Robotic surgery for early stage cervical cancer: Evolution and current trends

Novel prognostic nomograms in cervical cancer based on analysis of 1075 patients

OBJECTIVE

To explore the factors affecting the prognosis of cervical cancer (CC), and to construct and evaluate predictive nomograms to guide individualized clinical treatment.

METHODS

The clinicopathological and follow-up data of CC patients from June 2013 to December 2019 in Sun Yat-sen Memorial Hospital of Sun Yat-sen University were retrospectively analyzed. Log-rank test was used for univariate survival analysis, and Cox multivariate regression was used to identify independent prognostic factors, based on which nomogram models were established and evaluated in multiple aspects.

RESULTS

Patients were randomly assigned into the training (n = 746) and validation sets (n = 329). Survival analysis of the training set identified cervical myometrial invasion, parametrial involvement, and malignant tumor history as prognosticators of postoperative DFS and pathological type, cervical myometrial invasion, and history of STD for OS. C-index was 0.799 and 0.839 for the nomograms for DFS and OS, respectively. Calibration curves and Brier scores also indicated high performance. Importantly, decision curve analysis suggested great clinical applicability of these nomograms.

CONCLUSIONS

In this study, we analyzed a cohort of 1075 CC patients and identified DFS- or OS-associated clinicohistologic characteristics. Two nomograms were subsequently constructed for DFS and OS prognostication, respectively, and showed high performance in terms of discrimination, calibration, and clinical applicability. These models may facilitate individualized treatment and patient selection for clinical trials. Future investigations with larger cohorts and prospective designs are warranted for validating these prognostic models.

Peri-operative and survival outcomes analysis of patients with endometrial cancer managed by three surgical approaches: a long-term Bulgarian experience

The study aim was to assess the peri-operative, oncologic, and survival outcomes for patients with endometrial cancer (EC) managed by abdominal hysterectomy (AH), laparoscopic hysterectomy (LH), or robotic hysterectomy (RH) approaches at premier centers in Bulgaria. We analyzed histologically diagnosed EC cases operated via any of the three surgical methods during 2008-2019. Data analyses included patients and tumor characteristics, peri-operative outcomes, and disease status. We grouped FIGO stages I and II to represent early-stage EC and to investigate their survival. Kaplan-Meier and Cox regression analyses were performed to determine disease-free survival (DFS) and overall survival (OS). Consecutive 917 patients (AH = 466; LH = 60, RH = 391) formed the basis of study analyses. Most of demographics and tumor characteristics of the patients were comparable across the groups except few minor variations (e.g., LH/RH cases were younger, heavier, more stage IA, endometrioid, G1, low-risk group). LH and RH group cases had significantly lower operative time than AH (p < 0.001), shorter hospital length-of-stay (p < 0.001), higher post-operative Hgb (p < 0.001). RH cases had fewer blood transfusions than AH or LH (p < 0.001). Cox multivariate analyses indicate that OS was not influenced by the type of surgical approach. Despite the fact that the DFS in "early-stage" EC is significantly better in AH group than RH, the type of surgery (i.e., AH, LH, or RH) for "all stages" is insignificant factor for DFS. With our long-term experience, minimally invasive surgical approach resulted in superior peri-operative, oncologic, and survival outcomes. Specifically, RH is not only safe in terms of post-operative results, but also for mortality and oncologic rates.

Analysis of abdominal vs. robotic radical hysterectomies for patients with cervical cancer: a Bulgarian experience

To assess and compare the peri-operative, oncologic, and survival outcomes for women with cervical cancer (CC) treated with abdominal radical hysterectomy (ARH) versus robotic radical hysterectomy (RRH) approaches in Bulgaria. We retrospectively analyzed patients with histologically diagnosed CC operated via ARH or RRH methods during January-2008 to April-2019. The data analyzed include patients and tumor characteristics, peri-operative outcomes, and disease status. Kaplan-Meier method and Cox regression analysis were performed to determine disease-free survival (DFS) and overall survival (OS). There were consecutive 1347 patients (ARH = 1006, RRH = 341), which formed the basis of study analyses. Women in the RRH group had significantly shorter median hospital length-of-stay than ARH cases (7 vs. 11 days, p < 0.001), higher post-operative hemoglobin (116 vs. 108 g/L, p < 0.001), and fewer blood transfusions (7.3% vs. 21.5%, p < 0.001), respectively. The overall incidence of post-operative complications was also lower in the RRH vs. ARH group (2.1% vs. 9.4%, p < 0.001). Median follow-up time for ARH vs. RRH groups was 4.32 vs. 5.24 years, respectively (p < 0.001). Kaplan-Meier analysis demonstrated that the RRH cohort had a significantly higher survival rate compared to the ARH group (CC-specific death 8.5% vs. 16.5% respectively). Mean time to recurrence did not differ significantly in either surgical approach (p = 0.495). Cox multivariate regression showed no significant impact of surgical approach on DFS or OS. No significant difference in DFS or OS between ARH vs. RRH for CC was observed. RRH approach does not lead to inferior oncologic outcomes and is associated with better peri-operative outcomes. In regard to "all stages" of CC, we found robotic surgery safer compared to laparotomy, and thus consider RRH a better surgical treatment option for patients with CC.

