadenectomy of the lower paracervical pathway in patients with uterine cancer

( Iori Kisu ),( Hidetaka Nomura ),( Miho Iida ),( Kouji Banno ),( Tetsuro Shiraishi ),( Moito Iijima ),( Kayoko Nakamura ),( Kiyoko Matsuda ),( Nobumaru Hirao ) 대한산부인과학회 2021 Obstetrics & Gynecology Science Vol.64 No.6

Objective The pelvic lymphatic drainage system comprises the upper and lower paracervical pathways (LPPs). Lymph node dissection of the LPP, including the cardinal ligament, internal iliac, internal common iliac, and presacral lymph nodes, requires higher surgical skills because of the anatomical limitations of the pelvic cavity and the dissection of vessels while preserving the nerves in the pelvic floor. In this video, we demonstrate rectal mobilization for laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer. Methods Rectal mobilization was performed before complete pelvic lymph node dissection of the LPP. The pararectal space was opened widely and the connective tissue between the presacral fascia and prehypogastric nerve fascia was dissected bilaterally, allowing the rectum to be pulled. Results This procedure created a wide-open space in the pelvic floor, allowing clear visualization of the nerves and lymph nodes of the LPP. Laparoscopic complete lymph node dissection of the LPP was performed in the open space while preserving the hypogastric and pelvic splanchnic nerves and isolating the extensive network of blood vessels in the pelvic cavity. Conclusion Rectal mobilization enabled the safe execution of laparoscopic complete pelvic lymph node dissection of the LPP in patients with uterine cancer.

Clinical significance of systematic retroperitoneal lymphadenectomy during interval debulking surgery in advanced ovarian cancer patients

Haruko Iwase,Toshio Takada,Chiaki Iitsuka,Hidetaka Nomura,Akiko Abe,Tomoko Taniguchi,Ken Takizawa 대한부인종양학회 2015 Journal of Gynecologic Oncology Vol.26 No.4

Objective: To investigate the clinical significance of systematic retroperitoneal lymphadenectomy during interval debulking surgery (IDS) in advanced epithelial ovarian cancer (EOC) patients. Methods: We retrospectively reviewed the medical records of 124 advanced EOC patients and analyzed the details of neoadjuvant chemotherapy (NACT), IDS, postoperative treatment, and prognoses. Results: Following IDS, 98 patients had no gross residual disease (NGRD), 15 had residual disease sized <1 cm (optimal), and 11 had residual disease sized ≥1 cm (suboptimal). Two-year overall survival (OS) and progression-free survival (PFS) rates were 88.8% and 39.8% in the NGRD group, 40.0% and 13.3% in the optimal group (p<0.001 vs. NGRD for both), and 36.3% and 0% in the suboptimal group, respectively. Five-year OS and 2-year PFS rates were 62% and 56.1% in the lymph node-negative (LN–) group and 26.2% and 24.5% in the lymph node-positive (LN+) group (p=0.0033 and p=0.0024 vs. LN–, respectively). Furthermore, survival in the LN+ group, despite surgical removal of positive nodes, was the same as that in the unknown LN status group, in which lymphadenectomy was not performed (p=0.616 and p=0.895, respectively). Multivariate analysis identified gross residual tumor during IDS (hazard ratio, 3.68; 95% confidence interval, 1.31 to 10.33 vs. NGRD) as the only independent predictor of poor OS. Conclusion: NGRD after IDS improved prognosis in advanced EOC patients treated with NACT-IDS. However, while systematic retroperitoneal lymphadenectomy during IDS may predict outcome, it does not confer therapeutic benefits.

Practice patterns of adjuvant therapy for intermediate/high recurrence risk cervical cancer patients in Japan

Yuji Ikeda,Akiko Furusawa,Ryo Kitagawa,Aya Tokinaga,Fuminori Ito,Masayo Ukita,Hidetaka Nomura,Wataru Yamagami,Hiroshi Tanabe,Mikio Mikami,Nobuhiro Takeshima,Nobuo Yaegashi 대한부인종양학회 2016 Journal of Gynecologic Oncology Vol.27 No.3

Objective: Although radiation therapy (RT) and concurrent chemoradiotherapy (CCRT)are the global standards for adjuvant therapy treatment in cervical cancer, many Japaneseinstitutions choose chemotherapy (CT) because of the low frequency of irreversible adverseevents. In this study, we aimed to clarify the trends of adjuvant therapy for intermediate/highriskcervical cancer after radical surgery in Japan. Methods: A questionnaire survey was conducted by the Japanese Gynecologic OncologyGroup to 186 authorized institutions active in the treatment of gynecologic cancer. Results: Responses were obtained from 129 facilities. Adjuvant RT/CCRT and intensitymodulatedRT were performed in 98 (76%) and 23 (18%) institutions, respectively. On theother hand, CT was chosen as an alternative in 93 institutions (72%). The most commonregimen of CT, which was used in 66 institutions (51%), was a combination of cisplatin/carboplatin with paclitaxel. CT was considered an appropriate alternative option to RT/CCRTin patients with risk factors such as bulky tumors, lymph node metastasis, lymphovascularinvasion, parametrial invasion, and stromal invasion. The risk of severe adverse events wasconsidered to be lower for CT than for RT/CCRT in 109 institutions (84%). Conclusion: This survey revealed a variety of policies regarding adjuvant therapy amonginstitutions. A clinical study to assess the efficacy or non-inferiority of adjuvant CT iswarranted.

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.

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.