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Principles of Gynecologic Oncology Surgery PEDRO T. RAMIREZ, MD Professor David M. Gershenson Distinguished Professor in Ovarian Cancer Research Director of Minimally Invasive Surgical Research and Education Department of Gynecologic Oncology and Reproductive Medicine The University of Texas MD Anderson Cancer Center Houston, Texas MICHAEL FRUMOVITZ, MD, MPH Professor and Fellowship Director Department of Gynecologic Oncology and Reproductive Medicine The University of Texas MD Anderson Cancer Center Houston, Texas NADEEM R. ABU-RUSTUM, MD Chief, Gynecology Service Professor, Weill Cornell Medical College Vice Chair Technology Department of Surgery Memorial Sloan Kettering Cancer Center New York, New York 1600 John F. Kennedy Blvd. Ste 1600 Philadelphia, PA 19103-2899 PRINCIPLES OF GYNECOLOGIC ONCOLOGY SURGERY ISBN: 978-0-323-42878-1 Copyright © 2019 by Elsevier, Inc. All rights reserved. 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Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Library of Congress Cataloging-in-Publication Data Names: Ramirez, Pedro T., editor. | Frumovitz, Michael, editor. | Abu-Rustum, Nadeem R., editor. Title: Principles of gynecologic oncology surgery / [edited by] Pedro T. Ramirez, Michael Frumovitz, Nadeem R. Abu-Rustum. Description: Philadelphia, PA : Elsevier, [2019] | Includes bibliographical references and index. Identifiers: LCCN 2018008119 | ISBN 9780323428781 (hardcover : alk. paper) Subjects: | MESH: Genital Neoplasms, Female—surgery | Gynecologic Surgical Procedures—methods Classification: LCC RC280.G5 | NLM WP 145 | DDC 616.99/465—dc23 LC record available at https://lccn.loc.gov/2018008119 Senior Content Strategist: Sarah Barth Senior Content Development Specialist: Joanie Milnes Publishing Services Manager: Catherine Albright Jackson Senior Project Manager: Claire Kramer Design Direction: Brian Salisbury Printed in China Last digit is the print number: 9 8 7 6 5 4 3 2 1 To my father, Tomas, and my mother, Juanita, who sacrificed it all so that our family could have a better future. To my sister, Maria, for her consistent support and loyalty. To my children, Gabriela, Peter, Johnny, Sofia, and Emma, for the love and happiness they bring each day. To my wife, Gloria, for her sacrifices, patience, encouragement, support, constant inspiration, and most important, her love. Pedro T. Ramirez To my wife, Amie, and my children, Robert, Natalie, and Andrew. Thank you for your love and encouragement. Nadeem R. Abu-Rustum To my wife, Karen, and sons, Alex and Jonathan, for enduring countless hours and Sunday mornings away from home and for my father, Billy, who would have been incredibly proud and although a general gynecologist, would have read this book cover to cover, relishing every page. Michael Frumovitz Contributors Nadeem R. Abu-Rustum, MD Luis M. Chiva, MD, PhD Chief, Gynecology Service Chair of Department of Obstetrics and Gynecology Professor, Weill Cornell Medical College University of Navarra Vice Chair Technology Madrid, Spain Department of Surgery Memorial Sloan Kettering Cancer Center David Cibula, MD, PhD New York, New York Gynecologic Oncology Center Department of Obstetrics and Gynecology David M. Adelman, MD, PhD, FACS First Faculty of Medicine Associate Professor Charles University in Prague and General University Hospital Division of Plastic Surgery in Prague The University of Texas MD Anderson Cancer Center Prague, Czech Republic Houston, Texas Kathryn G. Cunningham, MD Giovanni Aletti, MD Fellow Associate Professor in Obstetrics and Gynecology Department of Urology University of Milan The University of Texas MD Anderson Cancer Center Director, Unit of New Therapeutic Strategies in Ovarian Houston, Texas Cancer European Institute of Oncology Pedro F. Escobar, MD, FACOG, FACS Milan, Italy Instituto Gyneco-Oncológico San Juan, Puerto Rico Mara B. Antonoff, MD Associate Clinical Professor of Surgery Assistant Professor Cleveland Clinic Department of Thoracic and Cardiovascular Surgery Cleveland, Ohio The University of Texas MD Anderson Cancer Center Houston, Texas Ramez N. Eskander, MD Assistant Clinical Professor Anne-Sophie Bats, MD Division of Gynecologic Oncology Paris Descartes University Department of Reproductive Medicine Sorbonne Paris Cité University of California San Diego School of Medicine Moores Cancer Center Assistance Publique–Hôpitaux de Paris La Jolla, California Hôpital Européen Georges-Pompidou Gynecological and Breast Cancer Surgery Anna Fagotti, MD Paris, France Division of Gynecologic Oncology Catholic University of the Sacred Heart David M. Boruta, MD Rome, Italy Associate Professor Department of Obstetrics and Gynecology Gwenael Ferron, MD, PhD Tufts University School of Medicine Department of Surgical Oncology Chief of Gynecologic Oncology Institut Claudius Regaud–Institut Universitaire du Cancer Steward