Oncological Results of Laparoscopically Assisted Radical Vaginal Hysterectomy in Early-Stage Cervical Cancer: Should We Really Abandon Minimally Invasive Surgery?

Simple Summary

Some recently published studies in early-stage cervical cancer patients have shown that minimally invasive surgery (MIS), including laparoscopic and robotic approaches, might offer lower survival rates than classic open surgery. We evaluated the oncological results of a series of patients treated by laparoscopically assisted radical vaginal hysterectomy (LARVH), an infrequently used MIS technique. We included 115 patients with early-stage cervical cancer (IA1 with lymphovascular invasion, IA2, IB1, and IIA < 2 cm; International Federation of Gynecology (FIGO), 2008). The 3- and 4.5-year disease-free survival rates were 96.7% and 93.5%, respectively, and the overall survival was 97.8% and 94.8%, respectively. These survival data are comparable with those reported with the open radical hysterectomy but presented the advantages of MIS. LARVH offers excellent disease control in women with early-stage cervical cancer and can be considered as an adequate MIS alternative to open radical hysterectomy.

Abstract

Background: Recent evidence indicates that some minimally invasive surgery approaches, such as laparoscopic and robotic-assisted radical hysterectomy, offer lower survival rates to patients with early-stage cervical cancer than open radical hysterectomy. We evaluated the oncological results of a different minimally invasive surgery approach, that of laparoscopically assisted radical vaginal hysterectomy (LARVH) in this setting. Methods: From January 2001 to December 2018, patients with early-stage cervical cancer were treated by LARVH. Colpotomy and initial closure of the vagina were performed following the Schauta operation, avoiding manipulation of the tumor. Laparoscopic sentinel lymph node (SLN) biopsy was performed in all cases. Women treated between 2001 and 2011 also underwent pelvic lymphadenectomy. Results: There were 115 patients included. Intraoperative complications occurred in nine patients (7.8%). After a median follow-up of 87.8 months (range 1–216), seven women (6%) presented recurrence. Four women died (mortality rate 3.4%). The 3- and 4.5-year disease-free survival rates were 96.7% and 93.5%, respectively, and the overall survival was 97.8% and 94.8%, respectively. Conclusion: LARVH offers excellent disease-free and overall survival in women with early-stage cervical cancer and can be considered as an adequate minimally invasive surgery alternative to open radical hysterectomy.

Minimally invasive surgery versus laparotomy for radical hysterectomy in the management of early-stage cervical cancer: Survival outcomes

OBJECTIVE

To compare oncologic and perioperative outcomes in patients who underwent minimally invasive surgery (MIS) compared to laparotomy for newly diagnosed early-stage cervical carcinoma.

METHODS

We retrospectively identified patients who underwent radical hysterectomy for stage IA1 with lymphovascular invasion (LVI), IA2, or IB1 cervical carcinoma at our institution from 1/2007-12/2017. Clinicopathologic characteristics and surgical and oncologic survival outcomes were compared using appropriate statistical testing. Multivariable Cox regression analysis was used to control for potential confounders.

RESULTS

We identified 196 evaluable cases-117 MIS (106 robotic [90.6%]) and 79 laparotomy cases. Cohorts had similar age, BMI, substage, histologic subtype, clinical and pathologic tumor size, positive margins, and presence of LVI. The MIS group had more cases with no residual tumor in the hysterectomy (24.8% vs. 10.1%, P = 0.01). The laparotomy group had more cases with positive nodes (29.1% vs. 17.1%, P = 0.046) and more patients who received adjuvant therapy (53.2% vs. 33.3%, P = 0.006). Median follow-up was ~4 years. Five-year disease-free survival (DFS) rates were 87.0% in the MIS group and 86.6% in the laparotomy group (P = 0.92); 5-year disease-specific survival (DSS) rates were 96.5% and 93.9%, respectively (P = 0.93); and 5-year overall survival (OS) rates were 96.5% and 87.4%, respectively (P = 0.15). MIS was not associated with DFS, DSS, or OS on multivariable regression analysis. The rate of postoperative complications was significantly lower in the MIS cohort (11.1% vs. 20.3%; P = 0.04).

