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The Adoption of Single-Port Laparoscopic Full Staging for Endometrial Cancer: Safety, Learning Curve and Surgical Outcome
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Figure 1. Overall survival for patients with early stage USC, by surgical approach Log-rank test: p=0.029
was based on surgeon preference. Demographic and clinical data were abstracted and compared by surgical approach including medical history, surgical procedures, postoperative complications, adjuvant therapies and oncologic outcomes. Progression-free survival (PFS) and overall survival (OS) were summarized using Kaplan-Meier methods and compared by surgical approach using log rank tests. Setting: The surgeries were performed at 2 different tertiary care centers by gynecologic oncologists. The fellows and residents participated in the care of all the patients. Patients: A total of 95 patients with Stage I/II USC were included. Intervention: 70 patients (73.7%) underwent surgical staging via a minimally invasive approach (24 laparoscopic, 46 robotic) and 25 patients (26.3%) underwent staging via laparotomy. Measurements and Main Results: Comorbid diseases such as diabetes (p=0.004) and prior malignancy (p=0.032) were more common among those patients who underwent laparotomy. The extent of surgical staging was similar by surgical approach. Twice as many patients who underwent staging via a minimally invasive approach (53.6%) received adjuvant chemotherapy and radiation compared with patients who underwent staging via laparotomy (25.0%, p=0.103). PFS was not statistically significantly different between surgical approaches, though there may be a potential benefit to minimally invasive surgery (p=0.173). There was a statistically significant OS advantage among those who underwent minimally invasive surgery compared to open surgery (p=0.029). Conclusion: Surgical staging via minimally invasive surgical approaches may lead to improved PFS and OS in women with early-stage USC. 124 Feasibility of Robotic Laparoendoscopic Single Site Surgery in the Gynecologic Oncology Setting Moukarzel L, Fader AN, Tanner EJ. Kelly Gynecologic Oncology Service, Johns Hopkins Medical Institutions, Baltimore, Maryland Study Objective: To explore the feasibility of incorporating robotic laparoendoscopic single-site (R-LESS) surgery into gynecologic oncology care. Design: Retrospective case series. Setting: Academic university hospital. Patients: Women undergoing R-LESS hysterectomy for gynecologic malignancies or preinvasive disease by two gynecologic oncologists between 2013 and 2015. Intervention: We incorporated R-LESS as part of standard surgical management for highly selected patients undergoing hysterectomy for common gynecologic oncology indications.
S49
Measurements and Main Results: We identified 23 patients undergoing R-LESS hysterectomy meeting study criteria over a two year period. Indications for hysterectomy included preinvasive disease (9), uterine cancer (7), cervical cancer (3), and hereditary gynecologic cancer risk (4). Mean body mass index was 26.2 (range: 19 - 34) and mean uterine size was 8.3 cm (range: 5.5 - 10.5). Eight patients had prior major abdominal surgery. Twenty patients underwent R-LESS extra-fascial hysterectomy with a mean operative time of 173 minutes (range: 115 - 334). Procedures performed concurrently included bilateral salpingo-oophorectomy (BSO, 16), pelvic sentinel lymph node (SLN) mapping (7), and pelvic lymphadenectomy (1). One patient with endometrial cancer was converted to multiport surgery to complete a pelvic and para-aortic lymphadenectomy due to high risk disease. Three patients underwent R-LESS radical hysterectomy, BSO, SLN mapping and pelvic lymphadenectomy with a mean operative time of 399 minutes (range: 336 - 451). Estimated blood loss was 95 mL (range: 10 - 200). Most patients (91%) were discharged within 24 hours of surgery. Only one patient developed a postoperative complication (small bowel obstruction requiring readmission). Conclusion: In highly selected patients, R-LESS extra-fascial hysterectomy is associated with acceptable operative times and perioperative outcomes. With additional experience, surgeons may be able to offer this approach to patients undergoing increasingly complex procedures, even in the gynecologic oncology setting. 125 The Adoption of Single-Port Laparoscopic Full Staging for Endometrial Cancer: Safety, Learning Curve and Surgical Outcome Barnes H, Spencer R, Uppal S, Rice L, Al-Niaimi A. Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin Study Objective: To report the safety, feasibility, learning curve and surgical outcome for single-port laparoscopic full staging of endometrial cancer. Design: Retrospective review of 53 consecutive cases. Setting: Tertiary-care academic institution with ABOG-accredited gynecologic oncology fellowship. Patients: Patients with endometrial cancer who underwent single-port laparoscopic full staging of endometrial cancer from 3/2012 to 8/2014.