Health Care System Toulouse, France Boston, Massachusetts Katherine Fritton, MD Robert Bristow, MD, MBA Department of Gynecology and Obstetrics Professor and Chair The Johns Hopkins University Obstetrics and Gynecology Baltimore, Maryland University of California, Irvine School of Medicine Orange, California Michael Frumovitz, MD, MPH Professor and Fellowship Director Jvan Casarin, MD Department of Gynecologic Oncology and Reproductive Research Fellow Medicine Division of Gynecologic Surgery The University of Texas MD Anderson Cancer Center Mayo Clinic Houston, Texas Rochester, Minnesota vi Contributors vii Fabio Ghezzi, MD Javier Magrina, MD Professor and Head Director of Minimally Invasive Gynecologic Surgery Department of Obstetrics and Gynecology Mayo Clinic University of Insubria Scottsdale, Arizona Varese, Italy President, Fellowship Board of Directors American Association of Gynecologic Laparascopists Gretchen E. Glaser, MD Cypress, California Consultant Division of Gynecologic Surgery Andrea Mariani, MD, MS Mayo Clinic Professor Rochester, Minnesota Division of Gynecologic Surgery Mayo Clinic Tam T.T. Huynh, MD Rochester, Minnesota Department of Thoracic and Cardiovascular Surgery Department of Interventional Radiology Alejandra Martinez, MD The University of Texas MD Anderson Cancer Center Department of Surgical Oncology Houston, Texas Institut Claudius Regaud–Institut Universitaire du Cancer Toulouse, France Maria D. Iniesta, MD, PhD Senior Coordinator Clinical Studies Patrice Mathevet, MD, PhD Department of Gynecologic Oncology and Reproductive Department of Gynecology Medicine CHU Vadois The University of Texas MD Anderson Cancer Center Lausanne, Switzerland Houston, Texas Reza J. Mehran, MD Anuja Jhingran, MD Department of Thoracic and Cardiovascular Surgery Department of Radiation Oncology The University of Texas MD Anderson Cancer Center Division of Radiation Oncology Houston, Texas The University of Texas MD Anderson Cancer Center Houston, Texas Craig A. Messick, MD Assistant Professor of Surgery Jose A. Karam, MD Department of Surgical Oncology Assistant Professor Section of Colon and Rectal Surgery Department of Urology The University of Texas MD Anderson Cancer Center The University of Texas MD Anderson Cancer Center Houston, Texas Houston, Texas Bassem Mezghani, MD Anna Kuan-Celarier, MD Department of Surgical Oncology Resident Institut Claudius Regaud–Institut Universitaire du Cancer Department of Obstetrics and Gynecology Toulouse, France Louisiana State University Health Science Center Salah Azaiz Cancer Institute New Orleans, Louisiana Tunis, Tunisia Eric Leblanc, MD Lucas Minig, MD, PhD Head, Department of Gynecologic Oncology Head Centre Oscar Lambret Department of Gynecology Lille, France Instituto Valenciano de Oncologia Valencia, Spain Fabrice Lécuru, MD, PhD University Paris Descartes Miziana Mokbel, MD Sorbonne Paris Cité Assistance Publique–Hôpitaux de Paris School of Medicine Hôpital Européen Georges-Pompidou Assistance Publique–Hôpitaux de Paris Gynecological Cancer and Breast Cancer Surgery Gynecological and Breast Cancer Surgery Paris, France Paris, France Camilla Nero, MD Mario M. Leitao, Jr., MD Division of Gynecologic Oncology Attending Gynecologic Oncologist Catholic University of the Sacred Heart Department of Surgery Rome, Italy Memorial Sloan Kettering Cancer Center Professor of Obstetrics and Gynecology Weill Cornell Medical College New York, New York viii Contributors Crystal Nhieu, MD, BS Giovanni Scambia, MD Resident Division of Gynecologic Oncology Department of Obstetrics and Gynecology Catholic University of the Sacred Heart Louisiana State University Health Science Center Rome, Italy Baton Rouge, Louisiana Brooke A. Schlappe, MD Rene Pareja, MD Gynecologic Oncology Fellow Department of Gynecologic Oncology Department of Surgery Instituto Nacional de Cancerologia Memorial Sloan Kettering Cancer Center Bogotá, Colombia New York, New York Clínica de Oncología Astorga Medellín, Colombia Yukio Sonoda, MD Gynecologic Oncologist Manuel Penalver, MD Department of Surgery Chairman, Department of Obstetrics and Gynecology Memorial Sloan Kettering Cancer Center Herbert Wertheim College of Medicine New York, New York Florida International University Miami, Florida Edward Tanner, MD Assistant Professor George T. Pisimisis, MD Department of Gynecology and Oncology Department of Thoracic and Cardiovascular Surgery The Johns Hopkins University Department of Interventional Radiology Baltimore, Maryland The University of Texas MD Anderson Cancer Center Houston, Texas Audrey T. Tsunoda, MD, PhD Surgical Oncologist Pedro T. Ramirez, MD Department of Surgical Oncology Professor Erasto Gaertner Hospital David M. Gershenson Distinguished Professor in Ovarian Curitiba, Brazil Cancer Research Director of Minimally Invasive Surgical Research and Stefano Uccella, MD, PhD Education Consultant Department of Gynecologic