CONCLUSIONS

MIS radical hysterectomy for cervical carcinoma did not confer worse oncologic outcomes in our single-center and concurrent series of patients with early-stage cervical carcinoma.

Comparative analysis of robotic vs laparoscopic radical hysterectomy for cervical cancer

BACKGROUND

Cervical cancer is the most common gynecological malignancy, ranking first in female reproductive malignancies with more than 500000 new cases and 275000 deaths each year. Traditionally, open radical hysterectomy is considered the standard surgical procedure for the treatment of resectable cervical cancer. The latest guidelines from the National Comprehensive Cancer Network and the European Society of Gynecological Oncology suggest that open surgery and laparoscopic surgery (using traditional laparoscopic or robotic techniques) are the main surgical approaches for radical hysterectomy for patients with stage IA2-IIA cervical cancer. Robotic surgery has been increasingly used in abdominal surgery and has shown more beneficial effects.

AIM

To analyse the perioperative conditions, complications, and short-term and long-term effects in patients undergoing robotic radical hysterectomy (RRH) and laparoscopic radical hysterectomy (LRH) to compare their clinical efficacy, safety, and feasibility.

METHODS

The perioperative data of patients undergoing RRH and LRH were extracted and collected from the database of surgical treatments for cervical cancer for statistical analysis.

RESULTS

Of the patients, 342 underwent LRH for cervical cancer, and 216 underwent RRH. The total complication rate was 9.65% (20 patients) in the RRH group and 17.59% (60 patients) in the LRH group. The complication rate was significantly lower in the RRH group than in the LRH group. There was no significant difference in the follow-up period (P = 0.658). The total recurrence rates were 15.7% and 12% in the RRH and LRH groups, respectively. The progression-free survival time was 28.91 ± 15.68 mo and 28.34 ± 15.13 mo in the RRH and LRH groups, respectively (P = 0.669). The overall survival (OS) rates were 92.13% and 94.45% in the RRH and LRH groups, respectively (P = 0.292). The OS time was 29.87 ± 15.92 mo and 29.41 ± 15.14 mo in the RRH and LRH groups, respectively (P = 0.732). The survival curves and the progression-free survival curves were not statistically significantly different between the two groups (P = 0.407 and 0.28, respectively).

CONCLUSION

RRH is associated with significantly less operative time and blood loss than LRH. The two procedures have similar complication rates, OS, and progression-free survival time.

Efficacy of robotic radical hysterectomy for cervical cancer compared with that of open and laparoscopic surgery: A separate meta-analysis of high-quality studies

BACKGROUND

To perform a meta-analysis of high-quality studies comparing robotic radical hysterectomy (RRH) vs laparoscopic radical hysterectomy (LRH), and open radical hysterectomy (ORH) for the treatment of cervical cancer.

METHODS

A systematic search of PubMed, Embase, Cochrane Library, and Web of Science was performed to identify studies that compared RRH with LRH or ORH. The selection of high-quality, nonrandomized comparative studies was based on a validated tool (methodologic index for nonrandomized studies) since no randomized controlled trials have been published. Outcomes of interest included conversion rate, operation time, intraoperative estimated blood loss (EBL), length of hospital stay (LOS), morbidity, mortality, number of retrieved lymph nodes (RLNs), and long-term oncologic outcomes.

RESULTS

Twelve studies assessing RRH vs LRH or ORH were included for this meta-analysis. In comparison with LRH, there was no difference in operation time, EBL, conversion rate, intraoperative or postoperative complications, LOS, and tumor recurrence (P > .05). Compared with ORH, patients underwent RRH had less EBL (weighted mean difference [WMD] = -322.59 mL; 95% confidence interval [CI]: -502.75 to -142.43, P < .01), a lower transfusion rate (odds ratio [OR] = 0.14, 95% CI: 0.06-0.34, P < .01), and shorter LOS (WMD = -2.71 days; 95% CI: -3.74 to -1.68, P < .01). There was no significant difference between RRH and LRH with respect to the operation time, intraoperative or postoperative complications, RLN, and tumor recurrence (P > .05).

CONCLUSION

Our results indicate that RRH is safe and effective compared to its laparoscopic and open counterpart and provides favorable outcomes in postoperative recovery.

