Locoregional recurrence after laparoscopic radical trachelectomy: the vaginal cuff must be closed to avoid tumor cell contamination of the peritoneal cavity

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.

Investigating the possible impact of peritoneal tumor exposure amongst women with early stage cervical cancer treated with minimally invasive approach

INTRODUCTION

Recent findings show a detrimental impact of the minimally invasive approach on patients with early stage cervical cancer (ECC). Reasons beyond these results are unclear. The aim of the present article is to investigate the possible role of peritoneal contamination during intracorporeal colpotomy.

METHODS

patients with early stage cervical cancer were divided into 2 groups: no intraperitoneal exposure (N-IPE) intraperitoneal exposure (IPE) during minimally invasive surgery. Patients of the 2 groups were propensity-matched according to the major risk factors.

RESULTS

226 cases of the IPE group had a significant worst prognosis than the 142 cases of the N-IPE group (4.5-years disease free survival: 86.6% vs 95.9% respectively, p = 0.005), while N-IPE had similar survival to open surgery (4.5-years disease free survival: 95.0% vs 90.5% respectively, p = 0.164). Distant recurrence was more frequent among IPE patients with a borderline significance (3.5% vs 0.4% among IPE and N-IPE respectively, p = 0.083). On multivariate analysis, intraperitoneal tumor exposure was an independent prognostic factors for worse survival; patients belonging to the N-IPE group had a risk of recurrence of about 3-fold lower compared to patients of the IPE group (hazard ratio: 0.37, 95% confidence interval: 0.15-0.88, p = 0.025).

CONCLUSION

it would be advisable that further prospective studies investigating the efficacy of different surgical approach in ECC take into consideration of this issue. Moreover, all other measures that could potentially prevent peritoneal exposure of tumor should be adopted during minimally invasive surgery for early stage cervical cancer to provide higher survival outcomes.

Laparoscopic radical hysterectomy with transvaginal closure of vaginal cuff - a multicenter analysis

OBJECTIVE

Laparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy.

METHODS

Between August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator.

RESULTS

A total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2-86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1-288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery.

CONCLUSION

The combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

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.

Intestinal metastasis after total laparoscopic radical trachelectomy for stage IB1 cervical cancer: A case report

•Simultaneous sigmoid colon and rectum metastasis after LRT.•Caution should be exercised in expanding conventional indications in fertility preserving surgery.•Cervical tumor exposure to CO2 should be avoided during surgery.

Four Surgical Approaches to Cervical Excision During Laparoscopic Radical Trachelectomy for Early Cervical Cancer

STUDY OBJECTIVE

To compare the clinical and oncological outcomes of four different approaches of cervical excision (CE) during radical trachelectomy (RT) for early cervical cancer.

DESIGN

A retrospective comparative observational study was performed at Gynecology Department of the Hospital Italiano de Buenos Aires in Buenos Aires, Argentine. The study was composed of all consecutive women who had undergone laparoscopic RT for early cervical cancer between May 2011 and July 2016. They were divided in four groups according with different surgical approaches to perform the CE during RT; which are also detailed. (Canadian Task Force Classification III).

SETTING

Tertiary care hospital.

INTERVENTION

CE during radical trachelectomy for early cervical cancer.

MEASUREMENT AND MAIN RESULTS

A total of 7, 6, 6 and 3 patients undergone Type A, B, C and D cervical excision during RT, respectively. No significant differences in terms of age, BMI, surgical time and length of hospital stay were found according with different types of CE. Patients in Type D had, however, a significantly higher EBL, p =.006. Similar histology characteristics in terms of histology type, tumor grade and size, as well as lymph node count were observed among groups. Only grade 1-2 postoperative complications were noted in 9 patients. One local recurrence after Type B CE was treated with radical surgery plus chemoradiaton; while other patient after Type A CE relapsed with peritoneal carcinomatosis managed with chemotherapy.

CONCLUSION

Different types of cervical excision that are here described should be used according to each case based on specific clinical factors.