Outcome Conversion
Time (minutes)
Total Multiple Ports Laparotomy Para-aortic LND Pelvic LND Hysterectomy/BSO Total
EBL (mL) Length of Hospital Stay (days) Surgical Site Total Infection (SSI) Superficial SSI Deep SSI Organ Space SSI Readmission Total Medical Surgical Ventral Hernia
Total (n=53)
1st 1/2 2nd 1/2 Cohort Cohort (n=26) (n=27) P-value
2 (3.7%) 1 (1.8%) 1 (1.8%) 66 49 69 184 360 1
1 0 76 59 76 211 620 1
0 1 56 39 62 157 100 1
3 (5.6%) 1
2
1 0 2 5 3 2 1
(1.8%) 0
1
(3.7%) (9.4%) (5.6%) (3.7%) (1.8%)
1 3 2 1 0
1 2 1 1 1
0.03 0.01 NS 0.02 0.001
S50
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Intervention: Single-port laparoscopic staging of endometrial cancer (total hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy with omentectomy when indicated). Measurements and Main Results: Mean age was 63 years (18-76) and mean BMI was 34 kg/m2 (27-46). Medical co-morbidity in 23/53 (43%), and 37/53 (70%) had previous abdominal surgery. Histology included: grade 1 (19%), grade 2 (13%), grade 3 (51%), papillary serous (10%), and clear cell (7%). Post-operatively, 73% of patients were stage I, 2% were stage II, 21% were stage III, and 4% were stage IV. Conversion rate to multiple ports or to laparotomy was 3.7%. Average total surgical time was 184 minutes. Comparing the second half of our cohort (cases 27-53) to the first half, we saw significant improvement in the total operative time (211 vs. 157 minutes p=0.02), specifically to paraaortic lymphadenectomy time (76 vs. 56 minutes p=0.03) and pelvic lymphadenectomy time (59 vs. 39 minutes p=0.01). The estimated blood loss improved from 620 mL to 100 mL (p=0.001). The rate of surgical-site infection was 3/53 (5.6%) and readmission rate was 5/53 (9.4%) with 5.6% for medical indications and 3.7% surgical indications. Rate of ventral hernia was 1/53 (1.8%) with an average of 45 days follow-up (15-387 days). Results: Conclusion: Single-port laparoscopic staging of endometrial cancer is a safe and feasible technique to introduce into a gynecologic oncology practice with similar complication rates, discharge timing, and operative times to other minimally invasive modalities. Drastic improvement in surgical time can be seen after approximately 25 cases. 126 A Retrospective Descriptive Comparison Study of Transvaginal Ultrasound Scan Findings With Histology Findings on Postmenopausal Women Who Underwent Hysteroscopy for Endometrial Assessment Gnanachandran C, Paul W. Gynaecology, University Hospital Coventry & Warwickshire, Coventry, Westmidlands, United Kingdom Study Objective: To improve clinical effectivenss in investigation for postmenopausal bleeding. To evaluate the detection rate of endometrial polyps by transvaginal ultrasound scan in postmenopausal women with abnormal endometrial thickness. To define an endometrial thickness, that helps to identify postmenopausal women with a high risk of having an endometrial polyp. Design: Retrospective descriptive study. Outcomes were compared with histology outcomes. Setting: Postmenopausal women who underwent Hysteroscopy for endometrial assessment. Patients: Population: postmenopausal women who underwent a transvaginal scan followed by hysteroscopy within 28 days of the scan over a two year period (390 cases). Measurements and Main Results: 390 patients were included in the study. The mean age and standard deviation for the women in the dataset are 63.9 and 9.4 years respectively. 143 (37%) women had ultrasound findings suggestive of an endometrial polyp and 140 (36%) had a thickened endometrium but no evidence of an endometrial polyp on USS. The remaining 107 cases (27%) had inconclusive USS findings, and an endometrial polyp could not be neither diagnosed or excluded. When a scan was suggestive of an endometrial polyp in postmenopausal women, the positive predictive value of a polyp in histology was 118/ 143= 82%. Mantel-Haenszel common odds ratio estimate shows that the statistical significance of the risk of having an endometrial polyp is higher when the endometrial thickness is 9mm and above compared to if the endometrial thickness is 8 mm or below. Conclusion: Diagnosis of endometrial polyps or exclusion of endometrial polyps in postmenopausal women by Transvaginal scan alone is not good enough. For a clinically effective pathway or protocol to decide the need of
