Laparoscopic Radical Hysterectomy with Enclosed Colpotomy and without the Use of Uterine Manipulator for Early-Stage Cervical Cancer

An optimized robotic surgical technique for cervical cancer: investigating whether the use of the pulling robotic arm has better surgical outcomes

Objective

The evidence for adopting the 3^rd robotic arm (RA) called the pulling RA rather than a uterine manipulator to manipulate the uterus in the robotic radical hysterectomy (RRH) for cervical cancer is still limited. We present a single-center retrospective experience comparing using the pulling RA to replace a uterine manipulator vs. using a uterine manipulator to manipulate the uterus in RRH.

Methods

106 patients diagnosed with IA, IB1-IB2 and IIA1 cervical cancer were retrospectively included for intraoperative and postoperative parameters analysis. 50 patients received RRH by adopting the pulling RA instead of a uterine manipulator to pull the uterus (3-RA RRH group), and another 56 patients were performed RRH with a uterine manipulator (2-RA RRH group). RRH with the pulling RA consisted of a camera arm, 3 RAs including a pulling RA, and 2 conventional assistant arms (3-RA RRH group). In comparison, RRH with a uterine manipulator included 2 RAs and 2 conventional assistant arms (2-RA RRH group). Besides, 3-RA' RRH group was selected from the 25^th-50^th cases in the 3-RA RRH group based on the learning curve and was compared with the 2-RA RRH group in terms of intraoperative and postoperative parameters.

Results

The patients' early post-operative complication (≤7 days) (p=0.022) and post-operative anemia (p < 0.001) of the 3-RA RRH were significantly lower than that in the 2-RA RRH group. The results of comparing the 2-RA RRH group with the 3-RA' RRH group were consistent with the aforementioned results, except for the operative time (220.4 vs. 197.4 minutes, p=0.022) and hospital stay (7.8 vs. 8.7 days, p=0.034). The median follow-up in the 3-RA RRH and 2-RA RRH groups was 29 and 50 months till March 2023. The 3-RA RRH and 2-RA RRH groups' recurrence rates were 2% (1/50) and 5.4% (3/56), respectively. The mortality in the 3-RA RRH and 2-RA RRH groups was 2% (1/50) and 3.5% (2/56), respectively.

Conclusion

Our study suggested that replacing the uterine manipulator via the 3^rd RA is viable; the results showed comparable surgical outcomes between the two methods. Thus, 3-RA RRH could be considered a well-executed surgical option in well-selected patients.

Effect of modified radical laparoscopic hysterectomy versus open radical hysterectomy on short-term clinical outcomes in early-stage cervical cancer: a single-center, prospective, randomized controlled trial

BACKGROUND

The long-term prognosis of minimally invasive surgery and open surgery for early cervical cancer is controversial. This study mainly discusses the feasibility and effectiveness of the endocutter in radical laparoscopic hysterectomy for early cervical cancer.

METHODS

A single-center, prospective, randomized controlled trial of modified radical laparoscopic hysterectomy on patients with FIGO stage IA1 (lymphovascular invasion), IA2, and IB1 cervical cancer, between January 2020 and July 2021. Patients were randomly assigned into laparoscopic radical hysterectomy (LRH) and open radical hysterectomy (ORH) groups. The ORH group used right-angle sealing forceps for vaginal stump closure, whereas the LRH group used endoscopic staplers. The primary outcomes included the evaluation of the patient's perioperative indicators, as well as short- and long-term complications. Recurrence and overall survival were considered secondary outcomes.

RESULTS

As of July 2021, 17 patients were enrolled in the laparoscopic surgery group and 17 in the open surgery group. The hospitalization time of the laparoscopic group was significantly shorter than those of the open group (15 min vs. 9 min, P < 0.001). The vaginal stump closure time in the laparoscopic group was longer than that in the open surgery group, and the difference was statistically significant (P < 0.001). Post-operative catheter removal (P = 0.72), drainage tube removal time (P = 0.27), number of lymph node dissections (P = 0.72), and incidence of intraoperative and post-operative complications between the two groups (P > 0.05). The median blood loss in the laparoscopic group was 278 ml, and it was 350 ml in the laparotomy group. The intraoperative blood transfusion rate was lower in the laparoscopic group; however, these differences did not reach statistical significance (P = 0.175). Vaginal margin pathology and peritoneal lavage cytology were negative, and all the patient's vaginal stumps healed without infection. The median follow-up time of the laparoscopic group was 20.5 months, and it was 22 months for the open surgery group. There was no recurrence in all patients during the follow-up period.

