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STUDY OBJECTIVE To investigate the factors associated with poorer oncologic outcomes in patients undergoing laparoscopic radical hysterectomy (LRH) for early stage cervical cancer. DESIGN Multicenter retrospective study. SETTING Three gynecologic oncology referral centers. PATIENTS Patients with International Federation of Gynecology and Obstetrics 2009 stage IA (positive lymphovascular space invasion)-IB1 cervical cancer between January 2006 and June 2018. INTERVENTIONS LRH (Piver type II-III hysterectomies). Lymph-node dissection was accomplished according to the tumor characteristics. MEASUREMENTS AND MAIN RESULTS Surgical and oncologic outcomes were analyzed. Overall, 186 patients met the inclusion criteria, 16 (8.6%) experienced a recurrence, and 9 (4.8%) died of the disease (median follow-up period 37.9 months). Surgery-related complications did not influence disease-free survival. All the recurrences (16/16; 100%) occurred in patients with stage IB1 disease (p = .02), and 15 (93.7%) in cases involving tumors ≥2 cm. No association between positive lymph node and recurrence was detected (p =.82). Patients who had a preoperative diagnosis through conization (93; 50%) had a significantly lower rate of recurrence than those who underwent cervical biopsy (93; 50%): 1/93 (1.1%) vs 15/93 (16.1%); p

Background: Primary prevention through vaccination is a prophylactic approach aiming to reduce the risk of developing human papillomavirus (HPV)-related lesions. No mature and long-term data supported the adoption of vaccination in women undergoing conization. Methods: This is a retrospective multi-institutional study. Charts of consecutive patients undergoing conization between 2010 and 2014 were collected. All patients included had at least 5 years of follow-up. We compared outcomes of patients undergoing conization plus vaccination and conization alone. A propensity-score matching algorithm was applied in order to reduce allocation biases. The risk of developing recurrence was estimated using Kaplan-Meir and Cox hazard models. Results: Overall, charts of 1914 women were analyzed. The study group included 116 (6.1%) and 1798 (93.9%) women undergoing conization plus vaccination and conization alone, respectively. Five-year recurrence rate was 1.7% (n = 2) and 5.7% (n = 102) after conization plus vaccination and conization alone, respectively (p = 0.068). After the application of a propensity-score matching, we selected 100 patients undergoing conization plus vaccination and 200 patients undergoing conization alone. The crude number of recurrences was 2 (2%) and 11 (5.5%) for patients undergoing conization plus vaccination and conization alone, respectively (p = 0.231). Vaccination had no impact on persistent lesions (no negative examination between conization and new cervical dysplasia, p = 0.603), but reduced the risk of recurrent disease (patients who had at least one negative examination between conization and the diagnosis of recurrent cervical dysplasia, p = 0.031). Conclusions: Patients having vaccination experience a slightly lower risk of recurrence than women who had not, although not statistically significantly different. Further evidence is needed to assess the cost effectiveness of adopting vaccination in this setting.

Objective Sentinel node mapping (SLNM) has replaced lymphadenectomy for staging surgery in apparent early-stage endometrial cancer (EC). Here, we evaluate long-term survival of three different approaches of nodal assessment in EC. Methods This is a multi-institutional retrospective study evaluating long-term outcomes (at least 3 years) of patients having lymphadenectomy, SLNM followed by lymphadenectomy and SLNM alone. We applied a propensity-matched algorithm. Survival outcomes were assessed using Kaplan-Meier and Cox proportional hazard models Results Applying a propensity score matching algorithm we selected 180 patients having SLNM (90 SLNM vs. 90 SLNM followed by lymphadenectomy). Additionally, a control group of 180 patients having lymphadenectomy was selected. Overall, 10% of patients were diagnosed with positive nodes. Low volume disease was observed in 16 cases (5 micrometastasis and 11 isolated tumor cells). Patients having SLNM followed by lymphadenectomy had a higher possibility to be diagnosed with a stage IIIC disease in comparison to lymphadenectomy alone (p=0.02); while we did not observe a difference in the diagnostic value of SLNM followed by lymphadenectomy and SLNM (p=0.389). Median follow-up time was 69 (7–206) months. There were no statistical differences in terms of disease-free (p=0.570, log-rank test) and overall survival (p=0.911, log-rank test); Similarly, they did not impact on survival outcomes after stratification by low, intermediate and high-risk patients. Conclusions Our study highlighted that SLNM provides similar long-term oncologic outcomes than lymphadenectomy, even in high-risk patients. Further evidence is warranted to assess the prognostic value of low volume disease detected by ultrastaging in patients following SLNM.