Oncology and Reproductive Department of Obstetrics and Gynecology Medicine University of Insubria The University of Texas MD Anderson Cancer Center Varese, Italy Houston, Texas Giuseppe Vizzielli, MD Reitan Ribeiro, MD Division of Gynecologic Oncology Surgical Oncologist Catholic University of the Sacred Heart Medical Residency Director Rome, Italy Department of Surgical Oncology Erasto Gaertner Hospital Vanna Zanagnolo, MD Curitiba, Brazil Division of Gynecology European Institute of Oncology Emery Salom, MD Milan, Italy Clerkship Director and Assistant Professor Florida International University Oliver Zivanovic, MD College of Medicine Attending Physician Division of Gynecologic Oncology Department of Surgery Miami, Florida Memorial Sloan Kettering Cancer Center New York, New York Gloria Salvo, MD Department of Gynecologic Oncology and Reproductive Medicine The University of Texas MD Anderson Cancer Center Houston, Texas David A. Santos, MD Assistant Professor of Surgery Department of Surgical Oncology The University of Texas MD Anderson Cancer Center Houston, Texas Foreword The first edition of Principles of Gynecologic Oncology Surgery for recurrent disease. The ovarian cancer section provides a capitalizes on the talents of three world-renowned experts in comprehensive roadmap for the surgical management of this the field of gynecologic cancer surgery. Drs. Ramirez, Frumo- disease, including indications for laparoscopic assessment for vitz, and Abu-Rustum have used the vast expertise of leaders cytoreduction through radical upper abdominal procedures and in the field—in the United States and abroad—to produce one intestinal surgery for the debulking of advanced ovarian cancer. of the most comprehensive textbooks on the surgical manage- In addition to the chapters on surgical management of ment of patients with gynecologic cancer. In the textbook’s gynecologic cancers, one of the major strengths of Principles of first section, “Anatomy and Principles of Surgery,” the editors Gynecologic Oncology Surgery is its coverage of surgery on the and authors provide their readers with in-depth descriptions of gastrointestinal and urinary tracts, as well as the management basic principles of anatomy required for radical upper abdomi- of surgical complications associated with these procedures. nal and pelvic surgery. The authors also integrate detailed high- Finally, the management of complications associated with radia- lights of all the items in the guidelines for the timely issue of tion therapy, as well as techniques in pelvic reconstruction and Enhanced Recovery After Surgery (ERAS). The subsequent the role of minimally invasive approaches with laparoscopic and sections focus on detailed descriptions of surgical procedures robotic techniques, provides for a well-rounded and compre- according to anatomic site of disease, including vulvar, cervi- hensive textbook. cal, uterine, and ovarian cancer. For each disease site, individual Principles of Gynecologic Oncology Surgery is destined to be chapters explore intricate surgical procedures, including state of an authoritative, high-quality resource in the field for years to the art techniques of sentinel lymph node mapping for cervi- come, whether for a resident, fellows in training, or a well- cal and endometrial cancers. In addition, the disease chapters established practitioner. This textbook will play a significant provide a comprehensive review of surgical techniques. For cer- role in developing and sharpening the skills of those dedicated vical cancer this includes the entire spectrum of surgical pro- to the surgical treatment of women with gynecologic cancer. cedures from conservative fertility-sparing procedures for early stage disease to radical surgery for more advanced disease, with Richard R. Barakat, MD a separate section highlighting ultraradical pelvic exenteration ix Preface In gynecologic oncology surgery, the surgeon must have a The goal of this textbook is to provide a format designed so that detailed understanding of the anatomy and basic principles of surgeons will have quick and easy access to relevant information— radical abdominal and pelvic surgery. In addition, each surgeon a textbook that will present information that is simple to under- must have a vast fund of knowledge about diagnosing and man- stand and fast to apply. In other words, we hope that surgeons will aging complications related to such complex surgical proce- use this book as a tool that will allow them to go over the steps dures. In this first edition of Principles of Gynecologic Oncology of each procedure just before entering the operating room. We Surgery, we aim to provide a comprehensive surgical textbook have compiled chapters that will serve as a roadmap to navigate that will serve not only experienced surgeons in gynecologic the complex anatomy of the abdomen or pelvis, with figures and oncology