Laparoscopy vs. laparotomy in conservative surgical treatment for severe endometriosis

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Cost and quality-of-life analyses of surgery forearly endometrial cancers laparotomy vs. laparoscopy Spirtos N.M.; SchIaerth J.B.; Gross G.M.; Spirtos T.W.; Schlaerth A.C.; Ballon S.C. z .I. OBSTET. GYNEZOL. 1996 174/6 (1795-1800) Objective: The purpose of this study was to determine whether the cost or quality of life associated with surgical treatment of presumed early-stage endometrial cancer differed on the basis of the surgical approach. Study design: A retrospective analysis was performed on a consecutive series of women with presumed early-stage endometrial cancer treated at the Women’s Cancer Center of Northern California. The senior author was the surgeon, co-surgeon, or assistant on all cases. The women comprise two groups with different surgical approaches. The first group of 17 women underwent exploratory laparotomy, total abdominal hysterectomy, bilateral salpingooophorectomy, and pelvic and aortic lymphadenectomy. The second group of 13 women underwent the same surgery by laparoscopy. The two groups were compared with a two-tailed Student’s t-test. Variables analyzed included age, height, weight, Quetelet Index, and predisposing medical problems. Lymph node counts were compiled. Hospital costs were broken down into four cost categories: (1) operating room; (2) hospital bed; (3) pharmacy; and (4) anesthesia. A two-tailed Student’s t-test was also used in this analysis. Issues examined regarding quality of life included: (1) average hospital stay; (2) complications; and (31 time to return to normal activity. Results: The patient population differed significantly (P < 0.05) with regard to weight and Quetelet Index. The laparotomy group required significantly longer hospitalization than the laparoscopy group (6.3 vs. 2.4 days, P < O.OOl), resulting in higher overall hospital costs ($19 158 vs. $13 988, P < 0.05). Similarly, patients undergoing laparotomy took longer to return to normal activity (5.3 weeks vs. 2.4 weeks, P < 0.0001). Conclusion: Laparoscopic management of endometrial cancer may result in significant cost savings and improved quality of life as demonstrated by shortened hospital stays and an earlier return to normal activity. Laparoscopy vs. laparotomy in conservative surgical treatment for severe endometriosis Crosignani P.G.; Vercellini P.; Biffignandi F.; Costantini W.; Cortesi I.; Imparato E. ITA FERTIL. STERIL. 1996 66/S (706-711) Objective: To determine the outcome of laparoscopy compared with laparotomy in conservative surgical treatment for severe endometriosis. Design: Comparison of non-randomized historical surgical series. Setting: Two teaching hospitals and

of Gynecology

& Obstetrics

56 (1997) 213-223

221

referral centers specializing in reparative and reconstructive surgety. Patient(s): A total of 216 patients operated for severe endometriosis during a S-year period. Intervention(s): Conservative surgical treatment at laparoscopy (n = 67) or laparotomy (n = 149) with median follow-up of 24 months. Main outcome measure(s): Cumulative probability of pregnancy in previously infertile patients (22 in the laparoscopy group and 70 in the laparotomy group) and cumulative probability of pain recurrence in subjects with moderate or severe symptoms before surgery (47 in the laparoscopy group and 108 in the laparotomy group). Result(s): The 24-month cumulative probability of pregnancy according to the Kaplan-Meier method was 44.9% after laparoscopy and 62.7% after laparotomy. The 24-month cumulative probability of symptoms recurrence evaluated with a 0-3-point verbal rating scale was, respectively, 16.4% vs. 20.3% for dysmenorrhea, 33.3% vs. 15.4% for deep dyspareunia, and 25.0% vs. 15.9% for nonmenstrual pain. The corresponding figures obtained with a lo-point linear analogue scale were 20.3% vs. 24.7%, 28.6% vs. 10.4%, and 17.5% vs. 20.1%. No difference is statistically significant. Conclusion(s): Laparoscopy and laparotomy seem equally effective in the treatment of infertility and chronic pelvic pain associated with severe endometriosis. However, a trend was observed toward a higher pregnancy rate and lower dyspareunia recurrence rate after surgery for severe endometriosis performed at laparotomy compared with laparoscopy.

Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy Spirtos N.M.; Schlaerth J.B.; Kimball R.E.; Leiphart V.M.; Ballon S.C.; Figge D.C.; Kaplan P.; Blanchette H.; Schlesinger R.; Adamson G.D. USA AM. J. OBSTET. GYNECOL. 1996 174/6 (176331768) Objective: The purpose of this study was to incorporate a wide range of operative laparoscopic techniques to complete a type III radical hysterectomy with aortic and pelvic lymphadenectomy. Study design: A type III radical hysterectomy with bilateral aortic and pelvic lymph node dissection was separated into eight component parts: (1) right and left aortic lymphadenectomy; (2) right and left pelvic lymphadenectomy; (31 development of the paravesical and pararectal spaces; (41 ureteral dissection; (5) ligation and dissection of the uterine artety; (6) development of the vesicouterine and rectovaginal spaces; (7) resection of the parametria; and (8) resection of the upper vagina. The adequacy of the component parts was determined and documented on video. Results: Complete aortic and pelvic lymphadenectomy and a type III radical hysterectomy were performed by operative laparoscopy. Argon beam coagulation and countertraction facilitated pelvic and aortic lymph node dissection, including removal of nodal tissue lateral to the lilac vessels. Ureteral dissection with resection of the cervicovesical fascia (‘the tunnel’) was completed with right-angle dissectors, vascular clips, and argon-beam coagulation. Resection of the cardinal and ureterosacral liga-