Endometrial cancer (EC) is the most common gynecological malignancy in developed countries, and surgery represents the pivotal part of treatment. Hysterectomy and salpingo-oophorectomy allow removing the primary tumor and defining patients at higher risk, who might benefit from adjuvant therapies. Minimally invasive surgery is associated with superior postoperative outcomes and represents a safe and effective approach for surgical staging of EC. The lymph node status evaluation in EC is still a matter of debate. Over the last twenty years much has changed, moving from a full systematic pelvic and paraaortic lymphadenectomy for staging purpose to the removal of the pelvic (with or without paraaortic) lymph nodes only in selected EC classes of risk. Two randomized trials failed to demonstrate survival benefits of lymphadenectomy in case of apparent early stage EC; however, its prognostic role has never been questioned. At present, with the aim of reducing the surgical-related morbidity, sentinel node mapping is emerging as a safe and valid alternative to lymphadenectomy for EC staging, demonstrating high accuracy and an increased detection of lymph nodes metastasis. Here, we performed a review of the most significant studies, which supported the changes in the lymph node status evaluation for EC over the last two decades.

At the beginning of 2020, coronavirus disease 2019 (COVID‐19) spreads worldwide. Patients with ovarian cancer should be considered at high‐risk of developing severe morbidity related to COVID‐19. Most of them are diagnosed in advanced stages of disease, and they are fragile. Here, we evaluated the major impact of COVID‐19 on patients with ovarian cancer, discussing the effect of the outbreak on medical and surgical treatment.

Objective Uterine serous carcinoma (USC) is a rare highly aggressive disease. In the present study, we aimed to investigate the survival implication of the systematic lymphadenectomy in patients who underwent surgery for apparent early-stage USC. Methods Consecutive patients with apparent early-stage USC surgically treated at six Italian referral cancer centers were analyzed. A comparison was made between patients who underwent retroperitoneal staging including at least pelvic lymphadenectomy “LND” vs. those who underwent hysterectomy alone “NO-LND”. Baseline, surgical and oncological outcomes were analyzed. Kaplan- Meier curves were calculated for disease-free survival (DFS) and disease-specific survival (DSS). Associations were evaluated with Cox proportional hazard regression and summarized using hazard ratio (HR). Results One hundred forty patients were analyzed, 106 LND and 34 NO-LND. NO-LND group (compared to LND group) included older patients (median age, 73 vs.67 years) and with higher comorbidities (median Charlson Comorbidity Index, 6 vs. 5) (p

Objective Coronavirus disease 2019 (COVID-19) has caused rapid and drastic changes in cancer management. The Italian Society of Gynecology and Obstetrics (SIGO), and the Multicenter Italian Trials in Ovarian cancer and gynecologic malignancies (MITO) promoted a national survey aiming to evaluate the impact of COVID-19 on clinical activity of gynecologist oncologists and to assess the implementation of containment measures against COVID-19 diffusion. Methods The survey consisted of a self-administered, anonymous, online questionnaire. The survey was sent via email to all the members of the SIGO, and MITO groups on April 7, 2020, and was closed on April 20, 2020. Results Overall, 604 participants completed the questionnaire with a response-rate of 70%. The results of this survey suggest that gynecologic oncology units had set a proactive approach to COVID-19 outbreak. Triage methods were adopted in order to minimize in-hospital diffusion of COVID-19. Only 38% of gynecologic surgeons were concerned about COVID-19 outbreak. Although 73% of the participants stated that COVID-19 has not significantly modified their everyday practice, 21% declared a decrease of the use of laparoscopy in favor of open surgery (19%). However, less than 50% of surgeons adopted specific protection against COVID-19. Additionally, responders suggested to delay cancer treatment (10%-15%), and to perform less radical surgical procedures (20%-25%) during COVID-19 pandemic. Conclusions National guidelines should be implemented to further promote the safety of patients and health care providers. International cooperation is of paramount importance, as heavily affected nations can serve as an example to find out ways to safely preserve clinical activity during the COVID-19 outbreak.