but also trainees and all those interested in learning illustrations that will provide descriptive strategies to achieve the the pertinent details related to various topics of surgery for each best results in the surgery. Video demonstrations, when appli- disease site in gynecologic cancers. The guiding principles for cable, will also allow the reader to have immediate access to the any gynecologic surgeon are (1) to understand the relevant and operating room of the skilled surgeons who wrote each chapter updated literature related to a disease site or surgically related and to learn from them the secrets to the success of their surgi- topic, (2) to have a solid understanding of the principles of eval- cal approach. The success of this textbook rests on the contribu- uation and management of most surgical scenarios in gyneco- tions from each of the internationally renowned chapter authors. logic oncology surgery, and (3) to derive treatment based on the They have all put in a tremendous amount of effort in writing and most up-to-date published literature. editing of the c hapters. In addition, the entire project would not This book is intended for all who wish to have a step-by-step have been p ossible without the tremendous amount of work, guid- guide to the most commonly performed procedures in gyne- ance, patience, and experience of the Elsevier editing team. We are cologic oncology. Our intent is for students of surgery, both deeply grateful to all who have contributed to this textbook. novice and experienced, to have a classic textbook where they Finally, we are indebted to our mentors who, since early in our can go not only to find the most relevant and concise source of careers, took the time and the effort to teach us their approach literature on a particular subject but also to seek details on the and to provide us with the best “tips and tricks” to make com- specific and key steps of surgical procedures and where they can plex surgical procedures more feasible. Their constructive criti- learn the ideal approach for each step of the surgery from lead- cism and detailed explanations are the essence of this textbook. ing surgeons throughout the world. The inspiration they provided is translated in the pages of this The world of surgery in gynecologic oncology is evolving textbook as a testament to the legacy that each of our surgical at a fast pace. Surgeons today are required to have a mastery mentors instilled in us. Our duty is to see that this textbook of innumerable approaches to gynecologic cancer surgery and serves as a tool that will enable gynecologic oncology surgeons are expected to become proficient not only in open surgery but throughout the world to provide the best and most comprehen- also in minimally invasive surgery, such as laparoscopy and sive surgical care to patients with gynecologic cancers. We are robotic surgery. New tools are constantly being developed that also grateful to our patients who not only endure the burden demand the surgeon’s time and skill, particularly in the early of disease but also allow us the privilege, every day, to care for learning phases. In addition, surgeons are expected to learn them. The gynecologic oncology surgeon must remind himself new approaches in the management of gynecologic cancers, or herself every day that he or she is gifted with the amazing such as sentinel lymph node mapping, with the understanding responsibility of eradicating cancer, and that to fulfill this hon- that the quality of the surgery dictates whether a patient will orable task, we must seek each day to expand our fund of knowl- have a full lymphadenectomy or be spared such a procedure edge, enhance our surgical skills, and integrate new and novel and potentially avoid its associated adverse effects. This evolu- approaches and technology. Most of all, though, we must seek tion of surgical education has changed the methods by which to remain humble in the face of such profound responsibility. surgeons acquire the necessary skills to perform gynecologic Let us all remember that each time we enter the operating room, oncology surgery, and these include surgical simulators, web- our fate and that of our patient lie not only in the skills of our based surgical training, seminars on video series, and live tele- hands or the capacity of our tools but more so on our ability to surgery. These are among some of the most common avenues make sound decisions that will always prioritize, above all, the for learning today, and therefore surgeons must adapt to this well-being of our patients. We hope that this textbook will serve wave of “nontraditional” learning. In this textbook, we aim to all who read it to become not only better surgeons and clinicians provide such video-based teaching when applicable. Surgeons but also better doctors. will be able to observe some of the most skilled surgeons in the world performing