CONCLUSIONS

Modified LRH with endocutter closure of the vaginal stump is an effective approach and not inferior to ORH in treating patients with early-stage cervical cancer.

TRIAL REGISTRATION

ChiCTR2000030160, date of registration February 26, 2020 ( https://www.chictr.org.cn/showprojen.aspx?proj=49809 ).

Does the Use of a Uterine Manipulator or Intracorporeal Colpotomy Confer an Inferior Prognosis in Minimally Invasive Surgery-Treated Early-stage Cervical Cancer?

STUDY OBJECTIVE

To identify whether the use of a uterine manipulator (UM) or intracorporeal colpotomy conferred inferior short-term survival among patients treated for early-stage cervical cancer.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-based hospital.

PATIENTS

1169 patients with stage IB1 to IB2 cervical cancer.

INTERVENTIONS

All patients underwent minimally invasive radical hysterectomy and pelvic lymphadenectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 1169 patients diagnosed with preoperative stage IB1 to IB2 cervical cancer were primarily treated with surgery from 2018 to 2019. The eligible patients had a median age of 48 years (range, 23-76 years), and the median follow-up time was 34 months (range, 3.57-50.87 months). The 2-year overall survival rate of the patients with pathologic stage IB1 and IB2 was 99.8% and 98.8%, respectively, according to the 2018 International Federation of Gynecology and Obstetrics staging system. Univariable analysis revealed that the UM group had a 7.6-times higher risk of death than that of the manipulator-free group (p = .006), but multivariable analysis clarified that only tumor size (p = .016; hazard ratio, 2.285; 95% confidence interval, 1.166-4.479) and parametrial involvement (p = .003; hazard ratio, 3.556; 95% confidence interval, 1.549-8.166) were independent risk factors for overall survival. There was no statistically significant difference in survival between patients who underwent intracorporeal and protective colpotomy.

CONCLUSION

Short-term survival outcomes in women undergoing minimally invasive radical hysterectomy for treatment of early-stage cervical cancer did not differ when a UM was avoided or when a protective colpotomy was performed.

Spillage and displacement of indocyanine green-stained tissues from uterine cervix to pelvic peritoneum: A proof of concept study for colpotomy approach in minimally invasive surgery

OBJECTIVE

To analyze peritoneal spillage and displacement of indocyanine green (ICG)-stained tissues from uterine cervix to pelvis during intracorporeal/vaginal colpotomy in laparoscopic-assisted hysterectomy.

MATERIALS AND METHODS

Eleven patients undergoing laparoscopic-assisted hysterectomy were included. One patient with an incidental diagnosis of endometrial cancer was excluded. Of the 10 patients, five underwent intracorporeal colpotomy (IC) and five received vaginal colpotomy (VC) during laparoscopic-assisted hysterectomy. Approximately 5 cm of resected round ligament from each patient was stained with ICG and cut to 1.0 × 1.0 cm in size. Four to five fragments of ICG-stained tissues were placed and sutured on the uterine cervix before colpotomy. During and after colpotomy, serial pictures under white and fluorescence light were taken to document peritoneal spillage and displacement of ICG-stained tissues to the pelvic peritoneum.

RESULTS

Peritoneal spillage of ICG occurred in the entire IC group. Displacement of ICG-stained tissues from uterine cervix to pelvic peritoneum were visualized in three (60%) patients undergoing IC. In the five patients who received VC, peritoneal spillage of ICG and displacement of ICG-stained tissue to pelvic peritoneum did not occur. There were no perioperative complications.

CONCLUSIONS

IC in minimally invasive radical hysterectomy should not be performed because peritoneal spillage of ICG and displacement of ICG-stained tissues from uterine cervix to pelvis frequently occurs during IC. Therefore, specific measures to prevent tumor exposure during colpotomy should be implemented in cervical cancer patients.

Safety and efficacy of a modified technique of laparoscopic radical hysterectomy for cervical cancer

AIM

Objective to investigate the feasibility, safety, and short-term efficacy of laparoscopic radical hysterectomy without uterine lifter combined with self-locking nylon band.

