Study Objective: To evaluate whether extraction laparotomy (EL) for intact specimen removal adversely affected the feasibility or safety of same-day discharge (SDD) in patients undergoing minimally invasive surgery (MIS) for confirmed or suspected gynecologic malignancies. Design: Retrospective study. Setting: Single-institution study. Patients: Patients undergoing MIS for gynecologic malignancy at a single institution, who underwent EL (N = 67) matched controls (N = 134). Interventions: Comparing SDD rates, complications, readmission, and outpatient follow-up after between patients requiring EL and those who did not after minimally invasive gynecologic surgery. Measurements and Main Results: A total of 1224 patients were identified. Sixty-seven patients underwent EL for men extraction. From the remainder, 134 patients were selected as age-matched controls. SDD rate was 83% (EL) (no EL) (p = .39). There was no difference in median pain scores (1.8 vs 1.9 p = .86), length of stay (0 days (p = .41), 30-day readmission rate (6% vs 3%) (p = .45), emergency department visit (13% vs 10%) (p = .76), or any contact (34% vs 39%) (p = .53), between the groups. Specimen weight was higher for EL (524 g vs 142 g, p <.001), estimated blood loss (104 mL vs 46 mL, p <.001), and surgery time was increased by 22 minutes in the EL group vs 99 min, p <.001). Patients who underwent EL did require more narcotics in postanesthesia care unit (20.5 vs morphine equivalent, p = .033); however, this did not translate to increased number of narcotics prescribed at discharge. logistic regression, a higher specimen weight trended to increase the likelihood of admission (odds ratio, 1.04; confidence interval, 1.01-1.08); however, surgery time, time in postanesthesia care unit, race, body mass index, surgery type, for EL did not predict SDD or need for admission. Conclusion: MIS patients who require EL can still achieve SDD. SDD is safe and feasible without increased risk mission, pain score, or unscheduled patient contact postoperatively. (c) 2024 AAGL. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Objective:Describe surgical outcomes of patients undergoing HIPEC with cisplatin (C) alone or cisplatin/paclitaxel (CP), compared to interval debulking surgery (IDS) without HIPEC, and stratify disease-free survival (DFS) by treatment and homologous recombination (HR) status. Methods:Retrospective chart review of patients with advanced ovarian cancer undergoing IDS with and without HIPEC between 2018-2024. DFS was compared using a log rank test. Cox proportional hazards model was used to test association between treatment group and recurrence. Results:74 patients were included: 20 in no HIPEC, 28 in HIPEC-C, and 26 in HIPEC-CP groups. Duration of surgery was shortest in no HIPEC group (159 ± 64 min vs HIPEC-C 377 ± 54 min vs HIPEC-CP 400 ± 48 min, p < 0.0001). Post-operatively, there was no difference in days to return of bowel function (p = 0.17) or Grade II-IV complications (p = 0.39). HIPEC-C group had longest time to discharge (4.5 ± 1.2 post-operative days vs no HIPEC 3.8 ± 1.9 vs HIPEC-CP 3.6 ± 0.9, p = 0.002). Twenty-nine (39.2 %) patients were HR deficient (HRD). Median DFS did not differ between treatment groups (no HIPEC 17.0 months vs HIPEC-C 13.87 months vs HIPEC-CP 19.25 months, p = 0.853). Median DFS was higher in HRD vs HRP (HR proficient) patients (40.5 months vs 11.4 months, HR 0.32 (95 % CI: 0.19-0.57, p = 0.0001). Conclusions:Addition of paclitaxel to cisplatin at the time of IDS with HIPEC had no effect on peri-operative morbidity. No differences in DFS were seen between treatment groups. HRD group had a significantly longer DFS, when compared to HRP. Tumor genetics and HR status likely drive response to treatment in advanced ovarian cancer.

