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Introduction: Cervical cancer management often relies on surgical interventions, among which open total mesometrial resection (TMMR) has gained prominence. This abstract gives an insight into the technique of TMMR in the surgical treatment of cervical cancer. TMMR involves precise dissection of the mesometrium surrounding the cervix, aiming for optimal oncological outcomes while minimizing surgical morbidity. Methods or Technique: TMMR entails meticulous dissection of the mesometrium surrounding the cervix, following embryonic planes to ensure complete removal of the primary tumour and associated lymphadenectomy. Access to the abdomen is achieved through either a muscle-cutting transverse or midline abdominal incision. The procedure emphasizes meticulous dissection and removal of the tumour-containing area, with careful attention to preserving vital structures such as the ureters and pelvic autonomic nerves to minimize postoperative complications. Extensive lymphadenectomy, including first and second echelon nodal groups, and in selected cases, third echelon nodes such as lower paraaortic nodes, is performed. Conclusion: TMMR offers several advantages, including precise identification and preservation of vital structures, thorough lymphadenectomy, and favourable oncological outcomes with improved survival rates. Importantly, TMMR allows for the avoidance of radiation therapy in the majority of operable cervical cancer cases. In conclusion, TMMR represents a cornerstone in the surgical management of cervical cancer, striking a balance between oncological efficacy, radiation avoidance, and preservation of patients' quality of life.

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A radical hysterectomy is the standard method of surgical treatment for patients with early-stage cancer of the uterine cervix. It was first introduced more than 100 years ago. Since then, various and many different radical procedures, which diverge in terms of radicality, have been described. Inconsistencies are clearly seen in practical anatomy, which were defined as surgically created artifacts. Moreover, the disparity of the procedure is most notable regarding the terminology of pelvic connective tissues and spaces. Despite these controversies, the procedure is widely performed and implemented in the majority of guidelines for the surgical treatment of cancer of the uterine cervix. However, a different and unique concept of surgical treatment of cervical cancer has been reported. It is based on ontogenetic anatomy and maps any tissue in the mature organism according to its embryologic development. The clinical implementation of this theory in the context of early cervical cancer is total mesometrial resection. The present article aims to describe and compare the anatomical and surgical basics of a radical hysterectomy (type C1/C2) and total mesometrial resection. Discrepancies regarding the terminology, resection lines, and surgical planes of both procedures are highlighted in detail. The surgical anatomy of the pelvic autonomic nerves and its surgical dissection is also delineated. This is the first article that compares the discrepancy of classic anatomy and ontogenic anatomy regarding surgical treatment of cancer of the uterine cervix. Clinical data, oncological outcome, and neoadjuvant and adjuvant treatment regarding both procedures are not the topic of the present article.

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PURPOSE: Previous anatomical studies of the urogenital fascia (UGF) have focused on males, and there is a lack of relevant anatomical studies on the distribution of the extraperitoneal UGF in females. METHODS: In this investigation, guided by the embryonic development of the female urogenital system, the ventral pelvic fascia structure of 10 female cadavers was dissected, and the distribution and morphology of female extraperitoneal UGF were observed, recorded in text, photographs and video, and 3D modeling was performed. RESULTS: We find that in the female extraperitoneal space there is a migratory fascial structure, the UGF, which surrounds the urogenital system and extends from the perinephric region to the pelvis along with the development of the urogenital organs. The two layers of the UGF are composed of loose connective tissue rich in fat that surrounds the urogenital organs, their accessory vascular structures, and the nerves of the abdominopelvic cavity. In the pelvis, it participates in the formation of the ligamentous structures around the rectum and uterus. Finally, it surrounds the bladder and gradually moves into the loose connective tissue of the medial umbilical fold. CONCLUSIONS: Sorting out the distribution characteristics of UGF has some reference value for studying the metastasis of gynecological tumors, the biomechanical structure of the female pelvis, and the surgical methods of gynecology, colorectal surgery, and hernia surgery.