METHODS

The clinical data of 152 patients who underwent a laparoscopic radical hysterectomy in the Department of gynecology and oncology of Changzhou maternal and child health hospital from January 2017 to June 2020 were analyzed retrospectively, including 97 patients who used uterine lifter (traditional laparoscopic radical hysterectomy) and 55 patients who underwent operation without uterine lifter but combining with self-locking nylon band (modified laparoscopic radical hysterectomy). The differences in operation time, intraoperative blood loss, the width of excised parauterine tissue, the length of the excised vaginal wall, postoperative pathology and short-term prognosis between the two groups were compared and analyzed.

RESULTS

There were no significant differences between the two groups in operation time, intraoperative blood loss, the width of parauterine tissue, and the length of the vaginal wall (p > 0.05). There were no significant differences in the number of lymph nodes, pelvic lymph node metastasis rate and depth of cervical interstitial infiltration between the two groups (p > 0.05), the infiltration rate of lymphatic vascular space in the traditional group was higher than that in the improved group (p < 0.05).

CONCLUSION

It is feasible and safe for laparoscopic radical hysterectomy without uterine lifter combining with a self-locking nylon band to seal the vaginal wall. The uterine lifter may lead to lymphatic vascular space infiltration of tumor cells.

Round ligament suspension and vaginal purse-string suture: Newly optimized techniques to prevent tumor spillage in laparoscopic radical trachelectomy for cervical cancer

AIM

The purpose of this study was to investigate the surgical techniques and clinical feasibility of nonuterine manipulator and enclosed colpotomy to avoid cancer cell spillages in laparoscopic radical trachelectomy (LRT) for patients with early-stage cervical cancer.

METHODS

We performed the newly optimized surgical techniques of round ligament suspension and vaginal purse-string suture in LRT in 12 patients with early-stage cervical cancer from May 2019 to October 2020. Surgical information and postoperative results were recorded.

RESULTS

All 12 patients successfully underwent LRT with round ligament suspension and vaginal purse-string suture, and no conversion to laparotomy was required. The median operation time was 268.5 min (range 200-320 min), including 5 min of round ligament suspension, and the median blood loss was 20 mL (range 5-50 mL). The median number of pelvic lymph nodes removed was 27 (range 19-35), and median amounts of paracervical tissue was 24 mm (range 21-26 mm) and vaginal tissue was 18 mm (range 16-26 mm). No intraoperative complication or serious postoperative complications were reported.

CONCLUSION

Round ligament suspension and vaginal purse-string suture techniques are feasible and effective in LRT. They can replace uterine manipulator and unprotected colpotomy with satisfactory perioperative outcomes.

Radical Hysterectomy After the LACC Trial: Back to Radical Vaginal Surgery

OPINION STATEMENT

Classical radical vaginal hysterectomy first performed by Anton Pawlik in Prague in 1888 and popularized by Frederic Schauta is now a historical technique virtually abandoned due to painful perineal incision, a high rate of urinary dysfunction, and the inability to perform lymph node assessment. However, the heritage of this approach has been still used and taught in a few centers outside their Austrian birthplace. A combined vaginal and laparoscopic approach was developed in the 1990s by French and German surgeons who designed diverse surgical techniques for which a novel classification is proposed. All these techniques are different from the so-called laparoscopically assisted radical vaginal hysterectomy (LARVH), a term widely used for laparoscopic radical hysterectomies with vaginal extraction of the specimen. Interestingly, after the publication of the LACC trial (Laparoscopic Approach to Cervical Cancer), the radical vaginal approach has found a very timely application. The creation of a vaginal cuff before performing radical laparoscopic hysterectomy described in 2007 by Leblanc as "Schautheim" operation can be used as a protective maneuver to avoid tumor spillage and potentially overturn the negative outcome of minimally invasive surgery in early-stage cervical cancer. As a result, the combination of radical vaginal and laparoscopic steps of surgery is one possible evolution after the LACC trial that needs further investigation. The forgotten vaginal surgical technique needs a specific learning curve. The creation of a vaginal cuff should be mastered by every gynecological oncologist.

Retrospective Analysis of Cervical Cancer Treatment Outcomes: Ten Years of Experience with the Vaginal Assisted Radical Laparoscopic Hysterectomy VARLH

BACKGROUND

LACC trial demonstrated inferiority of laparoscopic approach for the treatment of early-stage cervical cancer. There are still limited data from retrospective trials regarding whether survival outcomes after laparoscopic radical hysterectomy are equivalent to those after open abdominal radical hysterectomy. In this study, we present results of combined vaginal radical laparoscopic hysterectomy in the treatment of early-stage cervical cancer.