OBJECTIVE:The objective of the study was to evaluate the feasibility and safety of same-day discharge of patients undergoing minimally invasive comprehensive surgical staging for endometrial and cervical cancer.STUDY DESIGN:We performed a retrospective review of consecutive patients from January 2008 to December 2011 undergoing comprehensive staging for endometrial or cervical cancer by traditional laparoscopy or robotic-assisted laparoscopy and intended for same-day discharge. Patients accomplishing same-day discharge were compared with those who required admission. Clinical and demographic data, perioperative outcomes, and postoperative patient contacts within 6 weeks were collected. Multivariate logistic regression modeling was used to determine factors associated with admission and unscheduled patient contacts within 2 weeks of surgery.RESULTS:A total of 141 patients were identified. One hundred eighteen patients (83.7%) underwent same-day discharge and 23 (16.3%) required overnight admission. The variables that significantly predicted overnight admission were severe pain in the postanesthesia care unit (odds ratio [OR], 6.81; 95% confidence interval [CI], 1.74-26.6; P = .006), delayed ability to tolerate oral intake (OR, 9.3; 95% CI, 2.25-38.6, P = .002), traditional laparoscopic vs robotic-assisted surgical approach (OR, 9.05; 95% CI, 2.34-35.1; P = .001), and surgery start time at 2:00 pm or later (OR, 36.8; 95% CI, 6.19-219.3; P < .0001). There was no difference in the readmission rate between patients undergoing same-day discharge compared with overnight admission (11% vs 17%, P = .48). No variables significantly predicted unscheduled patient contact within 2 weeks of surgery at P < .01.CONCLUSION:Same-day discharge for patients undergoing laparoscopic or robotic-assisted laparoscopic staging for endometrial or cervical cancer is feasible and safe. There are low complication rates and few readmissions or unscheduled patient contacts within 2 weeks of surgery.

The aim of this work is to compare operative and anesthetic outcomes in patients undergoing minimally invasive endometrial cancer staging, with lymphadenectomy performed via transperitoneal, extraperitoneal, or robotic-assisted methods. Sixty-six consecutive patients (24 transperitoneal, 19 extraperitoneal, and 23 robotic) were identified who underwent laparoscopic-assisted endometrial cancer staging with pelvic and para-aortic lymphadenectomy. Patients were divided into three groups based on method of para-aortic lymphadenectomy. Anesthetic and surgical times were longest in the extraperitoneal group. Patients undergoing robotic surgery had the shortest hospital stay and lowest conversion rate to laparotomy. Patients undergoing robotic lymphadenectomy had more pelvic and para-aortic nodes removed compared with the transperitoneal method. There was no difference in number of para-aortic nodes removed in the robotic versus extraperitoneal methods. The extraperitoneal group had highest peak end-tidal CO2 levels and highest narcotic requirements, while patients in the robotic group had highest peak inflation pressures and lowest pain scores. There were no differences in complication rates amongst the three groups. Robotic-assisted staging is superior to other minimally invasive methods in terms of most operative outcomes. Extraperitoneal lymphadenectomy is equivalent to robotic surgery where number of aortic nodes is concerned, but is associated with higher end-tidal CO2 levels and narcotic requirements. Peak inflation pressures were highest in the robotic group, with no apparent adverse consequences.

