Ilker Kahramanoglu

Practical strategies for environmentally sustainable practices in gynecologic oncology

Sustainability in health care is an increasingly urgent priority, and gynecologic oncology (as a resource-intensive surgical specialty) offers opportunities to reduce environmental impact without compromising patient care. This review provides actionable, evidence-based strategies that individual clinicians, departments, and institutions can readily implement into routine practice. Practical anesthetic strategies, such as total intravenous anesthesia, regional anesthesia, and low-flow techniques, substantially decrease greenhouse gas emissions. Transitioning from disposable to reusable surgical instruments, drapes, and gowns significantly curbs waste. Energy-efficient solutions in the operating room, including optimized heating, ventilation, air conditioning systems, as well as light emitting diode lighting, minimize unnecessary energy use. Optimizing diagnostic imaging through clinical justification and powering down equipment when feasible further decreases energy consumption. Pharmaceutical-related strategies, including accurate chemotherapy dosing, safe medication disposal through drug take-back programs, and environmentally conscious procurement, mitigate harmful emissions and pharmaceutical waste. Surgical techniques such as sentinel lymph node biopsy, rather than extensive lymphadenectomy, also support sustainability goals by reducing resource consumption and procedural waste. Digital innovations, notably telemedicine, demonstrate clear environmental advantages by minimizing patient travel, particularly for routine follow-up and the collection of patient-reported outcomes. Enhanced Recovery After Surgery protocols, promoting shorter hospital stays and digital preoperative assessments, represent additional avenues for improvement. Preventive interventions, such as human papillomavirus vaccination programs and early cancer screening, are vital long-term sustainability investments, reducing resource-intensive treatments associated with advanced disease. By highlighting practical examples from recent studies and clinical experience, this review aims to encourage widespread adoption of sustainable practices in gynecologic oncology, aligning clinical excellence with global environmental goals.

Comparison of oncologic outcome of preoveratively presumed low-risk endometrial cancer patients who underwent only bilateral pelvic sentinel lymph node (SLN) removal and those who underwent pelvic lymphadenectomy in addition to bilateral pelvic SLN removal: Turkish Gynecologic Oncology Group (TRSGO-SLN-009)

We aimed to compare the oncological outcomes of patients with bilateral sentinel lymph nodes (SLNs) detection and removed with those who underwent pelvic lymphadenectomy (PLA) in addition to bilateral SLNs removal. This multicenter, retrospective study included cases of endometrioid type, grade I-II endometrial cancer, in which bilateral SLNs were detected and removed. Patients who had only bilateral SLNs detected and removed (group I) and patients who had bilateral SLNs detected and removed and subsequent additional bilateral PLA (group II) were included in the evaluation. In group I (n=216), SLN metastasis rate was 5.5% and in group II (n=251), it was 10.3%. The low-volume disease detection rate was 4.6% in group I and 4.8% in group II. In group II, in patients with SLN macrometastasis had also 28.6% non-SLN macrometastasis. No false-negative results occurred in group II. Recurrence was detected 1.8% in group I and 5% in group II; however, there was no significant difference (p=0.083). Disease-free survival and overall survival, were almost same between the groups (hazard ratio [HR]=2.11; 95% confidence interval [CI]=0.681-6.588; p=0.187) and (HR=1.531; 95% CI=0.392-5.975; p=0.537), respectively. SLN mapping, ultrastaging, and immunohistochemical staining can identify low-volume metastases that may not be identified with classic lymphadenectomy and hematoxylin & eosin staining. It has been observed that adding PLA beyond SLN mapping did not provide an additional positive contribution to survival. For endometriod type grade I-II patients, detection of bilateral SLNs in both hemipelvis only, if detectable, is an adequate approach.

Current practice with operative hysteroscopy for fertility preservation in endometrial cancer and endometrial premalignancies

The primary aim was to analyze the current practices on the use of operative hysteroscopy for preserving fertility in patients diagnosed with endometrial cancer and premalignancies. Our secondary objectives included investigating medical therapy and analyzing reported pregnancy-related outcomes subsequent to fertility preservation procedures. We performed a semi-systematic literature review on PubMed, employing pertinent terms related to hysteroscopy, fertility preservation, and endometrial cancer and premalignancies. Patients undergoing operative hysteroscopy with or without following medical treatment were included. We adhered to the PRISMA 2020 statement and utilized Covidence software to manage our systematic review. We performed a pooled analysis on various outcomes. Our final analysis included 15 studies evaluating 458 patients, where 238 (52.0%) were diagnosed with endometrial cancer, and 220 (48.0%) had endometrial premalignancies. With 146 pregnancies in our study, the overall pregnancy rate was 31.9%. Among these, 97 resulted in live births, accounting for 66.4% of the reported pregnancies. In terms of medical treatment, various forms of progestins were reported. Complications or adverse effects related to operative hysteroscopy were not reported in more than half of the studies. Among those studies that did report them, no complications nor adverse effects were documented. After hysteroscopic resection, complete response to medical treatment has been reported in 65.5% of the overall cases. Our review sheds light on the contemporary landscape of operative hysteroscopy for fertility preservation in endometrial cancer and premalignancies. Future studies should include the integration of molecular classification into fertility-preserving management of endometrial malignancies to offer a more personalized and precise strategy.