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Laparoscopía , Sistema Urogenital , Masculino , Humanos , Femenino , Sistema Urogenital/anatomía & histología , Pelvis , Recto , Fascia/anatomía & histología , Peritoneo , Cadáver , Formaldehído

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We aimed to evaluate the accuracy of ultrasonography with gynecologic examination performed by a gynecological oncologist and magnetic resonance imaging (MRI) interpreted by a radiologist for the local and regional staging of patients with early-stage cervical cancer. The study was a single-site sub-analysis of the multi-institutional prospective, observational Total Mesometrial Resection (TMMR) Register Study, which included all consecutive study patients from Gdynia Oncology Center. Imaging results were compared with pathology findings. A total of 58 consecutive patients were enrolled, and 50 underwent both ultrasonography and MRI. The accuracy of tumor detection and measurement errors was comparable across ultrasonography and MRI. There were no significant differences between ultrasonography and MRI in the accuracy of detecting parametrial involvement (92%, confidence interval (CI) 84-100% vs. 76%, CI 64-88%, p = 0.3), uterine corpus infiltration (94%, CI 87-100% vs. 86%, CI 76-96%, p = 0.3), and vaginal fornix involvement (96%, CI 91-100% vs. 76%, CI 64-88%, p = 0.3). The importance of uterine corpus involvement for the first-line lymph node metastases was presented in few cases. The accuracy of ultrasonography was higher than MRI for correctly predicting tumor stage: International Federation of Gynecology and Obstetrics (FIGO)-2018: 69%, CI 57-81% vs. 42%, CI 28-56%, p = 0.002, T (from TNM system): 79%, CI 69-90% vs. 52%, CI 38-66%, p = 0.0005, and ontogenetic tumor staging: 88%, CI 80-96% vs. 70%, CI 57-83%, p = 0.005. For patients with cervical cancer who are eligible for TMMR and therapeutic lymphadenectomy, the accuracy of ultrasonography performed by gynecological oncologists is not inferior to that of MRI interpreted by a radiologist for assessing specific local parameters, and is more accurate for local staging of the disease and is thus more clinically useful for planning adequate surgical treatment.

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BACKGROUND/AIM: There is a lack of data concerning the surgical treatment of locally advanced squamous cell carcinoma of the uterine cervix (LACC) with neoadjuvant and adjuvant chemotherapy (NACT, ACT) as well as total mesometrial resection (TMMR). The aim of the study was to present a novel approach for treating LACC using a tumor response score for NACT. PATIENTS AND METHODS: A total of 12 patients with LACC were treated with NACT [cisplatin, ifosfamide, paclitaxel (TIP)], TMMR and ACT containing TIP. To measure the response during NACT, we scored i) the maximum tumor diameter (maxTD) in gynecological examination, ii) the MRI for radiologic maxTD, iii) the tumor volume and iv) the squamous cell carcinoma antigen before and after two applications of TIP. RESULTS: TIP reduced all score-parameters in 10 of 12 patients (p<0.005). We found a possible reduction of lymph node metastasis in 72.7%. The proposed score detected sufficient and insufficient tumor response. CONCLUSION: TIP followed by TMMR with ACT could be a possibility for patients denying radiochemotherapy. The tumor response score can detect patients with inadequate benefit from NACT.

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Cuello del Útero/efectos de los fármacos , Cuello del Útero/cirugía , Neoplasias del Cuello Uterino/tratamiento farmacológico , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/cirugía , Adulto , Protocolos de Quimioterapia Combinada Antineoplásica/uso terapéutico , Carcinoma de Células Escamosas/tratamiento farmacológico , Carcinoma de Células Escamosas/patología , Carcinoma de Células Escamosas/cirugía , Cuello del Útero/patología , Quimioterapia Adyuvante/métodos , Femenino , Humanos , Histerectomía/métodos , Metástasis Linfática/tratamiento farmacológico , Metástasis Linfática/patología , Persona de Mediana Edad , Terapia Neoadyuvante/métodos