Foreword to the Second Edition ix Contributors xi Part One General Principles 1. Introduction 1 Steven A. Vasilev and Scott E. Lentz 2. Evidence-Based Medicine and Decision Support 11 Steven A. Vasilev 3. Vascular Access and Other Invasive Procedures 43 Paul Koonings and Scott E. Lentz 4. Fluids, Electrolytes, and Nutrition 69 Howard Silberman and Matthew Powers Part Two Perioperative Management of Gynecologic Surgery 5. Preoperative Evaluation 145 Devansu Tewari 6. Postoperative Surveillance and Perioperative Prophylaxis 161 Harriet O. Smith and Lejla Delic 7. Perioperative Infections: Prevention and Therapeutic Options 235 Amy Stenson 8. Intraoperative and Perioperative Considerations in Laparoscopy 261 Steven A. Vasilev and Scott E. Lentz Part Three Oncologic Perioperative Decision Making 9. Cervical Carcinoma 299 Fidel A. Valea 10. Endometrial Cancer 329 R. Wendel Naumann 11. Pelvic Masses and Ovarian Carcinoma 361 Margarett C. Ellison 12. Molar Gestation 377 Allison E. Axtell and Steven A. Vasilev 13. Perioperative Issues in the Management of Vulvar Cancer 389 Kathryn F. McGonigle and Maliaka W. Amneus Part Four Complimentary Medicine/Supportive Care 14. Perioperative Psychosocial Considerations 419 Judith McKay and Steven A. Vasilev 15. Pain Management in Gynecologic Oncology 443 Laszlo Z. Galffy and Clayton A. Varga 16. Fertility Preservation in the Gynecologic Cancer Patient 469 Nicole Fleming 17. Perioperative Herbal and Supplement Use 487 Alexander Vasilev and Steven Vasilev 18. End-of-Life Decision Making 509 Scott E. Lentz Index 539

Objectives. To determine recurrence patterns and survival outcomes of stage 11 uterine papillary serous carcinoma (UPSC) patients treated by various modalities with an emphasis on carboplatin/paclitaxel-based chemotherapy (CT)+/-radiotherapy (RT).Methods. A retrospective, multi-institution Study of women with stage II UPSC diagnosed from 1992 to 2006 was performed. All patients underwent comprehensive surgical staging. Treatment included observation (OBS), RT (vaginal brachytherapy, whole pelvic and/or whole abdominal therapy), or 2:3 cycles carboplatin/paclitaxel alone or with RT. Recurrence and survival outcomes were determined.Results. We identified 55 Subjects: 10 treated with OBS, 26 with RT alone and 19 with CT+/-RT. After a median follow-up of 33 mos (range, 10-119), 20 recurrences (36%) were observed. There was an overall difference in recurrence based upon treatment (p=.013). Specifically, all CT+/-RT treated patients had a lower risk of recurrence (11%) compared to patients treated by RT alone (50%) or OBS (50%). No patients treated with both CT+RT (n=12) experienced a recurrence. Treatment with CT was also associated with a decreased risk of recurrence on multivariate analysis (p=.015). Most recurrences were extra-pelvic (70%), occurred within 2 years (85%) and were not salvageable (84%). Five-year progression-free survival was 86% in chemotherapy-treated patients versus 41% in those not receiving chemotherapy (p=.010); overall survival was 88% in chemotherapy-treated patients versus 64% in those not receiving chemotherapy (p=.115).Conclusions. Stage II UPSC patients have a significant risk for unsalvageable, extra-pelvic recurrence. However, treatment with platinum/taxane therapy+/-RT appears to reduce this risk and is associated with improved progression free survival outcomes. (C) 2008 Elsevier Inc. All rights reserved.

Objectives. Stage I-II uterine papillary serous carcinoma (UPSC) patients have a significant risk for extrapelvic recurrence. However, clinicopathologic risk factors for recurrence are not well understood. This study was undertaken to define the prognostic factors for recurrence and survival in patients with early-stage UPSC.Methods. A retrospective, multi-institution analysis of surgically staged I-II UPSC patients was performed. Patients were treated by various adjuvant modalities. Age, race, sub-stage, percentage UPSC histology, lymphvascular space invasion (LVSI), tumor size and adjuvant treatment modality were evaluated for their effect on recurrence and survival outcomes.Results. We identified 206 patients. Forty patients (19.4%) had 5-49% UPSC, 55 (26.7%) had 50-99% and 111 patients (53.9%) had 100% UPSC in their respective uterine specimens. Twenty one percent of patients experienced a primary recurrence. On univariate analysis, age, increasing %UPSC, LVSI, and tumor size were not significantly associated with recurrence or progression-free survival (PFS). However, substage (p = 0.005) and treatment with platinum/taxane-based chemotherapy (p = 0.001) were associated with recurrence/PFS. On multivariate analysis, only chemotherapy (p = 0.01) was a significant factor affecting PFS, whereas age (p = 0.05), substage (p = 0.05), and chemotherapy (p = 0.02) were associated with overall survival.Conclusions. Traditional risk factors for recurrence and survival in patients with early-stage endometrial cancer may not be relevant in patients with UPSC. Patients with any percentage UPSC in their uterine specimens are at a significant risk for recurrence and poor survival outcomes. Given that Current clinicopathologic data does not accurately identify women most likely to benefit from adjuvant therapy, alternative prognostic markers based on novel techniques should be explored. (C) 2009 Elsevier Inc. All rights reserved.

