Use of Laparoscopy in the Treatment of Endometrial and Cervical Cancer - Results of a 2012 Germany-wide Survey

Evolving trends in the surgical therapy of patients with endometrial cancer in Germany: analysis of a nationwide registry with special emphasis on perioperative outcomes

PURPOSE

Endometrial cancer (EC) is the most common gynecological malignancy in women, with increasing incidence in the last decades. Surgical therapy is the mainstay of the initial management. The present study analyzed the evolving trends of surgical therapy in Germany in patients diagnosed with EC recorded in a nationwide registry.

METHODS

All patients with the diagnosis of EC undergoing open surgery, laparoscopic surgery, and robotic-assisted laparoscopic surgery between 2007 and 2018 were identified by international classification of diseases (ICD) or specific operational codes (OPS) within the database of the German federal bureau of statistics.

RESULTS

A total of 85,204 patients underwent surgical therapy for EC. Beginning with 2013, minimal-invasive surgical therapy was the leading approach for patients with EC. Open surgery was associated with a higher risk of in-hospital mortality (1.3% vs. 0.2%, p < 0.001), of prolonged mechanical ventilation (1.3% vs. 0.2%, p < 0.001), and of prolonged hospital stay (13.7 ± 10.2 days vs. 7.2 ± 5.3 days, p < 0.001) compared to laparoscopic surgery. A total of 1551 (0.04%) patients undergoing laparoscopic surgery were converted to laparotomy. Procedure costs were highest for laparotomy, followed by robotic-assisted laparoscopy and laparoscopy (8286 ± 7533€ vs. 7083 ± 3893€ vs. 6047 ± 3509€, p < 0.001).

CONCLUSION

The present study revealed that minimal-invasive surgery has increasingly become the standard surgical procedure for patients with EC in Germany. Furthermore, minimal-invasive surgery had superior in-hospital outcomes compared to laparotomy. Moreover, the use of robotic-assisted laparoscopic surgery is increasing, with a comparable in-hospital safety profile to conventional laparoscopy.

Conversion of intraperitoneal cytology during laparoscopic surgery of uterine cancer

INTRODUCTION

The laparoscopic surgery of uterine cancer is an oncological safe treatment option in early stage cancer. However, there are no data about whether laparoscopy can lead to intraperitoneal tumor cell dissemination. We aimed in our study to detect a possible cytological conversion during laparoscopic procedures.

METHODS

In this prospective study, we included all patients receiving laparoscopic treatment at the early stage endometrial and cervical cancer in the Department of Obstetrics and Gynecology at the University of the Saarland and obtained peritoneal wash for cytological examination at the beginning and at the end of laparoscopic surgery. All patients received stage-adjusted operative and adjuvant therapy.

RESULTS

We enrolled 43 patients [endometrial cancer (n = 24) and cervical cancer (n = 19)]. At the beginning of the operation, one patient with endometrial cancer and one patient with cervical cancer showed a positive cytology. One tumor cell conversion from negative to positive cytology during surgery was detected in a patient suffering from endometrial cancer stage FIGO Ia. The median duration of surgery was 191.8 ± 79.3 min. The average time of follow-up was 16.5 ± 10.3 month. At the end of data evaluation at December 2014, two patients (8.6 %) are suffering from recurrent disease, two patients died, none of these patients had a positive cytology. All patients with positive cytology are free of cancer.

CONCLUSION

During laparoscopic surgery of early stage endometrial and cervical cancer, only one conversion of cytology was detected, which proves that laparoscopy does not appear to increase the intraoperative tumor cell dissemination or rate of positive cytological results.

Complications in gynecological minimal-access oncosurgery

Complications are the limiting factors of all surgeries. More than performing the actual surgery, learning how to avoid complications before, during, and after surgery is the most important task of every surgeon. Severe complications can lead to patient death. Complications such as ureterovaginal fistulas, resulting from <2 s of inattentive preparation, can lead to years of hardship, suffering, accusation, and litigation. Excellent surgery is about performing the right surgery for the right patient without any complications. Minimally invasive surgery in complex cases is technically challenging. This article details the major causes of complications in laparoscopy for the gynecologic cancer patient and present strategies for prevention, early detection, and intra- and postoperative management.

Implementation of a robotic surgical program in gynaecological oncology and comparison with prior laparoscopic series