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The role and place of a radical hysterectomy in the concept of cervical cancer treatment, despite over one hundred years of its traditional use, still excites controversy. To fully understand the value of the surgical treatment, it is worth analysing and understanding the evolutionary path of the radical hysterectomy and the changes that have occurred in this method over the years. This knowledge will allow for a better understanding as to why the choice of therapy between surgery and radiochemotherapy in the early and locally advanced stages of cervical cancer still raise doubts. Both the introduced changes in the scope of surgery and the use of multi-module treatment - surgery with subsequent radiation therapy did not significantly improve the results of cancer treatment, but significantly increased the prevalence of side effects and therapy complications. As cervical cancer most often affects relatively young women, the number of potential years of life after treatment is high. Over 30% of women in Poland with cervical cancer are in the 45-49 years-old age group. From the perspective of these data, obtaining a high therapeutic index, which is defined as the ratio of the number of healed patients to complications and side effects of treatment significantly reducing the quality of life, is very important in the therapy process. Regardless of the classical radical surgery, which has evolved over many years, a new concept of radical hysterectomy based on tissue morphogenesis, called total mesometrial resection (TMMR) with therapeutic Lymph Node Dissection (tLND) with no adjuvant radiotherapy, has recently been proposed. Based on the ontogenetic research and the study of cancerous tumour development, the concept of TMMR was first introduced by M. Höckel in 2001. In the research conducted by the author, encouraging results of the treatment of stages IB1, IB2, IIA1 and IIA2, and selected cases of stage IIB [according to 2009 International Federation of Gynecology and Obstetrics (FIGO)] cervical cancer were obtained.

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Histerectomía/métodos , Calidad de Vida/psicología , Neoplasias del Cuello Uterino/cirugía , Femenino , Humanos , Persona de Mediana Edad , Polonia , Neoplasias del Cuello Uterino/psicología

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OBJECTIVE: To evaluate the feasibility and effect of mesureteral preservation on urinary complications in the context of total mesometrial resection (TMMR), a surgical treatment for cervical cancer. DESIGN: Retrospective cohort study with historic control. SETTING: Single tertiary academic centre. POPULATION: Women older than 18 with primary cervical cancer staged FIGO IB1-IIB enrolled in the prospective Leipzig School MMR study and underwent total mesometrial resection (TMMR) without adjuvant radiation. METHOD: We retrospectively analysed 100 consecutive TMMR procedures which were performed for cancer of the uterine cervix and in which the mesureter was preserved (intervention group, 01/2014-06/2017). We compared this group with the previous 100 consecutive TMMRs, which were performed before the introduction of mesureteral preservation (control group, 09/2010-01/2014). MAIN OUTCOME MEASURES: The occurrence of urological and specifically ureteral complications. RESULTS: Mesureteral preservation was feasible and was associated with a significant decrease in ureteral complications (11% without mesureteral preservation versus 3% with mesureteral preservation, P = 0.049). Furthermore, we found a significant decrease in the number of postoperative percutaneous nephrostomies and re-operations (7% versus none, P = 0.014). There was also a trend towards a decrease in other urinary complications such as postoperative bladder atony and uretero-vaginal fistulas. CONCLUSION: The mesureter constitutes a convenient dissection plane enabling the preservation of lateral ureteral blood supply during TMMR. In our study, maintenance of mesureteral integrity was associated with a significant reduction in ureteral complications. Mesureteral preservation might also be useful in other types of pelvic surgeries that carry a high risk of ureteral damage. TWEETABLE ABSTRACT: Surgical preservation of the mesureter in cervical cancer patients was associated with a reduction in urinary complications.

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Complicaciones Intraoperatorias/prevención & control , Mesenterio/cirugía , Tratamientos Conservadores del Órgano/métodos , Exenteración Pélvica , Complicaciones Posoperatorias , Uréter/lesiones , Obstrucción Ureteral , Neoplasias del Cuello Uterino , Femenino , Alemania/epidemiología , Humanos , Histerectomía/efectos adversos , Histerectomía/métodos , Escisión del Ganglio Linfático/efectos adversos , Escisión del Ganglio Linfático/métodos , Persona de Mediana Edad , Estadificación de Neoplasias , Órganos en Riesgo , Evaluación de Procesos y Resultados en Atención de Salud , Exenteración Pélvica/efectos adversos , Exenteración Pélvica/métodos , Complicaciones Posoperatorias/diagnóstico , Complicaciones Posoperatorias/prevención & control , Obstrucción Ureteral/diagnóstico , Obstrucción Ureteral/etiología , Obstrucción Ureteral/prevención & control , Neoplasias del Cuello Uterino/epidemiología , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/cirugía

