We report a case of an epithelioid smooth muscle tumor of low grade malignancy, known as smooth muscle tumor of uncertain malignant potential (STUMP), in a 65-year-old woman. The patient was referred to our hospital because of an abnormal result on screening of the uterus. We initially suspected leiomyosarcoma based on the findings of preoperative medical examinations and tests, so she underwent a total abdominal hysterectomy with salpingo-oophorectomy. The final diagnosis was a tumor with a low malignant potential (STUMP).

　　A 32-year-old woman underwent the laparoscopic ovarian cystectomy. During the operation, adrenaline was injected into her right ovary, because the amount of bleeding decreased. Soon after the injection, ventricular tachycardia occurred and her blood pressure increased to 190/125. The use of lidocaine induced the electrocardiogram to return to normal and brought down the blood pressure to a normal range. The operation was finished without hitch.　　Vasopressin has both an excellent hemostatic effect and cardiovascular side effects, and is often used at many medical facilities in Japan. But the treatment with vasopressin is neither covered by health insurance nor the relief system for sufferers from adverse drug reactions.　　So we usually use adrenaline which is insurable at laparoscopic operations. Adrenaline has also a hemostatic property, and causes severe cardiovascular adverse events such as ventricular tachycardia when used together with halogenated inhalation anesthetic. The Japanese Society of Anesthesiologists concludes that no serious side effects will arise from using adrenalin and sevoflurane or isoflurane based on its own findings.　　We had a case with ventricular tachycardia which occurred after an adrenaline local injection. But we recommend a careful use of adrenaline for local injection during a laparoscopic operation.

Objective: Previously, indications for laterally extended endopelvic resection (LEER) have excluded patients with sciatica because R0 resection has not been deemed possible [1].Because laparoscopy optimizes visualization and thus provides for meticulous dissection, we hypothesized that R0 resection can be achieved by means of laparoscopic LEER in patients with sciatica. This video article aimed to clarify the technical feasibility of laparoscopic LEER performed for laterally recurrent previously irradiated cervical cancer with concomitant sciatica. Methods: We investigated technical feasibility of laparoscopic LEER performed as a salvage therapy following abdominal radical hysterectomy and concurrent chemoradiotherapy in a patient suffering laterally recurrent cervical carcinoma with concomitant sciatica. The recurrent tumor involved the right external and internal iliac artery and vein, ileocecum, rectosigmoid colon, right ureter, right obturator nerve, and right sciatic nerve, with a resulting fistula between the tumor and the rectosigmoid colon, and severe sciatica.Resection of all these structures was essential for achievement of R0 status, and such resection means concomitant femoral bypass with prosthetic graft interposition and gastrointestinal/urinary tract resection. Results: Laparoscopic LEER with femoral-femoral artery bypass could be conducted without any postoperative complications. Pathological R0 resection could be achieved, and local recurrence could have been controlled. However, the patient died from liver and lung metastasis at 1 year after this resection surgery. Conclusion Laparoscopic LEER for a laterally recurrent previously irradiated cervical cancer with concomitant sciatica was technically feasible, however, further study involving a greater number of patients and longer follow-up period is warranted to determine the stringent indications.

Radical hysterectomy is a standard surgery to treat early-stage uterine cervical cancer. The Laparoscopic Approach to Cervical Cancer (LACC) trial has shown that patients receiving minimally invasive radical hysterectomy have a poorer prognosis than those receiving open radical hysterectomy; however, the reason for this remains unclear. The LACC trial had 2 concerns: the learning curve and the procedural effects. Appropriate management of the learning curve effect, including surgeons’ skills, is required to correctly interpret the result of surgical randomized controlled trials. Whether the LACC trial managed the learning curve effect remains controversial, based on the surgeons’ inclusion criteria and the distribution of institutions with recurrent cases. An appropriate surgical procedure is also needed, and avoiding intraoperative cancer cell spillage plays an important role during cancer surgery. Cancer cell spillage during minimally invasive surgery to treat cervical cancer is caused by several factors, including 1) exposure of tumor, 2) the use of a uterine manipulator, and 3) direct handling of the uterine cervix. Unfortunately, these issues were not addressed by the LACC trial. We evaluated the results of minimally invasive radical hysterectomy while avoiding cancer cell spillage for early-stage cervical cancer. Our findings show that avoiding cancer cell spillage during minimally invasive radical hysterectomy may ensure an equivalent oncologic outcome, comparable to that of open radical hysterectomy. Therefore, evaluating the importance of avoiding cancer cell spillage during minimally invasive surgery with a better control of the learning curve and procedural effects is needed.