Objective This study aimed to identify predictors of recurrence/persistence of cervical intraepithelial neoplasia grade 2+ (CIN2+) lesion (r-CIN2+) after primary conization. Methods Retrospective analysis involving all consecutive women having conization for CIN2+ between 1998 and 2018. The risk of r-CIN2+ was assessed using Kaplan-Meier and Cox models. Results Data of 3,212 women were retrospectively identified. After a mean follow-up of 47 (±22.2) months, 112 (3.5%) patients developed r-CIN2+. Mean time interval between prior conization and diagnosis of r-CIN2+ was 26.2 (±13.2) months. Via multivariate analysis, presence of high-risk human papillomavirus (HPV) types at the time of CIN2+ diagnosis, hazard ratio (HR)=3.40 (95% confidence interval [CI]=1.66-6.95) for HPV16/18 and HR=2.59 (95% CI=1.21-5.55) for HPV types other than 16/18, positive margins at primary conization, HR=4.11 (95% CI=2.04-8.26) and HPV persistence after conization, HR=16.69 (95% CI=8.20-33.9), correlated with r-CIN2+, independently. Considering age-specific HPV types distribution, we observed that HPV16/18 infection correlated to an increased risk of r-CIN2+ only in young women (aged ≤25 years; p=0.031, log-rank test); while in the older population (>25 years) HPV type(s) involved had not impact on r-CIN2+ risk (p>0.200, log-rank test). Conclusion HPV persistence is the main factor predicting r-CIN2+. Infection from HPV16/18 has a detrimental effect in young women, thus highlighting the need of implementing vaccination against HPV in this population. Further prospective studies are warranted for tailoring clinical decision-making for post-conization follow-up on the basis of risk factors.

Introduction/Background Following the results of LACC trial, laparoscopic treatment for early stage cervical cancer has become matter of debate. In the present investigation we aimed to evaluate predictors of recurrence after laparoscopic surgery for early stage cervical cancer (CC). Methodology A multi-centre retrospective study was conducted among patients who underwent laparoscopic radical surgery for FIGO 2009 stage IA (positive LVSI) - IB1 at three referral gynecologic oncology centers, between January 2006 and June 2018. All patients had radical hysterectomy (B-C1) with or without lymph node dissection according with tumour characteristics. Surgical and oncological outcomes were analysed. Results Among 186 patients who met the inclusion criteria, 16 (8,6%) experienced recurrence (6 vault, 9 pelvis, 5 abdominal, 3 distant, 7 multiple), and 9 (4.8%) died of disease over the follow-up period (median follow-up 38.0 months). Surgical-related complications did not influence survival outcomes. All the recurrences occurred in stage Ib1 disease, which has been found to be the main predictor of recurrence (p=0.02), while no association between positive lymph node and relapse was detected. Patients who had preoperative conization (93, 50%) had a significant lower rate of recurrence compared to those who had biopsy (93, 50%) (1/93, 1,1% vs. 15/93: 16,1% p=0.0003). After stratification by FIGO stage, patients with Ib1 tumor undergoing conization had significant favourable DFS compared to those who had only biopsy (p=0.012). Conclusion Preoperative conization might play a crucial role in patients undergoing laparoscopic treatment for early stage CC. Further studies are warranted to strength our finding. Disclosure Nothing to disclose.

Introduction: In the present study, perioperative outcomes of laparoscopy (LPS) were compared to open surgery (OS) for the treatment of large adnexal masses (AM).Material and methods: Retrospective...

We investigated the correlation between glandular cells (GC) detected at preoperative cervical-smear and the histologic findings and oncologic outcomes in patients undergoing surgery for endometrial cancer (EC). We retrospectively analyzed data of all consecutive EC patients who underwent surgery between January 1, 1990 and December 31, 2012 with preoperative cervical smear performed within 3 mo from the EC diagnosis. Basic descriptive, logistic regression and artificial neural network analyses were used. Five-year disease-free survival and overall survival were assessed using Kaplan-Meier and Cox hazard models. The study included 229 (89%) and 29 (11%) patients with normal cytology (control group) and GC (GC group), respectively. A higher proportion of elderly patients with nonendometrioid and FIGO grade 3 EC was observed in the GC group compared with the control group (P

