Eiji Kobayashi

A Survey of Current Practice and Perspectives on Lymphadenectomy in Minimally Invasive Surgery for Endometrial Cancer in Japan

ABSTRACT Objective This study investigated the reasons behind the decreasing trend of lymph node dissection for endometrial cancer (EC) in Japan, focusing on the impact of minimally invasive surgery (MIS) adoption, evolving clinical guidelines, and physician work‐style reform. Methods A cross‐sectional survey of the Japan Society of Gynecologic Oncology and Endoscopy (JSGOE) members was conducted to investigate facility demographics, MIS adoption, lymphadenectomy practices, factors influencing omission, impact of work‐style reform, and perspectives on future EC management, such as molecular classification and sentinel lymph node biopsy (SLNB). Results In total, 424 responses were received, representing a response rate of 67.8%. MIS adoption for EC is widespread in Japan, with laparoscopy preferred over robotic surgery. Lymphadenectomy is commonly performed; however, the criteria for omission varied among institutions, with clinical guidelines published by the Japanese Society of Gynecologic Oncology having the greatest impact. Physician work‐style reform significantly affected surgical practices such as surgical scheduling, adherence to time limits, and the number of surgeons participating in surgeries, while it had little impact on the criteria for lymphadenectomy omission. The adoption of molecular classifications is increasing with approximately half of the institutions planning to implement or having partially implemented them, while SLNBs remained relatively low. Conclusion This study highlights the significant impact of evolving clinical guidelines on lymphadenectomy practices for MIS for EC in Japan, and the limited impact of physician work‐style reform.

The value of vaginal cytology for postoperative surveillance of endometrial cancer

The value of conducting vaginal cytology surveillance after endometrial cancer (EC) surgery has not been fully established, yet in Japan it is still performed routinely in many institutions. We have retrospectively examined its diagnostic and prognostic values. We studied 759 EC cases that underwent hysterectomy at our hospital in Osaka, Japan from January 2010 to December 2019. Information on the clinicopathological factors at the time of initial and postoperative treatments, and the sites and diagnostic timing of recurrences were extracted from medical records and analyzed. Recurrences from primary EC were observed in 11.2% of the patients (85/759). In 23.5% of the cases (20/85), the recurrence included a vaginal component. The two most common single-sites of recurrence were vagina (14.1%, 12/85) and lung (12.9%, 11/85). The diagnosis of vaginal recurrence was made from symptoms and gynecological examination in 14 of the 20 cases. Only one was diagnosed solely by vaginal cytology; in that case, macroscopic lesions appeared two months after obtaining the abnormal cytology. We found that, in postoperative follow-up surveillance for EC, most cases of vaginal recurrence were first diagnosed by a careful pelvic examination. For current routine postoperative practice, monitoring critical symptoms and conducting careful gynecological examinations has been shown to be more important than cytological examinations.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross‐sectional survey for JSGOE members

AbstractAimMinimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross‐sectional questionnaire survey to ascertain the status of MIS for endometrial cancer.MethodsThe survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed.ResultsThe total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board‐certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan.ConclusionThis study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra‐fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

Postoperative lymphocyst formation after pelvic lymphadenectomy for gynecologic cancers: comparison between laparoscopy and laparotomy

The goal of this study was to evaluate, using definitive diagnostic criteria, the incidence of lymphocyst formation following pelvic lymphadenectomy for gynecological cancer, and to compare rates between the approaches of laparoscopy and laparotomy. We retrospectively reviewed the medical records of all patients who underwent pelvic lymphadenectomy for cervical or endometrial cancer between March of 2010 and March of 2016. We defined a lymphocyst as a circumscribed collection of fluid within the pelvic cavity, with a diameter of 2 cm or more, as diagnosed with ultrasound or computed tomography. During the six-year observational period, a pelvic lymphadenectomy was conducted in 196 women with clinical stage I uterine cancer; 90 cases underwent laparoscopy, 106 underwent laparotomy. The minimally invasive laparoscopic group had a lower estimated blood loss (p < 0.01), shorter hospital stay (p < 0.01). Lymphocysts were observed in 14.4% (13/90) of the laparoscopy cases, and in 15.1% (16/106) of the laparotomy cases which means no significant difference of lymphocyst (p = 1.00). The median size of symptomatic lymphocyst was significantly larger in laparotomy group than in laparoscopy group (4.8 cm v.s. 2.8 cm, median) (p = 0.04). Symptomatic lymphocysts were more common in laparotomy [7/90 (7.8%) vs 14/106 (13.2%) (p = 0.253)]. In a retrospective analysis with a strict diagnostic criteria, we could find no statistical difference in lymphocyst occurrence between laparoscopy and laparotomy. The median size of the lymphocyst was bigger and lymphocyst was likely to be symptomatic in the laparotomy group.

