The precaval nodes are identified and detached from the inferior vena cava. Once these steps have been accomplished, the nodal dissection is considered selleck products complete (Figure 3). Figure 3 Laparoscopic extraperitoneal paraaortic lymphadenectomy: (1) Inferior mesenteric artery; (2) aortic bifurcation; (3) lumbar artery and vein; (4) left ureter. The resected lymph nodes are extracted from the extraperitoneal cavity through the 10-mm port. The operative field is evaluated for hemostasis. At this time, the extraperitoneal space is deflated, and the abdominal cavity is insufflated. The laparoscope is once again placed through the port in the umbilicus. A 2- to 3-cm incision is made in the peritoneal sac to prevent lymphocyst formation. Conclusion Minimally invasive laparoscopic staging for advanced cervical cancer is viable and reproducible.
Although imaging modalities are improving, the current gold standard for determining lymph node status is surgical sampling. The transperitoneal laparoscopic lymphadenectomy approach offers less morbidity than the traditional laparotomy approach. The retroperitoneal laparoscopic approach has been demonstrated to decrease the risk of bowel injury and reduce abdominal adhesion formation, and prior abdominal surgery does not appear to be a factor.7 Further prospective clinical trials are necessary to better define the role of retroperitoneal laparoscopic surgery in the management of gynecologic malignancies. Additionally, as gyneoncologists become more familiar with robotic surgery, technically challenging surgery may become less difficult.
Main Points Clinical staging of cervical carcinoma correlates poorly with the true extent of disease. Lymphadenectomy can determine involvement of the lymph nodes not only in the pelvis, but also along the chain of lymph nodes around the aorta. In multiple studies, staging by laparoscopy compared with laparotomy has resulted in less blood loss, shorter hospital stay, less postoperative adhesion formation, and equivalent assessment of lymph node status. By avoiding entry into the peritoneal cavity, the risk of adverse events such as postoperative ileus, intraperitoneal adhesions, and intestinal obstruction was eliminated in the retroperitoneal laparoscopic lymphadenectomy. Robotic para-aortic lymphadenectomy may offer advantages over standard laparoscopy.
Footnotes No financial support was necessary in preparing this manuscript or acquiring data.
Urodynamic stress incontinence (USI) is the leakage of urine through an incompetent urethra in the absence of a detrusor contraction.1 The purest symptom of USI is urinary loss upon raising intra-abdominal pressure, as Drug_discovery in coughing. Ten percent of middle-aged women report weekly incontinence,2 although only 1 in 1000 women undergo curative surgery. USI may be complicated by intrinsic sphincter deficiency (ISD), detrusor overactivity or voiding disorder, or pelvic organ prolapse.