Objective To investigate survival outcomes in endometrioid endometrial cancer (EEC) patients with single vs. multiple positive pelvic lymph nodes. Methods We performed a retrospective evaluation of all consecutive patients with histologically proven International Federation of Gynecology and Obstetrics (FIGO) stage IIIC1 EEC who underwent primary surgical treatment between 2004 and 2014 at seven Italian gynecologic oncology referral centers. Patients with pre- or intra-operative evidence of extra-uterine disease (including the presence of bulky nodes) and patients with stage IIIC2 disease were excluded, in order to obtain a homogeneous population. Results Overall 140 patients met the inclusion criteria. The presence of >1 metastatic pelvic node was significantly associated with an increased risk of recurrence and mortality, compared to only 1 metastatic node, at both univariate (recurrence: hazard ratio [HR]=2.19; 95% confidence interval [CI]=1.2-3.99; p=0.01; mortality: HR=2.8; 95% CI=1.24-6.29; p=0.01) and multivariable analysis (recurrence: HR=1.91; 95% CI=1.02-3.56; p=0.04; mortality: HR=2.62; 95% CI=1.13-6.05; p=0.02) and it was the only independent predictor of prognosis in this subset of patients. Disease-free survival (DFS) and disease-specific survival (DSS) were significantly longer in patients with only 1 metastatic node compared to those with more than 1 metastatic node (p=0.008 and 0.009, respectively). Conclusion The presence of multiple metastatic nodes in stage IIIC1 EEC represents an independent predictor of worse survival, compared to only one positive node. Our data suggest that EEC patients may be categorized according to the number of positive nodes.

ObjectiveThe objective of this study was to determinate whether the introduction of nerve-sparing (NS) procedure influences surgical and survival outcomes of cervical cancer patients undergoing laparoscopic radical hysterectomy (LRH).MethodsData of consecutive patients undergoing minimally invasive radical with or without NS surgery for cervical cancer were enrolled in the study.ResultsSixty-three patients (66%) who had LRH were compared with 33 women (34%) undergoing NS-LRH. Among the NS group, 19 patients (57.6%) had surgery via minilaparoscopy (using 3-mm instruments). Baseline characteristics were similar between groups. Patients undergoing NS-LRH had shorter operative time (210 vs 257 minutes; P = 0.005) and higher number of pelvic lymph nodes yielded (29 [26–38] vs 22 [8–49]; P < 0.001) than patient in the control group. No differences in blood loss, complications, and parametrial width were observed. Patients were catheterized with an indwelling Foley catheter for a median of 3.5 days (2–7 days) and 5.5 days (4–7 days) in NS and non-NS groups, respectively (P = 0.01). Voiding dysfunctions occurred in 1 patient (3%) and 12 patients (19%) who underwent NS-LRH and standard LRH, respectively (P = 0.03). No differences in 3-year disease-free survival (P = 0.72) and overall survival (P = 0.71) were recorded.ConclusionsThe beneficial effects (in terms of operative time and number of nodes harvested) of NS-LRH are likely determined by the expertise of the surgeon because NS approach was introduced after having acquired adequate background in conventional LRH. Our data show that in experienced hands NS-LRH is safe and feasible. Moreover, NS technique reduces catheterization time and the rate of postoperative urinary dysfunction.

Study Objective To compare the use of low pneumoperitoneum pressure (LPP; 8 mm Hg) vs standard pneumoperitoneum pressure (SPP; 12 mm Hg) during mini-laparoscopic hysterectomy (MLH). Design Randomized controlled trial (Canadian Task Force classification I). Setting Tertiary care center. Patients Forty-two consecutive women scheduled to undergo MLH to treat benign uterine disease. Interventions Women were randomly selected to undergo MLH using LPP (n = 20) or SPP (n = 22). MLH was performed via 3-mm ancillary ports. Measurements and Main Results The primary outcome was to evaluate changes in abdominal and shoulder-tip pain via a 100-mm visual analog scale at 1, 3, and 24 hours postoperatively. All procedures were completed via mini-laparoscopy without the need to increase intra-abdominal pressure or convert to conventional laparoscopy or open surgery. Intraoperatively, 1 episode of severe bradycardia occurred in the LPP group, whereas no intraoperative complications were recorded in the SPP group (p = .47). No postoperative complications were recorded (p > .99). Abdominal pain was similar between groups at each time point. Incidence and intensity of shoulder-tip pain at 1 and 3 hours postoperatively was lower in the LPP group than in the SPP group (p .05). Rescue analgesic requirement did not differ statistically between the LPP and SPP groups (20% vs 41%, respectively; p = .19; odds ratio, 2.7; 95% confidence interval, 0.69–11.08). Conclusion In experienced hands, use of LPP is safe and feasible. During performance of MLH, compared with SPP, LPP is a simple method that offers advantages of less shoulder-tip pain.