BACKGROUND: A study was undertaken to determine recurrence patterns and survival outcomes of stage I uterine papillary serous carcinoma (UPSC) patients. METHODS: A retrospective, multi-institutional study of stage I UPSC patients diagnosed from 1993 to 2006 was performed. Patients underwent comprehensive surgical staging; postoperative treatment included observation (OBS); radiotherapy alone (RT); or platinum/taxane-based chemotherapy (CT) RT. RESULTS: The authors identified 142 patients with a median follow-up of 37 months (range, 7-144 months). Thirty-three patients were observed, 20 received RT alone, and 89 received CT +/- RT. Twenty-five recurrences (17.6%) were diagnosed, and 60% were extrapelvic. Chemotherapy-treated patients experienced significantly fewer recurrences than those treated without chemotherapy (P = .013). Specifically, CT RT patients had a lower risk of recurrence (11.2%) compared with patients who received RT alone (25%, P = .146) or OBS (30.3%, P = .016). This effect was most pronounced in stage IB/IC (P =.007). CT- and CT + RT-treated patients experienced similar recurrence, After multivariate analysis, treatment with chemotherapy was associated with a decreased risk of recurrence (P = .047). The majority of recurrences (88%) were not salvageable. Progression-free survival (PFS) and cause-specific survival (CSS) for chemotherapy-treated patients were more favorable than for those who did not receive chemotherapy (P = .013 and .081). Five-year PFS and CSS rates were 81.5% and 87.6% in CT RT, 64.1% and 59.5% in RT alone, and 64.7% and 70.2% for OBS. CONCLUSIONS: Stage I UPSC patients have significant risk for extrapelvic recurrence and poor survival. Recurrence and survival outcomes are improved in well-staged patients treated with platinum/taxane-based chemotherapy. This multi-institutional study is the largest to support systemic therapy for early stage UPSC patients. Cancer 2009;115:2119-27. (C) 2009 American Cancer Society.

OBJECTIVE:Primary carcinoma of the fallopian tube (PCFT) is a rare malignancy comprising 1% of genital tract cancers. We sought to compare survival trends between PCFT and ovarian carcinoma (OC) patients (pts) in a matched, case-control comparison.MATERIALS AND METHODS:Patients with PCFT were identified from five academic centers. Two OC controls were identified for each PCFT pt based on age, stage, and residual disease. All pts were surgically staged and treated with platinum based chemotherapy (CT) if indicated. PFS and OS were then compared with Kaplan-Meier analysis.RESULTS:96 PCFT cases and 189 OC controls were identified. 50 early stage PCFT were matched with 97 OC pts. The most common CT regimen was carboplatinum and paclitaxel in 84 and 86% respectively. Median follow-up was 57 and 42 months for the PCFT and OC groups and 5-year overall survival (OS) differed at 95% and 76% (p=0.02). 46 Stage III/IV PCFT pts were matched with 92 OC controls. 88.5% were optimally debulked. Median follow-up was 33 and 35 months for PCFT and OC pts and 3-year overall survival was 59% for both groups.CONCLUSIONS:This is the first study to compare outcomes for PCFT and OC in a matched, case-control comparison. Our study demonstrates that, for advanced stage PCFT, a similar survival outcome is obtained compared to OC patients. This should reassure clinicians that treatment of PCFT should mirror that of OC and that PCFT should be included in clinical trials.