operative hysteroscopy or hysteroscopy under general anaesthesia, for postmenopausal women, an endometrial thickness of 8 mm cut-off could be used in clinical practise. This finding needs to be studied further in prospective studies. 127 Suspected Vs. Unsuspected Uterine Leiomyosarcoma: Lessons From an Ethnically Diverse Tertiary Care Referral Center Pedroso J,2 Baquing MA,1 Brotherton J.1 1Department of Obstetrics & Gynecology, Harbor-UCLA Medical Center, Torrance, California; 2 Department of Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada Study Objective: The goal of this study is to compare demographic and clinical characteristics of women with suspected vs. non-suspected gynecologic cancer who had a final pathological diagnosis of leiomyosarcoma (LMS). Design: Retrospective Chart Review. Setting: Harbor-UCLA Medical Center, a teaching hospital serving uninsured, largely minority and underserved patients of Los Angeles Country. Patients: All patients who underwent hysterectomy for all reasons, excluding cesarean hysterectomies, (n=967) at Harbor-UCLA Medical Center from March 2009 to July 2013. Intervention: Demographic information, pathologic findings, surgical outcomes, and mortality rates were analyzed and findings compared. Measurements and Main Results: Of these patients 2.4% (24/967) were diagnosed with LMS on final pathology as identified from the tumor registry. 79% (19/24) had known or suspected malignancy, 21% (5/24) were not suspected to have malignancy. A total rate of 0.51% (5/967) of all hysterectomies had unsuspected LMS. None of the patients in our study, including those with unsuspected malignancy underwent a laparoscopic approach (institutional rate of TLH in 2011 was 19%). Preoperative, operative, and postoperative data were analyzed to further delineate differences between suspected and unsuspected malignancies with final pathological diagnosis of LMS. Conclusion: Preoperative risk assessment for uterine LMS remains ill defined. Analysis of the patients at our ethnically diverse tertiary care referral center demonstrate that women with unsuspected LMS may have risk factors that were not previously identified as well as characteristics that precluded a laparoscopic approach to hysterectomy. 128 Uterine Leiomyosarcoma: Experience From an Ethnically Diverse Tertiary Care Referral Center Baquing MA,1 Pedroso J,2 Brotherton J.1 1Department of Obstetrics & Gynecology, Harbor-UCLA Medical Center, Torrance, California; 2 Department of Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada Study Objective: The objective of this study is to determine the incidence of leiomyosarcoma (LMS) during a 5 year period at a tertiary care referral center and the associated demographic and clinical characteristics of the women with this diagnosis. Design: Retrospective Chart Review. Setting: Harbor-UCLA Medical Center, a teaching hospital serving uninsured, largely minority and underserved patients of Los Angeles Country. Patients: All patients who underwent hysterectomy (n=967) with final pathologic diagnosis of LMS (n=31) from the Tumor Registry at HarborUCLA Medical Center from March 2009 - July 2014. Intervention: Demographic and clinical data as well as pathological findings, surgical and survival outcomes were collected and analyzed for patients with diagnosis of LMS on final pathology. Measurements and Main Results: Of the 31 patients with LMS, 77% (24/31) underwent hysterectomy, while 23% (7/31) were diagnosed after alternative procedures. The mean age of patients was 52 (25-69) with a
Figure 1. Overall survival for patients with early stage USC, by surgical approach Log-rank test: p=0.029