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BACKGROUND: Based on ontogenetic-anatomic considerations, we have introduced total mesometrial resection (TMMR) and laterally extended endopelvic resection (LEER) as surgical treatments for patients with cancer of the uterine cervix FIGO stages I B1 - IV A. For a subset of patients with locally advanced disease we have sought to develop an operative strategy characterized by the resection of additional tissue at risk for tumor infiltration as compared to TMMR, but less than in LEER, preserving the urinary bladder function. METHODS: We conducted a prospective single center study to evaluate the feasibility of extended mesometrial resection (EMMR) and therapeutic lymph node dissection as a surgical treatment approach for patients with cervical cancer fixed to the urinary bladder and/or its mesenteries as determined by intraoperative evaluation. None of the patients received postoperative adjuvant radiotherapy. RESULTS: 48 consecutive patients were accrued into the trial. Median tumor size was 5cm, and 85% of all patients were found to have lymph node metastases. Complete tumor resection (R0) was achieved in all cases. Recurrence free survival at 5years was 54.1% (95% CI 38.3-69.9). The overall survival rate was 62.6% (95% CI 45.6-79.6) at 5years. Perioperative morbidity represented by grade II and III complications (determined by the Franco-Italian glossary) occurred in 25% and 15% of patients, respectively. CONCLUSION: We demonstrate in this study the feasibility of EMMR as a surgical treatment approach for patients with locally advanced cervical cancer and regional lymph node invasion without the necessity for postoperative adjuvant radiation.

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Adenocarcinoma/cirugía , Carcinoma Adenoescamoso/cirugía , Carcinoma de Células Escamosas/cirugía , Histerectomía/métodos , Escisión del Ganglio Linfático/métodos , Mesenterio/cirugía , Neoplasias del Cuello Uterino/cirugía , Adenocarcinoma/patología , Adulto , Anciano , Carcinoma Adenoescamoso/patología , Carcinoma de Células Escamosas/patología , Quimioterapia Adyuvante , Estudios de Factibilidad , Femenino , Humanos , Persona de Mediana Edad , Estadificación de Neoplasias , Pelvis , Complicaciones Posoperatorias/epidemiología , Estudios Prospectivos , Uréter/patología , Uréter/cirugía , Neoplasias del Cuello Uterino/patología , Adulto Joven

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STUDY OBJECTIVE: To report our experience with robotic total mesometrial resection (R-TMMR) comparing perioperative results with a series of laparoscopic total mesometrial resections (L-TMMRs). DESIGN: Multicenter retrospective case-control study (Canadian Task Force classification II-2). SETTING: Catholic University of the Sacred Heart of Rome (Italy) and Campobasso (Italy). PATIENTS: From July 2013 to August 2015 all cervical cancer patients with preoperative FIGO stage IA2 to IB1 were assessed at preoperative magnetic resonance imaging scan and clinically confirmed by investigation under anesthesia, complying strictly with the FIGO criteria. Surgical and postsurgical data of the TMMR procedures were collected. INTERVENTIONS: R-TMMR and L-TMMR for early cervical cancer were performed. MEASUREMENTS AND MAIN RESULTS: Twenty-one women underwent R-TMMR (cases) and 42 patients were submitted to L-TMMR (control subjects) for early cervical cancer. The median estimated blood loss was 150 mL in the cases and 200 mL in the control subjects (p = .992). The median operative time, calculated from the beginning of intraperitoneal procedures to skin closure, was 246 minutes in the cases and 260 minutes in the control subjects (p = .913). The median time to discharge from the hospital was postoperative days 4 (range, 2-5) and 6 (range, 4-15) for R-TMMR and L-TMMR, respectively (p = .001). CONCLUSION: The few differences we registered do not seem to be clinically relevant, thus making the 2 procedures comparable. Further prospective trials are needed to confirm our results.