The Laparoscopic Approach to Cervical Cancer (LACC) trial demonstrated that minimally invasive radical hysterectomy was inferior to the open approach [1]; this unexpected result could be attributed to the spillage of cancer cells [2]. Following the LACC trial, laparoscopic radical hysterectomy without an intrauterine manipulator upon completion of a vaginal cuff closure became the new standard treatment method [3]. However, the lack of intrauterine manipulator results in poor visualization and inadequate paracervical tissue resection. This study describes the no-look no-touch technique to address this difficulty. The core procedures in our no-look, no-touch laparoscopic radical hysterectomy are: (Step 1) Creation and closure of a vaginal cuff; (Step 2) Manipulation of the uterus without an intra-uterine manipulator; and (Step 3) Exposure of the paracervical tissues by the suspension technique. The patient eligibility for our procedure is as follows: 1) previously untreated cervical cancer (those who underwent diagnostic conization could be included); 2) clinical stage IA2, IB1, IB2, and IIA1 based on the 2018 International Federation of Gynecology and Obstetrics staging system; 3) histologically confirmed cervical cancer, including squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma. The important indication for this procedure is in cases where the tumor is less than 4 cm in diameter. We previously reported that our no-look no-touch technique enables smooth performance of laparoscopic radical hysterectomy without worsening oncologic outcomes [4]. According to a recent systematic review and meta-analysis [5], minimally invasive radical hysterectomy with vaginal cuff closure is a safe treatment option; however, it involves a steep learning curve, which has impeded its increased application. This video will hopefully make minimally invasive radical hysterectomy with protective maneuvers against cancer cell spillage more accessible. Based on our experiences, we propose that our transvaginal cervical tumor-concealing no-look no-touch technique will mitigate the risk of surgical spill of tumor cells during minimally invasive radical hysterectomy. The informed consent for use of this video was taken from the patient.

Objective: To describe anatomic patterns of the superficial uterine vein (sUV) and assess their association with aspects of the dissection procedure of the anterior layer of the vesicouterine ligament (aVUL) by retrospectively reviewing surgical videos. Methods: We analyzed patients who underwent laparoscopic radical hysterectomy for early-stage cervical cancer from 2014 to 2019. The primary endpoint was the time required for aVUL dissection. Multiple linear regression analyses were performed to identify factors influencing the time required for aVUL dissection. Results: Fifty-three Japanese patients were included. Two sUV configurations were observed:type 1 (the vein ran ventral to the ureter along the uterine artery) and type 2 (the vein did not run along the usual ventral course; it ran dorsal to the ureter or was absent). Approximately 30% of the sUVs were type 2. The total time for dissection of both sides of the aVUL was significantly shorter for type 2 sUVs than for type 1 sUVs. The number of hemostatic interventions during dissection of each side of the aVUL was significantly lower for type 2 sUVs than for type 1 sUVs. In the multivariate analysis, the sUV configuration was the factor significantly influencing the duration of aVUL dissection on each side (right side: β=−143.4;left side, β=−160.4). Conclusion We demonstrated that the sUV had 2 types of courses, ventral and others, and its course affected the time required for dissection and the number of hemostatic interventions.Our results provide information supportive of improved radical hysterectomy outcomes.