ObjectivesThe aim of this study was to analyze perioperative and long-term survival outcomes after either laparoscopic or open abdominal staging for apparent early-stage ovarian cancer.MethodsData of consecutive women with early-stage ovarian cancer undergoing comprehensive laparoscopic staging between 2003 and 2010 were matched with a historical cohort of patients undergoing open surgery. Five-year survival outcomes were analyzed using the Kaplan-Meier method. In addition, a systematic review of the literature and meta-analysis of comparative studies was performedResultsA total of 35 women undergoing staging via laparoscopy were compared with a cohort of 32 patients undergoing open surgery. Baseline characteristics were similar between groups. Spillage occurred in 6 and 4 patients in laparoscopic and open group, respectively (P = 0.59). Patients undergoing laparoscopy experienced longer operative time (P < 0.001), shorter hospital stay (P = 0.03), and lower postoperative complication rate (3% vs 28%; P = 0.005) than patients undergoing staging via open surgery. The median (range) follow-up period was 64 (37–106) and 100 (61–278) months for case and control, respectively (P < 0.001). Five-year disease-free survival (P = 0.12, log-rank test) and overall survival (P = 0.26, log-rank test) were not influenced by surgical approach. Pooled analyses of the literature results corroborate our results suggesting an improvement of perioperative results in the laparoscopic group in comparison with the open abdominal one. In comparison with open surgery, laparoscopy did not influenced spillage (odds ratio [OR], 0.78; 95% confidence interval [CI], 0.35–1.73) and upstaging rate (OR, 0.7; 95% CI, 0.38–1.27). No between-group differences in survival were observed (OR, 0.5; 95% CI, 0.21–1.21).ConclusionsLaparoscopy upholds open surgery in long-term oncologic control, reducing morbidity.

To investigate if low-dose aspirin influences the risk of bleeding and hemorrhagic complications during minimally invasive surgical staging for endometrial cancer.Retrospective study (Canadian Task Force classification II-2.)University teaching hospital.Three hundred seventeen endometrial cancer patients undergoing laparoscopic staging.Laparoscopic surgical staging included total laparoscopic hysterectomy plus bilateral salpingo-oophorectomy ± retroperitoneal staging.Forty-three (14%) low-dose aspirin users were compared with 274 (86%) nonaspirin users. Aspirin-treated patients were older than patients in the control group (71 [range, 50-85] vs. 64 [range, 27-92] years old, p.001). No between-group differences in intraoperative bleeding (p = .32), hemoglobin drop (p = .91), transfusions (p = .09), and hemorrhagic complications rate (p = .58) were recorded. Aspirin users had a lower lymphadenectomy rate in comparison with patients in the control group (p = .001). However, according to a subanalysis of patients undergoing retroperitoneal staging (20 aspirin users vs. 200 patients in the control group), no differences in bleeding (p = .53), hemorrhagic complications (p = 1.0), or transfusion rate (p = .25) were observed.Low-dose aspirin does not influence the risk of bleeding and hemorrhagic complications in endometrial cancer patients undergoing minimally invasive staging. Hence, the choice to continue or cease the use of low-dose aspirin should be guided only by perioperative cardiovascular risk stratification.