was based on surgeon preference. Demographic and clinical data were abstracted and compared by surgical approach including medical history, surgical procedures, postoperative complications, adjuvant therapies and oncologic outcomes. Progression-free survival (PFS) and overall survival (OS) were summarized using Kaplan-Meier methods and compared by surgical approach using log rank tests. Setting: The surgeries were performed at 2 different tertiary care centers by gynecologic oncologists. The fellows and residents participated in the care of all the patients. Patients: A total of 95 patients with Stage I/II USC were included. Intervention: 70 patients (73.7%) underwent surgical staging via a minimally invasive approach (24 laparoscopic, 46 robotic) and 25 patients (26.3%) underwent staging via laparotomy. Measurements and Main Results: Comorbid diseases such as diabetes (p=0.004) and prior malignancy (p=0.032) were more common among those patients who underwent laparotomy. The extent of surgical staging was similar by surgical approach. Twice as many patients who underwent staging via a minimally invasive approach (53.6%) received adjuvant chemotherapy and radiation compared with patients who underwent staging via laparotomy (25.0%, p=0.103). PFS was not statistically significantly different between surgical approaches, though there may be a potential benefit to minimally invasive surgery (p=0.173). There was a statistically significant OS advantage among those who underwent minimally invasive surgery compared to open surgery (p=0.029). Conclusion: Surgical staging via minimally invasive surgical approaches may lead to improved PFS and OS in women with early-stage USC. 124 Feasibility of Robotic Laparoendoscopic Single Site Surgery in the Gynecologic Oncology Setting Moukarzel L, Fader AN, Tanner EJ. Kelly Gynecologic Oncology Service, Johns Hopkins Medical Institutions, Baltimore, Maryland Study Objective: To explore the feasibility of incorporating robotic laparoendoscopic single-site (R-LESS) surgery into gynecologic oncology care. Design: Retrospective case series. Setting: Academic university hospital. Patients: Women undergoing R-LESS hysterectomy for gynecologic malignancies or preinvasive disease by two gynecologic oncologists between 2013 and 2015. Intervention: We incorporated R-LESS as part of standard surgical management for highly selected patients undergoing hysterectomy for common gynecologic oncology indications.
S49
Measurements and Main Results: We identified 23 patients undergoing R-LESS hysterectomy meeting study criteria over a two year period. Indications for hysterectomy included preinvasive disease (9), uterine cancer (7), cervical cancer (3), and hereditary gynecologic cancer risk (4). Mean body mass index was 26.2 (range: 19 - 34) and mean uterine size was 8.3 cm (range: 5.5 - 10.5). Eight patients had prior major abdominal surgery. Twenty patients underwent R-LESS extra-fascial hysterectomy with a mean operative time of 173 minutes (range: 115 - 334). Procedures performed concurrently included bilateral salpingo-oophorectomy (BSO, 16), pelvic sentinel lymph node (SLN) mapping (7), and pelvic lymphadenectomy (1). One patient with endometrial cancer was converted to multiport surgery to complete a pelvic and para-aortic lymphadenectomy due to high risk disease. Three patients underwent R-LESS radical hysterectomy, BSO, SLN mapping and pelvic lymphadenectomy with a mean operative time of 399 minutes (range: 336 - 451). Estimated blood loss was 95 mL (range: 10 - 200). Most patients (91%) were discharged within 24 hours of surgery. Only one patient developed a postoperative complication (small bowel obstruction requiring readmission). Conclusion: In highly selected patients, R-LESS extra-fascial hysterectomy is associated with acceptable operative times and perioperative outcomes. With additional experience, surgeons may be able to offer this approach to patients undergoing increasingly complex procedures, even in the gynecologic oncology setting. 125 The Adoption of Single-Port Laparoscopic Full Staging for Endometrial Cancer: Safety, Learning Curve and Surgical Outcome Barnes H, Spencer R, Uppal S, Rice L, Al-Niaimi A. Obstetrics and Gynecology, University of Wisconsin, Madison, Wisconsin Study Objective: To report the safety, feasibility, learning curve and surgical outcome for single-port laparoscopic full staging of endometrial cancer. Design: Retrospective review of 53 consecutive cases. Setting: Tertiary-care academic institution with ABOG-accredited gynecologic oncology fellowship. Patients: Patients with endometrial cancer who underwent single-port laparoscopic full staging of endometrial cancer from 3/2012 to 8/2014.