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Laparoscopía , Procedimientos Quirúrgicos Robotizados , Neoplasias del Cuello Uterino/cirugía , Adulto , Anciano , Estudios de Casos y Controles , Femenino , Humanos , Italia , Persona de Mediana Edad , Tempo Operativo , Estudios Retrospectivos

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OBJECTIVE: To analyze the feasibility of total mesometrial resection by laparoscopy (L-TMMR) in a multicentric series of early stage cervical cancer. METHOD: We prospectively evaluated a consecutive series of cervical cancer patients with pre-operative FIGO stages IA2-IB1 at the Catholic University in Rome and in Campobasso and the Charitè University in Berlin. All cases were assessed at pre-operative MRI scan and clinically confirmed by investigation under anesthesia, adhering strictly to the FIGO criteria. The surgical and post-surgical data were collected. RESULTS: 104 women with cervical cancer were admitted between July 2013 and August 2014 and among them 71 patients with pre-operative FIGO stages IA2-IB1 were treated with L-TMMR. One laparotomic conversion was registered. The median operative time was 260min (120-670min), estimated blood loss was 100cm(3) (25-900cm(3)), and the median length of hospital stay was 6days (2-26days). We observed 8 intra-operative complications including a vascular injury of the left internal iliac vein that caused conversion, 6 vesical injuries and 1 ureteral injury managed laparoscopically. Two vescico-vaginal fistula and one hemoperitoneum were observed as major post-operative complications (4.2%). CONCLUSION: L-TMMR can be safely performed in selected cervical cancer patients. Further larger prospective trials are needed to evaluate the oncological outcome of patients undergoing this surgical procedure.

Asunto(s)

Histerectomía/métodos , Neoplasias del Cuello Uterino/cirugía , Adulto , Anciano , Femenino , Humanos , Histerectomía/efectos adversos , Laparoscopía/efectos adversos , Laparoscopía/métodos , Escisión del Ganglio Linfático/métodos , Persona de Mediana Edad , Estadificación de Neoplasias , Estudios Prospectivos , Neoplasias del Cuello Uterino/patología

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AIM: The purpose of this study was to establish and analyze the laparoscopic technique of radical hysterectomy and para-aortic and pelvic lymphadenectomy and to retrospectively evaluate its feasibility and morbidity. PATIENTS AND METHODS: During a one-year period 12 patients underwent laparoscopic radical surgical procedures for cervical or endometrial cancer. All our patients underwent radical pelvic lymphadenectomy, whereas we performed radical para-aortic lymphadenectomy-alone in five patients and radical type-C hysterectomy in eight patients. RESULTS: The mean operating time for para-aortic and pelvic lymphadenectomy was 120 and 152 minutes respectively, and 153.75 minutes for type C hysterectomy. A mean of 41.6 pelvic lymph nodes and 21.2 para-aortic lymph nodes were removed. The mean extensions of parametrium in laparoscopic radical hysterectomy type C were 45×30 mm. CONCLUSION: Following a short learning curve, laparoscopic para-aortic and pelvic lymphadenectomy is a safe and effective technique for staging cervical, and endometrial cancer.

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Histerectomía/educación , Laparoscopía/educación , Aprendizaje , Escisión del Ganglio Linfático/educación , Adulto , Anciano , Anestesia , Neoplasias Endometriales/patología , Neoplasias Endometriales/cirugía , Femenino , Alemania , Humanos , Persona de Mediana Edad , Resultado del Tratamiento , Neoplasias del Cuello Uterino/patología , Neoplasias del Cuello Uterino/cirugía

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Objectives With the objective of improving outcomes in oncological surgery, a new concept of surgical anatomy deduced from embryonic development, called ontogenetic anatomy and compartment theory of local tumor spread, is proposed by Michael Höckel from Germany. Hypothesis Compartment resection enables the preservation of functionally important tissues of different embryonic origin despite its close proximity to the tumor and incomplete resection of the compartment results in increase in local recurrences. This approach should maximize local tumor control and minimize treatment-related morbidity. Total Mesometrial Resection (TMMR) This new surgical technique has been developed and standardized over past 12 years for cervical cancer with a high local control rate without need for adjuvant radiotherapy. Conclusion This Embryological based surgery holds a great promise for management of cervical cancer. However this novel surgery needs confirmation in multi institutional settings to translate research into practice for an excellent therapeutic index.