Background. Robotic surgery in gynaecological oncology is a rapidly developing field as it offers several technical advantages over conventional laparoscopy. An audit was performed on the outcome of robotic surgery during our learning curve and compared with recent well-established laparoscopic procedure data. Method. Following acquisition of the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, USA), we prospectively analysed all cases performed over the first six months by one experienced gynaecologist who had been appropriately trained and mentored. Data on age, BMI, pathology, surgery type, blood loss, morbidity, return to theatre, hospital stay, and readmission rate were collected and compared with a consecutive series over the preceding 6 months performed laparoscopically by the same team. Results. A comparison of two consecutive series was made. The mean age was somewhat different, 55 years in the robotic versus 69 years in the laparoscopic group, but obesity was a feature of both groups with a mean of BMI 29.3 versus 28.06, respectively. This difference was not statistically significant (P = 0.54). Three subgroups of minimal access surgical procedures were performed: total hysterectomy and bilateral salpingooophorectomy (TH + BSO), total hysterectomy and bilateral salpingooophorectomy plus bilateral pelvic lymphadenectomy (TH + BSO + BPLND), and radical hysterectomy plus bilateral pelvic lymphadenectomy (RH + BPLND). The mean time taken to perform surgery for TH + BSO was longer in the robotic group, 151.2 min compared to 126.3 min in the laparoscopic group. TH + BSO + BPLND surgical time was similar to 178.3 min in robotic group and 176.5 min in laparoscopic group. RH + BPLND surgical time was similar, 263.6 min (robotic arm) and 264.0 min (laparoscopic arm). However, the numbers in this initial analysis were small especially in the last two subgroups and do not allow for statistical analysis. The rate of complications necessitating intervention (Clavien-Dindo classification grade 2/3) was higher in the robotic arm (22.7%) compared to the laparoscopic approach (4.5%). The readmission rate was higher in the robotic group (18.2%) compared to the laparoscopic group (4.5%). The return to theatre in the robotic group was 18.2% and 4.5% in laparoscopic group. Uncomplicated robotic surgery hospital stay appeared to be shorter, 1.3 days compared to the uncomplicated laparoscopic group, 2.5 days. There was no conversion to the open procedure in either arm. Estimated blood loss in all cases was less than 100 mL in both groups. Conclusion. Robotic surgery is comparable to laparoscopic surgery in blood loss; however, the hospital stay in uncomplicated cases appears to be longer in the laparoscopic arm. Surgical robotic time is equivalent to laparoscopic in complex cases but may be longer in cases not requiring lymph node dissection. The robotic surgery team learning curve may be associated with higher rate of morbidity. Further research on the benefits to the surgeon is needed to clarify the whole picture of this versatile novel surgical approach.

Standardised Registration of Surgical Complications in Laparoscopic-Gynaecological Therapeutic Procedures Using the Clavien-Dindo Classification

Introduction: The registration of complications represents an important component in the evaluation of surgical therapeutic procedures. The aim of the present study was to examine the frequency of occurrence as well as the severity of surgical complications after laparoscopic-gynaecological operations in a standardised manner using the Clavien-Dindo system. Material and Methods: Altogether 7438 treatment courses after laparoscopic-gynaecological interventions by 9 working groups were evaluated. Covariates recorded were the technical complexity of the operation, type of study cohort, study size, data acquisition as well as study centre. Target variables recorded were the surgical morbidity rate, subdivided into mild (Clavien-Dindo grade I-II) and severe complications (Clavien-Dindo grade III-V). In addition, a binary logistic regression analysis for the mentioned covariates and the occurrence of surgical complication was carried out. Results: 946 complications were recorded (overall complication rate: 13 %). These included 664 mild complications (8.9 %) and 305 severe complications (4.1 %). A correlation was found between the covariates technical complexity (relative risk [rR] 1.37; p < 0.01), study size (rR: 0.35; p < 0.01) and study centre (rR 0.19; p < 0.01) and the occurrence of surgical complications. Conclusion: By means of a standardised registration of complications using the Clavien-Dindo classification it appears to be possible to limit the methodologically caused underestimation of surgical morbidity in the retrospective evaluation of gynaecological-endoscopic therapeutic procedures. Factors decisively influencing the surgical morbidity of gynaecological-laparoscopic therapeutic procedures are the respective operative experience of the treating facility as well as the technical complexity of the intervention.

Current and Future Status of Laparoscopy in Gynecologic Oncology

Laparoscopy is playing an increasingly important role in gynecologic oncology. The benefits of minimally invasive surgery for oncology patients and the quality of this treatment are well documented. Outcomes and quality of minimally invasive surgical procedures to treat cervical cancer were evaluated based on retrospective and case-control studies; outcomes and quality after minimally invasive treatment für early-stage low-risk endometrial cancer were also assessed in prospective randomized studies. If indicated, laparoscopic lymphadenectomy is both technically feasible and oncologically safe. Adipose patients in particular benefit from minimally invasive procedures, where feasible. The potential role of laparoscopy in neoadjuvant therapy for ovarian cancer and in surgery for early-stage ovarian carcinoma is still controversially discussed and is currently being assessed in further studies. Using a minimally invasive approach in gynecologic oncology procedures demands strict adherence to oncological principles and requires considerable surgical skill.

Postoperative Health-Related Quality of Life of Cervical Cancer Patients - A Comparison between the Wertheim-Meigs Operation and Total Mesometrial Resection (TMMR)

Introduction: The present study compares for the first time the standard therapy for cervical cancer in FIGO-stages IB-IIB, radical hysterectomy according to the Wertheim-Meigs operation, with the newly developed, nerve-sparing surgical technique, total mesometrial resection (TMMR) with regard to postoperative, health-related quality of life. Method: In the framework of a multicentre, retrospective cohort study a total of 110 cervical cancer patients were interviewed once by means of the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30) and the cervical cancer module (EORTC QLQ-CX24). The influence of the surgical method was investigated by analysis of covariance under control of age and the time elapsed between treatment and interview. Results: An influence of the therapeutic method was demonstrated in the EORTC scales physical function (p = 0.047), role function (p = 0.016), fatigue (p = 0.028), pain (p = 0.018), shortness of breath (p = 0.034), lack of appetite (p = 0.006) and diarrhoea (p = 0.012) in favour of the 74 women treated by TMMR. With regard to cognitive, emotional and social functioning as well as cervical cancer-specific symptoms, no significant differences between the therapy groups were found. Conclusion: The findings presented in this study suggest a superiority of TMMR in comparison to the previously employed radical hysterectomy according to Wertheim-Meigs with regard to the postoperative quality of life, especially in the fields of physical activity and fatigue. This needs to be validated in the course of prospective, multicentre studies. In addition, it must be clarified as to what extent the found effects are, in particular, due to the omission of an additional radiotherapy.