Outcome Conversion
Time (minutes)
Total Multiple Ports Laparotomy Para-aortic LND Pelvic LND Hysterectomy/BSO Total
EBL (mL) Length of Hospital Stay (days) Surgical Site Total Infection (SSI) Superficial SSI Deep SSI Organ Space SSI Readmission Total Medical Surgical Ventral Hernia
Total (n=53)
1st 1/2 2nd 1/2 Cohort Cohort (n=26) (n=27) P-value
2 (3.7%) 1 (1.8%) 1 (1.8%) 66 49 69 184 360 1
1 0 76 59 76 211 620 1
0 1 56 39 62 157 100 1
3 (5.6%) 1
2
1 0 2 5 3 2 1
(1.8%) 0
1
(3.7%) (9.4%) (5.6%) (3.7%) (1.8%)
1 3 2 1 0
1 2 1 1 1
0.03 0.01 NS 0.02 0.001
S50
Abstracts / Journal of Minimally Invasive Gynecology 22 (2015) S1–S253
Intervention: Single-port laparoscopic staging of endometrial cancer (total hysterectomy, bilateral salpingo-oophorectomy, and pelvic and para-aortic lymphadenectomy with omentectomy when indicated). Measurements and Main Results: Mean age was 63 years (18-76) and mean BMI was 34 kg/m2 (27-46). Medical co-morbidity in 23/53 (43%), and 37/53 (70%) had previous abdominal surgery. Histology included: grade 1 (19%), grade 2 (13%), grade 3 (51%), papillary serous (10%), and clear cell (7%). Post-operatively, 73% of patients were stage I, 2% were stage II, 21% were stage III, and 4% were stage IV. Conversion rate to multiple ports or to laparotomy was 3.7%. Average total surgical time was 184 minutes. Comparing the second half of our cohort (cases 27-53) to the first half, we saw significant improvement in the total operative time (211 vs. 157 minutes p=0.02), specifically to paraaortic lymphadenectomy time (76 vs. 56 minutes p=0.03) and pelvic lymphadenectomy time (59 vs. 39 minutes p=0.01). The estimated blood loss improved from 620 mL to 100 mL (p=0.001). The rate of surgical-site infection was 3/53 (5.6%) and readmission rate was 5/53 (9.4%) with 5.6% for medical indications and 3.7% surgical indications. Rate of ventral hernia was 1/53 (1.8%) with an average of 45 days follow-up (15-387 days). Results: Conclusion: Single-port laparoscopic staging of endometrial cancer is a safe and feasible technique to introduce into a gynecologic oncology practice with similar complication rates, discharge timing, and operative times to other minimally invasive modalities. Drastic improvement in surgical time can be seen after approximately 25 cases. 126 A Retrospective Descriptive Comparison Study of Transvaginal Ultrasound Scan Findings With Histology Findings on Postmenopausal Women Who Underwent Hysteroscopy for Endometrial Assessment Gnanachandran C, Paul W. Gynaecology, University Hospital Coventry & Warwickshire, Coventry, Westmidlands, United Kingdom Study Objective: To improve clinical effectivenss in investigation for postmenopausal bleeding. To evaluate the detection rate of endometrial polyps by transvaginal ultrasound scan in postmenopausal women with abnormal endometrial thickness. To define an endometrial thickness, that helps to identify postmenopausal women with a high risk of having an endometrial polyp. Design: Retrospective descriptive study. Outcomes were compared with histology outcomes. Setting: Postmenopausal women who underwent Hysteroscopy for endometrial assessment. Patients: Population: postmenopausal women who underwent a transvaginal scan followed by hysteroscopy within 28 days of the scan over a two year period (390 cases). Measurements and Main Results: 390 patients were included in the study. The mean age and standard deviation for the women in the dataset are 63.9 and 9.4 years respectively. 143 (37%) women had ultrasound findings suggestive of an endometrial polyp and 140 (36%) had a thickened endometrium but no evidence of an endometrial polyp on USS. The remaining 107 cases (27%) had inconclusive USS findings, and an endometrial polyp could not be neither diagnosed or excluded. When a scan was suggestive of an endometrial polyp in postmenopausal women, the positive predictive value of a polyp in histology was 118/ 143= 82%. Mantel-Haenszel common odds ratio estimate shows that the statistical significance of the risk of having an endometrial polyp is higher when the endometrial thickness is 9mm and above compared to if the endometrial thickness is 8 mm or below. Conclusion: Diagnosis of endometrial polyps or exclusion of endometrial polyps in postmenopausal women by Transvaginal scan alone is not good enough. For a clinically effective pathway or protocol to decide the need of