Case report: term birth after fertility-sparing treatments for stage IB1 small cell neuroendocrine carcinoma of the cervix

Background

Advances in cervical cancer management for childbearing women have led to less radical approaches. Use of fertility-sparing treatment to treat small cell neuroendocrine carcinoma (SCNEC) is challenging owing to the aggressive nature of the disease, even in early stage disease.

Case presentation

A 25-year-old nulligravida woman presented with malodorous vaginal discharge and was diagnosed to have an exophytic cervical SCNEC. A magnetic resonance image scan showed no evidence of parametrial invasion or distant metastasis. Clinical staging allocated her to stage IB1 disease. She underwent radical abdominal trachelectomy for reproductive purpose. Preoperative and postoperative chemotherapy with ifosfamide/etoposide/cisplatin combining gonadotropin-releasing hormone agonist were administered. She had a spontaneous, uneventful pregnancy and successfully delivered a term baby via cesarean section 7 years after treatment.

Conclusion

To our knowledge, we describe the first success in offering a fertility-preserving multimodality strategy to present favorable oncologic, reproductive, and obstetric outcomes in a fertile woman of stage I SCNEC. Individualized multimodality therapy may be utilized in specific patients with early-stage cervical cancer to preserve their fertility.

Minimally Invasive vs. Open Hepatectomy: a Comparative Analysis of the National Surgical Quality Improvement Program Database

BACKGROUND

While minimally invasive surgery (MIS) to treat liver tumors has increased, data on perioperative outcomes of MIS relative to open liver resection (O-LR) are lacking. We sought to compare short-term outcomes among patients undergoing MIS vs. O-LR in a nationally representative database.

METHODS

The National Surgical Quality Improvement Program database was used to identify patients undergoing hepatectomy between January 1 and December 31, 2014. Propensity score matching algorithm was used to balance differences in baseline characteristics among MIS and O-LR groups.

RESULTS

A total of 3064 patients were included in the study. After propensity matching, the baseline characteristics for O-LR and MIS groups were comparable (minimum p value = 0.12). Incidence of superficial surgical site infections, intraoperative or postoperative blood transfusions, and pulmonary embolism was lower among patients in MIS group compared to O-LR (p < 0.02). Liver failure and biliary leakage were also less frequent among patients undergoing MIS (p < 0.01). Similarly, MIS was associated with a shorter length of hospital stay (LOS) compared to O-LR (p < 0.001). Of note, 30-day postoperative mortality and readmission were comparable between the two groups.

CONCLUSIONS

Patients undergoing MIS had a lower postoperative morbidity and shorter LOS compared with patients undergoing O-LR. MIS is safe and may be associated with improved short-term outcomes following hepatic surgery.

Surgical Treatment of Early-Stage Cervical Cancer

Surgical treatment of cervical cancer has been a cornerstone in the management of this malignancy for more than 100 years. Today, for early-stage and low-risk cervical cancer, surgery is still considered the gold standard. If the preoperative assessment of the tumor reveals a situation prompting postoperative adjuvant radiochemotherapy, the latter should be planned as the primary treatment option, being preceded by staging laparoscopy including pelvic and paraaortic lymph node dissection. As an alternative to the open approach, the definitive surgical treatment should be either performed laparoscopically, or be laparoscopic-assisted, or laparoscopically robotic-assisted.

Navigation of a robot-integrated fluorescence laparoscope in preoperative SPECT/CT and intraoperative freehand SPECT imaging data: a phantom study

Robot-assisted laparoscopic surgery is becoming an established technique for prostatectomy and is increasingly being explored for other types of cancer. Linking intraoperative imaging techniques, such as fluorescence guidance, with the three-dimensional insights provided by preoperative imaging remains a challenge. Navigation technologies may provide a solution, especially when directly linked to both the robotic setup and the fluorescence laparoscope. We evaluated the feasibility of such a setup. Preoperative single-photon emission computed tomography/X-ray computed tomography (SPECT/CT) or intraoperative freehand SPECT (fhSPECT) scans were used to navigate an optically tracked robot-integrated fluorescence laparoscope via an augmented reality overlay in the laparoscopic video feed. The navigation accuracy was evaluated in soft tissue phantoms, followed by studies in a human-like torso phantom. Navigation accuracies found for SPECT/CT-based navigation were 2.25 mm (coronal) and 2.08 mm (sagittal). For fhSPECT-based navigation, these were 1.92 mm (coronal) and 2.83 mm (sagittal). All errors remained below the <1-cm detection limit for fluorescence imaging, allowing refinement of the navigation process using fluorescence findings. The phantom experiments performed suggest that SPECT-based navigation of the robot-integrated fluorescence laparoscope is feasible and may aid fluorescence-guided surgery procedures.