title: Laparoscopic extrafascial hysterectomy (completion surgery) after primary chemoradiation in patients with locally advanced cervical cancer: technical aspects and operative outcomes.
abstract: OBJECTIVE
  This study aimed to evaluate the feasibility and safety of laparoscopic extrafascial hysterectomy and bilateral salpingo-oophorectomy after primary chemoradiation (CRT) in patients with locally advanced cervical cancer (LACC) without evidence of nodal metastasis.
  
  
  BACKGROUND
  Currently, the standard of care for patients with advanced cervical cancer is concurrent CRT. There is an unequivocal correlation between presence of residual disease and risk of local relapse. Nevertheless, the importance of hysterectomy in adjuvant setting remains controversial.
  
  
  METHODS
  Prospective study with patients affected by bulky LACC (International Federation of Gynecology and Obstetrics stage IB2 up to IIB) treated initially with radical CRT who underwent laparoscopic surgery 12 weeks after therapy conclusion. Inclusion criteria were absence of signs for extrapelvic or nodal involvement on initial imaging staging, as well as complete clinical and radiologic response.
  
  
  RESULTS
  From January 2011 to March 2013, 33 patients were endoscopically operated. The mean age was 44 years (range, 21-77 years). Histologic finding revealed squamous cell carcinoma in 19 (60%) cases and adenocarcinoma in 14 (40%) cases. International Federation of Gynecology and Obstetrics stages distribution were as follow: 1B2, n = 3 (9%); IIA, n = 4 (11%); and IIB, n = 26 (80%). The mean pretherapeutic tumor size was 5.2 cm (range, 4-10.2 cm). Estimated blood loss was 80 mL (range, 40-150 mL), and mean operative time was approximately 104 minutes (range, 75-130 minutes). No casualty or conversion to laparotomy occurred. Hospital stay was in average 1.7 days (range, 1-4 days). Significant complication occurred in 12% of the cases; 2 vaginal vault dehiscence, 1 pelvic infection, and 1 ureterovaginal fistula. Nine (27%) patients had pathologic residual disease, and in 78% of these cases, histologic finding was adenocarcinoma (P = -0.048). All patients had free margins. After median follow-up of 16 months, all women have no signs of local recurrence.
  
  
  CONCLUSIONS
  Laparoscopic extrafascial hysterectomy (completion surgery) after primary CRT in patients with apparent node-negative LACC is a feasible and safe strategy to improve tumor local control mainly in cases of adenocarcinoma.
authors: Departments of *Gynecology, †Medical Oncology, ‡Radiotherapy, and §Division of Medical Statistics, Instituto do Câncer do Estado de São Paulo, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
authors: Giovanni
authors: G
authors: Favero
authors: Juliana
authors: J
authors: Pierobon
authors: Maria Luiza
authors: ML
authors: Genta
authors: Marcia Pereira
authors: MP
authors: Araújo
authors: Giovanni
authors: G
authors: Miglino
authors: Maria
authors: M
authors: Del Carmen Pilar Diz
authors: Heloísa
authors: H
authors: de Andrade Carvalho
authors: Julia Tizue
authors: JT
authors: Fukushima
authors: Edmund Chada
authors: EC
authors: Baracat
authors: Jesus Paula
authors: JP
authors: Carvalho
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D000328:Adult; D000368:Aged; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D059248:Chemoradiotherapy; D005260:Female; D006801:Humans; D007045:Hysterectomy, Vaginal / Q000379:methods*; D010535:Laparoscopy / Q000379:methods; D008875:Middle Aged; D011446:Prospective Studies; D016896:Treatment Outcome; D002583:Uterine Cervical Neoplasms / Q000601:surgery*; D055815:Young Adult