METHODS

This retrospective study was carried out at the Department of Gynecology in Mathilden Hospital (Herford, Germany). Between January 2008 and April 2018, all the patients with invasive cervical cancer who underwent combined vaginal assisted radical laparoscopic hysterectomy (VARLH) without the use of any uterine manipulator were enrolled to the study.

RESULTS

A total number of 124 patients with diagnosis of invasive cervical cancer were enrolled in the study. All of the patients underwent minimally invasive surgery and were divided according to FIGO 2019: stage IA (25.9%), IB1 (25.0%), IB2-IIB (28.4%), and III/IV (20.7%). Overall, the mean age of the patients was 51.84 years. After a study collection, a median follow-up was 45.6 (range 23.7-76.5) months. The 3- and 5-year disease-free survival rates for early-stage cervical cancer were both 98%, and the 3- and 5-year overall survival rates were 100% and 97%, respectively. We have not observed any recurrence in our study group of patients with early-stage cervical cancer.

CONCLUSIONS

Combined VARLH can be considered a safe and effective procedure for the treatment of early-stage cervical cancer. Surgical strategy with oncological principles determines the quality and long-term success of the operation in early cervical cancer regardless of laparoscopic approach.

The Surgeon's Proficiency Affected Survival Outcomes of Minimally Invasive Surgery for Early-Stage Cervical Cancer: A Retrospective Study of 851 Patients

Purpose

To compare the clinical outcomes of patients with early-stage cervical cancer who underwent minimally invasive surgery (MIS) by surgeons in different phases and evaluate whether the proficiency of surgeons affects the survival outcomes.

Materials and Methods

A total of 851 patients with early-stage cervical cancer who underwent radical hysterectomy between January 2008 and June 2018 (every year from January to June) at a tertiary hospital were retrospectively analyzed. We categorized patients into four phases according to their sequence (phase one, 1-10 cases; phase two: 11-20 cases; phase three: 21-30 cases; phase four: > 30 cases). Demographics and clinical and pathological data were collected and analyzed.

Results

There were no statistical differences between the open surgery and MIS groups regarding three- and five-year overall survival (OS) and disease-free survival (DFS). The OS and DFS of patients in the MIS group in phase one were significantly lower than those in later phases and those in the open surgery group after adjustment (OS, P = 0.009; HR, 2.896; 95%CI, 1.303-6.435; DFS, P = 0.009; HR, 2.712; 95%CI, 1.289-5.706). Survival outcomes were not statistically significant when comparing different surgeons.

Conclusion

The phase one cases of MIS had lower OS and DFS than those in later phases and those in the open surgery group. Thus, we suggest that the proficiency of surgeons is associated with survival outcomes of MIS. Favorable outcomes can be obtained after a certain number of MIS cases.

Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer

BACKGROUND

We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer.

METHODOLOGY

Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage.

RESULTS

All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6-14). All drains and urethral catheters were removed after a median of 7 days (range 5-11) and 16 days (range 12-21), respectively. A median of 26 (range 20-32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease.

CONCLUSION

We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.

Vaginal Closure Before Colpotomy with an Endo-Stapler to Prevent Tumor Spillage in Laparoscopic Surgery for Gynecological Malignancy

Background and Objectives

The aim of this study was to define new techniques for performing vaginal closure with endo-staplers to prevent tumor spillage during laparoscopic surgeries for endometrial cancer and early stage cervical cancer.

Methods

Thirteen patients were retrospectively studied for the use of endo-staplers for vaginal closure before colpotomy during laparoscopic surgeries for endometrial cancer and early stage cervical cancer to prevent tumor spillage.

Results

There were no short-term or any long-term complication related to the use of the endo-staplers for colpotomy in the surgeries included in this study.

Conclusion

Use of the endo-staplers to close the vagina before colpotomy according to the technique described is safe and feasible, with prevention of gross spillage of any malignant cells in the peritoneal cavity or vagina, which will further have a favorable oncologic outcome.

Potential prognostic factors in progression-free survival for patients with cervical cancer

Background

Cervical cancer continues to be one of the leading causes of cancer deaths among females in low and middle-income countries. In this study, we aimed to assess the independent prognostic value of clinical and potential prognostic factors in progression-free survival (PFS) in cervical cancer.

Methods

We conducted a retrospective study on 92 cervical cancer patients treated from 2017 to 2019 at the Zhuhai Hospital of Traditional Chinese and Western Medicine. Tumor characteristics, treatment options, progression-free survival and follow-up information were collected. Kaplan–Meier method was used to assess the PFS.