ObjectiveThis study was undertaken to evaluate the safety, feasibility, and the long-term effectiveness of laparoscopy in endometrial cancer patients aged 80 years or older.MethodsData of consecutive patients aged 80 years and older undergoing laparoscopic, open abdominal, and vaginal approaches were compared. Postoperative complications were graded per the Accordion Severity Classification. Survival outcomes within the first 5 years were analyzed using the Kaplan-Meier method.ResultsAmong 726 patients, 63 (9%) were aged 80 years and older. Laparoscopic, open abdominal, and vaginal surgery were performed in 22 (35%), 25 (40%), and 16 (25%) cases, respectively. All laparoscopic procedures were completed laparoscopically, whereas a conversion from vaginal to open procedure occurred (0% vs 6%; P = 0.42). Patients undergoing laparoscopy experienced similar operative time (P > 0.05), lower blood loss (P < 0.05), and shorter hospital stay (P < 0.05) than patients undergoing open and vaginal surgery. No intraoperative complications were recorded. Laparoscopy is related to a lower rate of postoperative complications (P = 0.09) and Accordion grade greater than or equal to 2 complications (P = 0.05) in comparison to open abdominal and vaginal surgery. The route of surgical approaches did not influence the 5-year disease-free (P = 0.97, log-rank test) and overall (P = 0.94, log-rank test) survivals.ConclusionsLaparoscopy seems to represent a safe and effective treatment of endometrial cancer in women aged 80 years or older. Our data suggest that in elderly women, laparoscopic surgery improves perioperative outcomes compared with open and vaginal approaches without compromising long-term survival.

To compare perioperative and long-term outcomes related to laparoscopic and open abdominal surgical management of cervical cancer.Propensity-matched comparison of prospectively collected data (Canadian Task Force classification II-1).University teaching hospital.Sixty-five propensity-matched patient pairs (130 patients) undergoing either laparoscopy or open abdominal surgical procedures to treat cervical cancer.Radical hysterectomy plus lymphadenectomy was performed via the laparoscopic (LRH) or open abdominal approach (RAH).Baseline characteristics of the study populations were similar. In the LRH group the procedure was converted to open surgery in 2 patients (2%). Compared with the RAH group, patients undergoing LRH experienced less blood loss (200 vs 500 mL; p.001), a lower transfusion rate (6% vs 22%; p = .02), similar operative time (245 vs 259.5 minutes; p = .26), and shorter length of hospital stay (4 vs 8 days; p.001). No between-group differences in intraoperative complications were recorded (p = 1.0); however, a trend toward a lower postoperative complication rate (Accordion system grade ≥ 3) was observed for LRH compared with RAH (4 patients [6%]) vs 12 patients [18%]; p = .06). Five-year disease-free survival (p = .6, log-rank test) and overall survival (p = .31, log-rank test) did not differ statistically between women undergoing LRH or RAH.Laparoscopy ensures the same results as open surgery insofar as radicality and long-term survival. Use of the laparoscopic approach is associated with improved short-term results, minimizing the occurrence of severe postoperative complications.

Objective To evaluate perioperative details, long-term outcomes, and postsurgical fertility in case of laparoscopic ureterolysis for deep endometriosis. Design Retrospective analysis of prospectively collected data. Setting Academic research center. Patient(s) One hundred nine consecutive women who underwent laparoscopic ureterolysis for deep endometriosis. Intervention(s) Laparoscopic excision of ureteral endometriosis (ureteral shaving was attempted in all cases). Main Outcome Measure(s) Perioperative details, long-term outcomes, fertility rates, and need for secondary surgery, stratifying on presence/absence of hydronephrosis. Predictors of longer operative time, pain recurrence, and fertility were also investigated. Result(s) No conversion to open surgery was necessary. Intraoperative ureteral injury occurred in one case (0.9%). Nine women (8.3%) underwent ureteral stenting. Eight cases (7.3%) of mild postoperative complications were registered; no case of severe complications or postoperative ureteral fistula occurred. An increase was observed in the risk of short-/long-term adverse outcomes, according to the grade of preoperative hydronephrosis. Of the 80 women with available follow-up data, secondary ureteral procedures were necessary in 5 women (6.3%), whereas 22 patients (27.5%) had recurrence of endometriosis symptoms. Among the 36 women who wished to conceive, a total of 26 pregnancies were registered in 20 women (55.6%). The miscarriage rate was 15.6%. Hydronephrosis grade ≥2 was independently associated with longer operative time and higher rate of symptoms recurrence. Adjuvant hormonal therapy after ureterolysis was the only independent factor associated with lower fertility rates. Conclusion(s) Laparoscopic ureterolysis is a safe procedure, with encouraging pregnancy rates and satisfactory long-term results. However, hydronephrosis grade ≥2 is associated with worse outcomes.