procedures of high complexity that will Pedro T. Ramirez, MD surely supplement and improve the surgical skills and practice Michael Frumovitz, MD of each reader. Nadeem Abu-Rustum, MD x SECTION 1 | Anatomy and Principles o“ mebooksfree CHAPTER 1 Introduction to Principles of Gynecologic Oncology Surgery PEDRO T. RAMIREZ The modern era of gynecologic oncology surgery began in becomestandardofcareinmostcenters,thusallowingpatients the 20th century with groundbreaking work by pioneering to undergo less morbid procedures with faster recoveries. surgeons who explored novel surgical options for women More recently, hysteroscopic resection ofendometrial tumors with gynecologic malignancies. Gynecologic oncology was in patients with low-risk disease has allowed young women not approved as a subspecialty ofobstetrics and gynecology interested in future fertility to undergo treatment that spares until 1973, when the American Board ofMedical Specialties theuteruswhileatthe sametimetreatsthe cancer. Eveninthe approveditasaspecialqualification.Subsequently,theSociety settingofadvancedovariancancer,patientsaremoreappropri- ofGynecologicOncology(SGO)wascreated,andmuchofthe atelyselectedforup-frontcytoreductivesurgeryorneoadjuvant credit for its foundation must be given to Hervy E. Averette chemotherapy according to the results of increasingly more andJohnI.Mikuta.ThefirstscientificmeetingoftheSGOwas accurateimagingmodalitiesandthroughthedirectassessment heldinKeyBiscayne, Florida, in 1969. ofabdominaltumorburdenbymeans oflaparoscopic surgery. Over the course ofthe past century, this specialtyhas wit- Similarly, improvements in perioperative management and nessed tremendous advances in surgical technique and indi- critical care allow surgeons to be much more aggressive when cations. Major innovations have been seen in imaging, cancer performing cytoreductive surgery or exenterative procedures detection, sentinellymphnode mapping, andtechnologywith in patients selected to undergo tumor debulking for advanced the introduction oflaparoscopyand robotic surgery. The field ovariancancer. has shifted from veryaggressive and deforming procedures to Principles ofGynecologic Oncology Surgery is a broad and moreprecise andconservative approaches. Womenwithgyne- comprehensive textbook for all surgeons whose primaryprac- cologic cancer have options that would never even have been tice involves the care ofwomen with gynecologic cancers. In considered until just a few years ago. In tumors ofthe vulva, eachchapter,thereaderlearnsthelatestandmostclinicallyrel— patients no longer undergo morbid radical tumor resection evantupdatesfromthepublishedliteratureonthetopicoffocus along with extensive groin lymphadenectomy. Extensive work of that particular chapter. In addition, each chapter presents evaluating the role of local excision combined with sentinel informationin a formatthat is practicalinthe managementof lymph node alone has led to the current tailored approaches patients with gynecologic malignancies. For each disease site, oiferedtopatients andthusadecreaseinratesofperioperative thereadershouldappreciate standardrecommendations inthe complications and long-term side effects, such as debilitating initial evaluation, the preoperative workup, the step-by-step lymphedema. The management ofcervical cancer has evolved approach to the surgical procedures pertinent to that disease from the times ofultraradical surgery, such as radical hyster- site,andthepostoperativeevaluationinthesettingofcomplica- ectomy,tomodifiedradicalsurgery, fertility-preservingradical tionsforeachoftheprocedurespresented. trachelectomy,orsimpleconization.Patientswithearlycervical Anumberofchaptersaddresstopicsthatareall-encompass- cancershouldnolongerbeexposedtoextensivelymphadenec- inginthe field ofgynecologic oncologysurgery. These include tomybut, rather, should undergo selective and targeted senti- chapters on Enhanced RecoveryAfterSurgery,whichis atopic nel lymph node mapping. For patients with locally advanced of significant impact in the perioperative care of all surgical cervical cancer, the role ofpretreatment selective lymph node patientsbut onethat isbecomingincreasinglymoreimportant dissection has been established as a tool to more definitively in allwomen undergoing gynecologic surgery. In that chapter, focus on the area ofinterest for radiation therapy. In patients the authors outline the current guidelines to be implemented with endometrial cancer, laparoscopy or robotic surgery has in any Enhanced Recovery After Surgery program, with an provided impressive outcomes, including fewer intraoperative emphasis on the importance ofcompliance with each ofthese and postoperative complications, when compared with open guidelines and, ultimately, a summaryofthe outcomes associ- surgery. Sentinel lymph node mapping algorithms have also ated with the implementation ofsuch programs. The textbook