Results

Results showed that the number of retrieved lymph nodes had a statistically significant effect on PFS of cervical cancer patients (P = 0.002). Kaplan-Meier survival curve analysis showed that cervical cancer patients with initial symptoms age 25–39 had worse survival prognoses (P = 0.020). And the using of uterine manipulator in laparoscopic treatment showed a better prognosis (P < 0.001). A novel discovery of our study was to verify the prognostic values of retrieved lymph nodes count combining with FIGO staging system, which had never been investigated in cervical cancer before. According to the Kaplan-Meier survival curve analysis and receiver operating characteristic (ROC) curve analysis, significant improvements were found after the combination of retrieved lymph nodes count and FIGO stage in predicting PFS for cervical cancer patients (P < 0.001, AUC = 0.826, 95% CI: 0.689–0.962).

Conclusion

Number of retrieved lymph nodes, initial symptoms age, uterine manipulator, and retrieved lymph nodes count combining with FIGO staging system could be potential prognostic factors for cervical cancer patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08243-3.

Cervical Cancer Surgery: Current State of Affairs

Cervical cancer surgery has a history of more than 100-years whereby it has transitioned from the open approach to minimally invasive surgery (MIS). From the era of clinical exploration and practice, minimally invasive gynecologic surgeons have never ceased to explore new frontiers in the field of gynecologic surgery. MIS has fewer postoperative complications, including reduction of treatment-related morbidity and length of hospital stay than laparotomy; this forms the mainstay of treatment for early-stage cervical cancer. However, in November 2018, the New England Journal of Medicine had published two clinical studies on cervical cancer surgery (Laparoscopic Approach to Cervical Cancer [LACC]). Following these publications, laparoscopic surgery for early-stage cervical cancer has come under intense scrutiny and negative perceptions. Many studies began to explore the concept of standardized surgery for early-stage cervical cancer. In this article, we performed a review of the history of cervical cancer surgery, outlined the standardization of cervical cancer surgery, and analyzed the current state of affairs revolving around cervical cancer surgery in the post-LACC era.

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.

Surgical Approach and Use of Uterine Manipulator Are Not Associated with LVSI in Surgery for Early-stage Cervical Cancer

STUDY OBJECTIVE

In 2018, the Laparoscopic Approach to Cervical Cancer trial reported that patients undergoing minimally invasive surgery for cervical cancer (CC) had poorer outcomes than patients undergoing open surgery. Several hypotheses have been made to explain the results. We aimed to investigate whether laparoscopic procedures and use of a uterine manipulator increase the risk of lymphovascular space invasion (LVSI) in early-stage CC.

DESIGN

A retrospective study.

SETTING

A Chinese women's and children's hospital.

PATIENTS

Patients with early-stage CC who underwent radical hysterectomy in West China Second University Hospital between April 2019 and May 2020.

INTERVENTIONS

Laparoscopic surgery (with uterine manipulator and uterine manipulator-free) and open surgery.

MEASUREMENTS AND MAIN RESULTS

A total of 979 patients diagnosed with CC were registered in West China Second University Hospital for surgical treatment. Of these, 525 patients underwent laparoscopic surgery and 454 patients underwent open surgery. In total, 735 patients with early-stage cancer underwent radical hysterectomy and pelvic lymphadenectomy, including 357 by laparoscopic surgery and 378 by open surgery. For those who underwent radical hysterectomy and pelvic lymphadenectomy, the incidence of LVSI was 48.41% and 47.34% in laparoscopic and open groups, respectively (p = .771). After 1:1 propensity score matching with age, International Federation of Gynecology and Obstetrics stage, pathology, and tumor size, the incidence of LVSI was 45.54% and 51.79% in laparoscopic and open groups, respectively (p = .186). Subdividing the laparoscopic group into uterine manipulator and uterine manipulator-free groups, the incidence of LVSI was 45.22% and 48.35%, respectively (p = .580). After propensity score matching with age, International Federation of Gynecology and Obstetrics stage, pathology, and tumor size, the incidence of LVSI was 45.78% and 55.42% in these 2 groups, respectively (p = .214). Multiple factor analysis revealed that lymph node metastasis and deep stromal invasion were associated with LVSI (p value <.05 in both groups).

CONCLUSION

The surgical approach and use of a uterine manipulator are not associated with LVSI in surgery for early-stage CC. Lymph node metastasis and deep stromal invasion are associated with LVSI.