PURPOSEIdentify features on preoperative computed tomography (CT) scans to predict suboptimal primary cytoreduction in patients treated for advanced ovarian cancer in institution A. Reciprocally cross validate the predictors identified with those from two previously published cohorts from institutions B and C.PATIENTS AND METHODSPreoperative CT scans from patients with stage III/IV epithelial ovarian cancer who underwent primary cytoreduction in institution A between 1999 and 2005 were retrospectively reviewed by radiologists blinded to surgical outcome. Fourteen criteria were assessed. Crossvalidation was performed by applying predictive model A to the patients from cohorts B and C, and reciprocally applying predictive models B and C to cohort A.RESULTSSixty-five patients from institution A were included. The rate of optimal cytoreduction ( 1 cm residual disease) was 78%. Diaphragm disease and large bowel mesentery implants were the only CT predictors of suboptimal cytoreduction on univariate (P < .02) and multivariate analysis (P < .02). In combination (model A), these predictors had a sensitivity of 79%, a specificity of 75%, and an accuracy of 77% for suboptimal cytoreduction. When model A was applied to cohorts B and C, accuracy rates dropped to 34% and 64%, respectively. Reciprocally, models B and C had accuracy rates of 93% and 79% in their original cohorts, which fell to 74% and 48% in cohort A.CONCLUSIONThe high accuracy rates of CT predictors of suboptimal cytoreduction in the original cohorts could not be confirmed in the cross validation. Preoperative CT predictors should be used with caution when deciding between surgical cytoreduction and neoadjuvant chemotherapy.

Objective. To determine if percent surface area involvement (SAI) of tumor in endometrial cancer is predictive of lymph node metastasis.Methods. A retrospective study was performed of all patients diagnosed with endometrial cancer at Magee Women's Hospital between January 1990 and December of 1995. Papillary serous and clear cell histologic subtypes were excluded. Pathology reports were reviewed for percent SAI, myometrial invasion, grade, histologic subtype, lymphvascular space invasion, and lymph node metastasis. Percent SAI was categorized into three groups: <35%, 35-80%, and >80%. The primary outcome variables were pelvic or periaortic lymph node metastasis. Univariate and multivariate analysis logistic regression models were used to determine predictors of nodal metastasis.Results. Of 558 patient records reviewed, 319 had lymph node dissections performed and 42 (13%) of those patients had positive lymph nodes. Two of 79 (3%) patients with <35% SAI had lymph node metastasis, 17 of 165 (10%) patients with 35-80% SAI had lymph node metastasis, and 23 of 75 (31%) patients with >80% SAI had lymph node metastasis. The percent SAI was significantly associated with lymph node inetastasis (p<0.001). Multivariate logistic regression indicated that for patients with >80% SAI, the odds of having lymph node metastasis were 10.8 times (CI 1.3-90.4) that for patients with similar tumor histology, grade, and invasion, but <35% SAI (p=0.03). A subset analysis of patients with superficial myometrial invasion was performed and 16% of patients with <50% myometrial invasion and >80% SAI had positive lymph nodes, while only 1.4% of patients with <50% myometrial invasion and <35% SAI had positive lymph nodes (p=0.02).Conclusion. Our analysis indicates that percent SAI is an independent risk factor for lymph node metastasis. Furthermore, assessing SAI with myometrial invasion gives a more accurate prediction of lymph node metastasis than myometrial invasion alone. This becomes clinically relevant when assessing risk factors for lymph node metastasis intraoperatively. (C) 2007 Elsevier Inc. All rights reserved.