Objective: The combination of cancer and hypercoagulable states is often called Trousseau syndrome. In particular, cerebral infarction caused by Trousseau syndrome is reported to have a poor prognosis. In gynecology, there are many reports of ovarian cancer and a few of uterine cancer. Since there has been no comprehensive report of Trousseau syndrome in cervical cancer, we aimed to summarize Trousseau syndrome in cervical cancer. Methods: Cerebral infarction caused by cancer-related arterial thrombosis was defined as Trousseau syndrome. Patients with cervical cancer diagnosed at our hospital between January 2014 and December 2021 were retrospectively reviewed using the hospital’s medical records. Results: A total of 1,432 patients were included in the study. Trousseau syndrome occurred in 6 patients (0.4%). The mean age of patients with Trousseau syndrome was 63 years (range:53–78 years). Of the 6 patients who developed Trousseau’s syndrome, 4 patients had it before or during initial treatment, and 2 during recurrent/relapsed disease treatment. The 4 patients who developed the syndrome before or during initial treatment had advanced disease: 1 in stage IIIC and 3 in stage IVB. In all cases, the disease was associated with progressive distant metastasis. The median survival time from the onset of Trousseau syndrome was 1 month (range: 0–6 months). Conclusion Cervical cancer causes Trousseau syndrome in cases of advanced disease with a short time between the onset of the syndrome and mortality.

Objective: To describe anatomic patterns of the superficial uterine vein (sUV) and assess their association with aspects of the dissection procedure of the anterior layer of the vesicouterine ligament (aVUL) by retrospectively reviewing surgical videos. Methods: We analyzed patients who underwent laparoscopic radical hysterectomy for early-stage cervical cancer from 2014 to 2019. The primary endpoint was the time required for aVUL dissection. Multiple linear regression analyses were performed to identify factors influencing the time required for aVUL dissection. Results: Fifty-three Japanese patients were included. Two sUV configurations were observed:type 1 (the vein ran ventral to the ureter along the uterine artery) and type 2 (the vein did not run along the usual ventral course; it ran dorsal to the ureter or was absent). Approximately 30% of the sUVs were type 2. The total time for dissection of both sides of the aVUL was significantly shorter for type 2 sUVs than for type 1 sUVs. The number of hemostatic interventions during dissection of each side of the aVUL was significantly lower for type 2 sUVs than for type 1 sUVs. In the multivariate analysis, the sUV configuration was the factor significantly influencing the duration of aVUL dissection on each side (right side: β=−143.4;left side, β=−160.4). Conclusion We demonstrated that the sUV had 2 types of courses, ventral and others, and its course affected the time required for dissection and the number of hemostatic interventions.Our results provide information supportive of improved radical hysterectomy outcomes.

Objective: The combination of cancer and hypercoagulable states is often called Trousseau syndrome. In particular, cerebral infarction caused by Trousseau syndrome is reported to have a poor prognosis. In gynecology, there are many reports of ovarian cancer and a few of uterine cancer. Since there has been no comprehensive report of Trousseau syndrome in cervical cancer, we aimed to summarize Trousseau syndrome in cervical cancer. Methods: Cerebral infarction caused by cancer-related arterial thrombosis was defined as Trousseau syndrome. Patients with cervical cancer diagnosed at our hospital between January 2014 and December 2021 were retrospectively reviewed using the hospital’s medical records. Results: A total of 1,432 patients were included in the study. Trousseau syndrome occurred in 6 patients (0.4%). The mean age of patients with Trousseau syndrome was 63 years (range:53–78 years). Of the 6 patients who developed Trousseau’s syndrome, 4 patients had it before or during initial treatment, and 2 during recurrent/relapsed disease treatment. The 4 patients who developed the syndrome before or during initial treatment had advanced disease: 1 in stage IIIC and 3 in stage IVB. In all cases, the disease was associated with progressive distant metastasis. The median survival time from the onset of Trousseau syndrome was 1 month (range: 0–6 months). Conclusion Cervical cancer causes Trousseau syndrome in cases of advanced disease with a short time between the onset of the syndrome and mortality.