Risk Factors for Recurrence after Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer: A Multicenter Retrospective Study

Simple Summary

In 239 women with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) undergoing robot-assisted radical hysterectomy in Spanish and Portuguese centers between 2009 and 2018, the overall survival rate was 94.1% after a median follow-up of 51 months. Recurrence was diagnosed in 26 patients. In the multivariate analysis, independent risk factors for recurrence were tumor size > 20 mm, adenocarcinoma as histological type, presence of positive pelvic lymph nodes, tumor grades 2 and 3, and not performing sentinel lymph node biopsy. The present oncological and surgical results surpassed the target of quality indicators in cervical cancer proposed by the European Society of Gynecology Oncology. When selecting a robot-assisted surgical approach to perform radical hysterectomy in the surgical treatment of primary early-stage cervical cancer, it is recommended to take into account the tumor grade and histological type, results of the sentinel lymph node biopsy, and the size of the tumor.

Abstract

This retrospective analysis aimed to assess the risk factors for recurrence in patients diagnosed with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) undergoing robot-assisted radical hysterectomy in Spain and Portugal between 2009 and 2018. A second primary objective was to audit the oncological outcomes according to quality indicators (QI) proposed by the European Society of Gynecology Oncology (ESGO). The study population included 239 women. After a median follow-up of 51 months, recurrence occurred in 26 patients (10.9%). Independent factors for recurrence were clinical tumor size > 20 mm (hazard ratio (HR) 2.37), adenocarcinoma as histological type (HR 2.51), positive pelvic lymph nodes (HR 4.83), tumor grade 2 (HR 4.99), tumor grade 3 (HR 8.06), and having not performed sentinel lymph node biopsy (SLNB) (HR 4.08). All 5 QI selected were surpassed by our results. In patients with early-stage cervical cancer undergoing robotic radical hysterectomy, clinicians should be aware that tumor grade 2 and 3, tumor size > 20 mm, adenocarcinoma, positive pelvic nodes, and lack of performance of SLNB are risk factors for recurrence. Fulfillment of QI targets of the ESGO might be considered as an objective oncological outcome indicator supporting the minimally invasive approach for early-stage cervical cancer treatment.

Laparoscopic Regional Radical Hysterectomy Showed Promising Clinical Outcomes in Early-stage Cervical Cancer

Objectives:

To evaluate the clinical outcomes of standardized and region-specific excision in laparoscopic radical hysterectomy (LRH) for early-stage cervical cancer (ECC).

Materials and Methods:

This is a retrospective case–controlled study from 2011 to December 2016. A total of 328 women with ECC (IA1, IA2, IB1, or IIA1) underwent primary surgery by laparoscopy or laparotomy in our institute. Women diagnosed as stage IB1 or IIA1 were treated with radical hysterectomy (RH) by open or laparoscopic route. The total parametrium excision in the process of RH was measured and highlighted in the study.

Results:

A total of 186 patients underwent open surgery and 142 ones were treated with laparoscopic surgery. Laparoscopic surgery was associated with less blood loss (194.43 ± 84.40 ml vs. 362.68 ± 253.36 ml, P < 0.01), shorter hospital stay (11 vs. 14 days, P < 0.01), and lower risk of blood transfusion (2.8% vs. 18.8%, P < 0.01). There was no significant difference in the postoperative complications between two groups (18/142, 12.7% vs. 21/186, 11.3%; P > 0.05). The rate of 5-year overall survival (OS) was 92.8% in laparoscopy group, similar to that of 94.4% in the open group (P = 0.762). Disease-free survival (DFS) rate at 3 years in laparoscopy group was decreased when compared to open group (91.8% vs. 95.0%, P = 0.030), but there was no significant difference in 3-year DFS among the women with tumor size <2 cm (100% vs. 97.0%, P = 0.818).

Conclusion:

Laparoscopic surgery was associated with better surgical outcomes compared to open surgery in ECC. 5-Year OS was comparable between the groups and cases with tumor size <2 cm showed no difference in 3-year DFS. LRH may be a better fit for women with tumor size <2 cm. Standardized region-specific RH helps to optimize the clinical outcomes of LRH in ECC.

Survival after minimally invasive surgery in early cervical cancer: is the intra-uterine manipulator to blame?