A retrospective assessment of the safety and efficacy of laparoscopic radical hysterectomy in Japan during the early years following its introduction: a Japanese Gynecologic Oncology Group study (JGOG1081S)

To evaluate the safety and efficacy of laparoscopic radical hysterectomy (LRH) for cervical cancer, in terms of morbidity and short-term oncologic outcome following LRH's introduction into Japan. We conducted a retrospective analysis of patients with early-stage cervical cancer (FIGO staging IA2, IB1, and IIA1) who underwent LRH from Dec 2014 to Dec 2016. We assessed the morbidity, overall survival (OS) and recurrence-free survival (RFS), and prognostic factors for RFS. A total of 251 patients were included from 22 facilities across Japan. There were 8 cases of stage IA2 cervical cancer, 226 of IB1, and 17 of IIA1. The median operating time was 343 min and the median blood loss was 190 ml. Two patients (0.8%) had a postoperative complication with a Clavien-Dindo classification of grade 3 or higher. After a median follow-up time of 15.6 months, the 2-year RFS was 87.4%, and the 2-year OS was 97.8%. When the 2-year RFS rate was compared with whether the patient pathologically had tumors of less than 2 cm, versus 2 cm or more, the RFS was 95.8% and 80.4%, respectively. Multivariate analysis found that tumor size and the route of lymph node removal were independent prognostic factors for recurrence. When LRH was first introduced into Japan, we found that the route of lymph node removal was an independent prognostic factor for recurrence in addition to large tumors (≥ 2 cm). Our results suggest that prognosis may be secured by paying attention to the lymph node removal route.

Overview of laparoscopic surgery for cervical cancer in Japan: Updates after the laparoscopic approach to cervical cancer trial

AbstractLaparoscopic radical hysterectomy (LRH) for cervical cancer has been reported to be similar oncologic outcome compared to abdominal radical hysterectomy (ARH) in many retrospective studies. In Japan, LRH has been covered by insurance since April 2018. In 2018, the same year that LRH became covered by insurance, Ramirez et al. at MD Anderson Cancer Center reported the results of a large phase III laparoscopic approach to cervical cancer trial (LACC trial) on the prognosis of open versus laparoscopic/robot‐assisted minimally invasive radical hysterectomy. The results showed that minimally invasive approaches were associated with a higher rate of recurrence and death. At this point, it is not clear what is wrong with LRH and why it has a poorer prognosis compared to ARH. In this report, after the LACC report, we would like to review the current status of minimally invasive surgery for cervical cancer and future directions.

Challenge to improve Japan's deplorable HPV vaccination rate by local government actions

AbstractAimIn Japan, in 2013, following reports of several alleged adverse reactions in young girls following vaccination, the previously successful national human papillomavirus infection (HPV) vaccination program collapsed rapidly. In the 8 years since vaccination rates have hovered near zero. In October of 2020, in an attempt to mitigate this lingering disaster, the Japanese Ministry of Health, Labor, and Welfare (MHLW) agency finally revised its HPV vaccination informational leaflet that was designed to be distributed by local governments nationwide. Prior to this revision, Toyonaka City, in Japan's Osaka province, had already begun sending out their own unique leaflet to girls in the targeted 6th–10th grades. As a preview of how MHLW's revised leaflet might eventually succeed, we have studied the HPV vaccination results from Toyonaka City's experiment.MethodThis study was a population‐based analysis that compared the monthly rates of new vaccinations in girls of a targeted grade school age group. We looked at rates before and after the leaflets were sent by Toyonaka City's Division of Health Promotion and Senior Services.ResultsThe vaccination rates between April 2020 and March 2021 were improved across all grades; 1.2% in 6th grade (p = 0.000185), 2.5% in 7th grade (p &lt; 0.0001), 3.5% in 8th grade (p &lt; 0.0001), 6.8% in 9th grade (p &lt; 0.0001), and a remarkable 16.5% in 10th grade (p &lt; 0.0001).ConclusionWhen a local government sends an HPV informational leaflet targeted at young girls, it can significantly improve their HPV vaccination rates.

Intracorporeal colpotomy using the Gutclamper as a novel clamping device to prevent tumor spillage during laparoscopic radical hysterectomy for cervical cancer

AbstractIntroductionTumor cell spillage during the colpotomy has been suspected as one reason for poor oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer. To prevent such tumor spillage in LRH, we focused on use of a Gutclamper which is a device originally designed to clamp the colon and rectum during colorectal resections.Materials and Surgical TechniqueA woman with stage IB1 cervical cancer underwent LRH using the Gutclamper. The Gutclamper was inserted into the abdominal cavity via 5‐mm trocar, the vagina was clamped, and an intracorporeal colpotomy was performed caudal to this device.DiscussionThe Gutclamper can be used to clamp the vaginal canal and avoid the exposure of cervical tumor, regardless of the surgeon's skills or patient conditions. An intracorporeal colpotomy using the Gutclamper can contribute to the standardization of LRH.