operative hysteroscopy or hysteroscopy under general anaesthesia, for postmenopausal women, an endometrial thickness of 8 mm cut-off could be used in clinical practise. This finding needs to be studied further in prospective studies. 127 Suspected Vs. Unsuspected Uterine Leiomyosarcoma: Lessons From an Ethnically Diverse Tertiary Care Referral Center Pedroso J,2 Baquing MA,1 Brotherton J.1 1Department of Obstetrics & Gynecology, Harbor-UCLA Medical Center, Torrance, California; 2 Department of Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada Study Objective: The goal of this study is to compare demographic and clinical characteristics of women with suspected vs. non-suspected gynecologic cancer who had a final pathological diagnosis of leiomyosarcoma (LMS). Design: Retrospective Chart Review. Setting: Harbor-UCLA Medical Center, a teaching hospital serving uninsured, largely minority and underserved patients of Los Angeles Country. Patients: All patients who underwent hysterectomy for all reasons, excluding cesarean hysterectomies, (n=967) at Harbor-UCLA Medical Center from March 2009 to July 2013. Intervention: Demographic information, pathologic findings, surgical outcomes, and mortality rates were analyzed and findings compared. Measurements and Main Results: Of these patients 2.4% (24/967) were diagnosed with LMS on final pathology as identified from the tumor registry. 79% (19/24) had known or suspected malignancy, 21% (5/24) were not suspected to have malignancy. A total rate of 0.51% (5/967) of all hysterectomies had unsuspected LMS. None of the patients in our study, including those with unsuspected malignancy underwent a laparoscopic approach (institutional rate of TLH in 2011 was 19%). Preoperative, operative, and postoperative data were analyzed to further delineate differences between suspected and unsuspected malignancies with final pathological diagnosis of LMS. Conclusion: Preoperative risk assessment for uterine LMS remains ill defined. Analysis of the patients at our ethnically diverse tertiary care referral center demonstrate that women with unsuspected LMS may have risk factors that were not previously identified as well as characteristics that precluded a laparoscopic approach to hysterectomy. 128 Uterine Leiomyosarcoma: Experience From an Ethnically Diverse Tertiary Care Referral Center Baquing MA,1 Pedroso J,2 Brotherton J.1 1Department of Obstetrics & Gynecology, Harbor-UCLA Medical Center, Torrance, California; 2 Department of Obstetrics & Gynecology, Las Vegas Minimally Invasive Surgery, Las Vegas, Nevada Study Objective: The objective of this study is to determine the incidence of leiomyosarcoma (LMS) during a 5 year period at a tertiary care referral center and the associated demographic and clinical characteristics of the women with this diagnosis. Design: Retrospective Chart Review. Setting: Harbor-UCLA Medical Center, a teaching hospital serving uninsured, largely minority and underserved patients of Los Angeles Country. Patients: All patients who underwent hysterectomy (n=967) with final pathologic diagnosis of LMS (n=31) from the Tumor Registry at HarborUCLA Medical Center from March 2009 - July 2014. Intervention: Demographic and clinical data as well as pathological findings, surgical and survival outcomes were collected and analyzed for patients with diagnosis of LMS on final pathology. Measurements and Main Results: Of the 31 patients with LMS, 77% (24/31) underwent hysterectomy, while 23% (7/31) were diagnosed after alternative procedures. The mean age of patients was 52 (25-69) with a