Objectives

Minimally invasive radical hysterectomy is associated with decreased survival in patients with early cervical cancer. The objective of this study was to determine whether the use of an intra-uterine manipulator at the time of laparoscopic or robotic radical hysterectomy is associated with inferior oncologic outcomes.

Methods

A retrospective cohort study was carried out of all patients with cervical cancer (squamous cell carcinoma, adenocarcinoma or adenosquamous carcinoma) International Federation of Gynecology and Obstetrics 2009 stages IA1 (with positive lymphovascular space invasion) to IIA who underwent minimally invasive radical hysterectomy at two academic centers between January 2007 and December 2017. Treatment, tumor characteristics, and survival data were retrieved from hospital records.

Results

A total of 224 patients were identified at the two centers; 115 had surgery with the use of an intra-uterine manipulator while 109 did not; 53 were robotic and 171 were laparoscopic. Median age was 44 years (range 38–54) and median body mass index was 25.8 kg/m2 (range 16.6–51.5). Patients in whom an intra-uterine manipulator was not used at the time of minimally invasive radical hysterectomy were more likely to have residual disease at hysterectomy (p<0.001), positive lymphovascular space invasion (p=0.02), positive margins (p=0.008), and positive lymph node metastasis (p=0.003). Recurrence-free survival at 5 years was 80% in the no intra-uterine manipulator group and 94% in the intra-uterine manipulator group. After controlling for the presence of residual cancer at hysterectomy, tumor size and high-risk pathologic criteria (positive margins, parametria or lymph nodes), the use of an intra-uterine manipulator was no longer significantly associated with worse recurrence-free survival (HR 0.4, 95% CI 0.2 to 1.0, p=0.05). The only factor which was consistently associated with recurrence-free survival was tumor size (HR 2.1, 95% CI 1.5 to 3.0, for every 10 mm increase, p<0.001).

Conclusion

After controlling for adverse pathological factors, the use of an intra-uterine manipulator in patients with early cervical cancer who underwent minimally invasive radical hysterectomy was not an independent factor associated with rate of recurrence.

The Development of a New Uterine Manipulation Method during Minimally Invasive Radical Hysterectomy

STUDY OBJECTIVE

The use of a vaginal uterine manipulator may compromise the oncological outcomes of patients with cervical cancer undergoing minimally invasive radical hysterectomy (MIS-RH). We aimed to describe the safety and efficacy of a novel uterine manipulation device during MIS-RH.

DESIGN

Retrospective study.

SETTING

A university hospital and a tertiary care hospital.

PATIENTS

Patients with early-stage cervical cancer who were treated with MIS-RH.

INTERVENTIONS

We developed the U-traction, a new device that consists of a 65-mm half-curved cutting needle with a 2.5-mm polyester tape (45-cm long), and investigated its utility to manipulate the uterus during MIS-RH.

MEASUREMENTS AND MAIN RESULTS

This study describes the utility and safety of the U-traction for uterine manipulation during laparoscopic or robotic RH in 8 patients with cervical cancer. Uterine manipulation was successfully and safely performed using the U-traction during laparoscopic or robotic RH in patients with cervical cancer without any complications. The application time was less than 5 minutes. In all cases, the use of a vaginal manipulator, an additional incision for an extra port, or the need for assistant surgeons for uterine manipulation was avoided.

CONCLUSION

The novel U-traction device allows for easy and reproducible uterine manipulation during MIS-RH. With this device, the use of a vaginal uterine manipulator can be avoided, and MIS-RH can be safely performed without the need for an assistant surgeon for uterine manipulation.

A Comparison of Laparoscopies and Laparotomies for Radical Hysterectomy in Stage IA1-IB1 Cervical Cancer Patients: A Single Team With 18 Years of Experience

Objective

To investigate the safety and efficacy of abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH) in managing early-stage cervical cancer.

Methods

This retrospective study comprised patients with FIGO stage IA1 with lymphovascular space invasion (LVSI), IA2, and IB1 cervical cancer who underwent radical hysterectomy performed by a single gynecologic oncology team at Peking Union Medical College Hospital from 2000–2018. The clinicopathological characteristics, surgical outcomes, and survival outcomes were compared between the two groups.

Results

The ARH and LRH groups consisted of 84 and 172 patients, respectively. The 5-year progression-free survival (PFS) rates were 89.3 and 95.9% in the ARH and LRH groups (P = 0.122, adjusted HR = 0.449, 95% CI: 0.162–1.239), respectively, while the 5-year overall survival (OS) rates were 95.2 and 98.8%, respectively (P = 0.578, adjusted HR = 0.650, 95% CI: 0.143–2.961). The presence of more than two comorbidities led to poor OS (P = 0.011). For patients with a BMI greater than 24 kg/m², LRH was associated with better PFS (P = 0.039). Compared with ARH, LRH was associated with a shorter operation time (248.8 vs. 176.9 min, P < 0.001), less blood loss (670.2 vs. 200.9 ml, P < 0.001), and lower postoperative ileus rates (2.4% vs. 0%, P = 0.042). No significant differences were observed in PFS and OS between 2006–2012, 2013–2015, and 2016–2018 in the LRH group (P = 0.126 and P = 0.583).

Conclusion

Compared with ARH, LRH yields similar survival and improved surgical outcomes in patients with early-stage cervical cancer. LRH is not inferior to ARH for select cervical cancer patients treated by a single team with adequate laparoscopy experience.

An Australian, single-centre study of surgical management outcomes for early-stage cervical cancer

BACKGROUND

The Laparoscopic Approach to Cervical Cancer (LACC) trial is the first phase III randomised, multicentred trial to compare oncologic outcomes associated with open radical hysterectomy vs minimally invasive surgery (MIS) for treatment of early cervical cancer.

AIM

To evaluate our surgical experience in patients with early cervical cancer.

METHODS AND MATERIALS

The Lifehouse Gynaecologic Oncology database was queried based upon the eligibility criteria of the LACC study and included all FIGO 2009 stage (1A1 with lymph vascular space invasion, 1A2, 1B1) cervical cancer women from 2008-2018. Patients were also included in our study if they had abdominal radical trachelectomy (ART), laparoscopic radical hysterectomy (TLRH) and robotic radical trachelectomy (RRT).

RESULTS

Forty-six women were identified with four exclusions. Thirty-seven women had stage 1B1 disease, 24 had a squamous cell carcinoma, 15 had an adenocarcinoma and three had an adenosquamous carcinoma of the cervix. Of the 42 eligible patients, 32 underwent an open abdominal approach (26 total abdominal radical hysterectomy (TARH), six ART) and ten a MIS approach (nine TLRH and one RRT) with a mean follow-up of 4.8 years. All 42 women had a pelvic lymph node dissection, eight women had nodal metastases and 16 patients received adjuvant chemoradiation. Two of the nine women in the laparoscopic radical hysterectomy group had a recurrence. Both had adenocarcinoma, stage 1B1 disease. There were no recurrences in the TARH group or radical trachelectomy groups.

CONCLUSION

Our data, albeit limited in number, have reflected the results of the LACC trial that MIS was associated with a lower disease-free survival than open radical hysterectomy.

Peritoneal contamination with ICG-stained cervical secretion as surrogate for potential cervical cancer tumor cell dissemination: A proof-of-principle study for laparoscopic hysterectomy

INTRODUCTION

Intracorporal colpotomy during radical hysterectomy for cervical cancer is discussed to be a risk factor for peritoneal dissemination of tumor cells. It might lead to increased recurrence rates after laparoscopic radical hysterectomy compared with abdominal hysterectomy, as shown by the recent LACC study. Data on the frequency or mechanisms of peritoneal contamination are missing. We aimed to analyze peritoneal contamination of cervical secretion during intracorporal colpotomy with a novel indocyaningreen (ICG)-based technique.

MATERIAL AND METHODS

In this prospective proof-of-principle study, patients undergoing routine laparoscopic or robot-assisted hysterectomy were selected. ICG was specifically applied to the cervical surface and routine surgery was performed. During colpotomy, pictures under white and fluorescence light were taken to evaluate frequency of contamination.

RESULTS

By using cervically applied ICG we were able to visualize directly peritoneal contamination with cervical secretion during intracorporal colpotomy. We detected peritoneal contamination in 9/12 (75%) patients undergoing routine laparoscopic hysterectomy. Contamination of laparoscopic instruments occurred in 60% of the patients. When contamination occurred, it was routinely detectable during all steps of colpotomy. There were no adverse effects during surgery.

CONCLUSIONS

Peritoneal contamination with cervical secretion frequently occurs during intracorporal colpotomy. This novel technique represents a promising tool for feasible and direct visualization of peritoneal contamination during colpotomy. The technique may be easily implemented in further studies on laparoscopic and abdominal hysterectomy and serve as a quality assessment tool for surgeons and surgical techniques.