Long-Term Oncological Outcomes After Laparoscopic Versus Abdominal Radical Hysterectomy in Stage IA2 to IIA2 Cervical Cancer: A Matched Cohort Study

Survival after minimally invasive radical hysterectomy with protective colpotomy for early-stage cervical cancer: A systematic review and meta-analysis

Minimally invasive surgery on treatment of early-stage cervical cancer is debatable. Traditional approaches of colpotomy are considered responsible for an inferior oncological outcome. Evidence on whether protective colpotomy could optimize minimally invasive technique and improve prognoses of women with early-stage cervical cancer remains limited. We produced a systematic review and meta-analysis to compare oncological outcomes of the patients treated by minimally invasive radical hysterectomy with protective colpotomy to those treated by open surgery according to existing literature. We explored PubMed, Embase, the Cochrane Library, and ClinicalTrials.gov from inception to December 2022. Inclusion criteria were: (1) randomized controlled trials or observational studies published in English, (2) studies comparing minimally invasive radical hysterectomy with protective colpotomy to abdominal radical hysterectomy in early-stage cervical cancer, and (3) studies comparing survival outcomes. Two reviewers performed the screening, data extraction, and quality assessment independently. A total of 8 retrospective cohort studies with 2020 women were included in the study, 821 of whom were in the minimally invasive surgery group, and 1199 of whom were in the open surgery group. The recurrence-free survival and overall survival in the minimally invasive surgery group were both similar to that in the open surgery group (pooled hazard ratio, 0.88 and 0.78, respectively; 95% confidence interval, 0.56-1.38 and 0.42-1.44, respectively). Minimally invasive radical hysterectomy with protective colpotomy on treatment of early-stage cervical cancer had similar recurrence-free survival and overall survival compared to abdominal radical hysterectomy. Protective colpotomy could be a guaranteed approach to modifying minimally invasive technique.

Identification of miRNAs and target genes associated with lymph node metastasis in cervical cancer using bioinformatics analysis

This study was designed to identify the differentially expressed miRNAs (DEMs) and genes (DEGs) in metastatic cervical cancer using bioinformatic tools. In this study, fifty-seven DEMs (48 downregulated and 9 upregulated) were identified, among which miR-4459 and miR-3195 expression was negatively associated with overall survival of cervical cancer patients. Then, 476 target DEGs were determined, and protein-protein interaction (PPI) network was constructed. Seventeen hub genes (LONRF2, CCNE2, AURKA, SYT1, NEGR1, PPP1R12B, GABRP, RAD51, CDK1, FBLN5, PRKG1, CDC6, CACNA1C, MEOX2, ANLN, MYLK, and EDNRB) were finally selected to construct the miRNA-hub gene network. Overall, our study discovered the key miRNAs and mRNAs related to lymph node metastasis (LNM) in cervical cancer, which helps discover candidate therapeutic targets for cervical cancer.

A comparison of concurrent chemoradiotherapy and radical surgery in patients with specific locally advanced cervical cancer (stage IB3, IIA2, IIICr): trial protocol for a randomized controlled study (C-CRAL trial)

BACKGROUND

At present, clinical dilemma remains to be solved in terms of therapy-choices for specific locally advanced cervical cancer (LACC) patients: 1) Although concurrent chemoradiotherapy (CCRT) is recommended as the first choice for them, many patients, influenced by the Chinese culture, prefer to choose radical surgery (RS) as their primary treatment. The difference between the 2 therapies in improving patient prognosis is still unknown. 2) Laparoscopy has been questioned since the noted Laparoscopic Approach to Cervical Cancer trial. Nevertheless, clinical research on laparoscopic surgery under the strict tumor-free principle is still underway globally, therefore whether laparoscopic surgery can be used for specific LACC is also an urgent issue to be explored.

METHODS

A multi-center, randomized controlled study is designed to investigate the effect of different treatment strategies on the prognosis and quality of life (QoL) in patients with specific locally LACC. A total of 402 patients will be enrolled over a period of 3 years. Eligible patients will be randomized (3:1) to either RS group or CCRT group. Patients assigned to RS group will be randomized (1:2) to the abdominal RS group or laparoscopic RS group. All patients will then be followed-up for 5 years. The primary end point is the 2-year progression-free survival (PFS). The secondary end points include 5-year PFS, 2-year overall survival (OS), 5-year OS, adverse events caused by RS or CCRT and QoL.

TRIAL REGISTRATION

Chinese Clinical Trial Registry Identifier: ChiCTR2000041315.

Intracorporeal colpotomy using the Gutclamper as a novel clamping device to prevent tumor spillage during laparoscopic radical hysterectomy for cervical cancer

INTRODUCTION

Tumor cell spillage during the colpotomy has been suspected as one reason for poor oncologic outcomes in laparoscopic radical hysterectomy (LRH) for cervical cancer. To prevent such tumor spillage in LRH, we focused on use of a Gutclamper which is a device originally designed to clamp the colon and rectum during colorectal resections.

MATERIALS AND SURGICAL TECHNIQUE

A woman with stage IB1 cervical cancer underwent LRH using the Gutclamper. The Gutclamper was inserted into the abdominal cavity via 5-mm trocar, the vagina was clamped, and an intracorporeal colpotomy was performed caudal to this device.

DISCUSSION

The Gutclamper can be used to clamp the vaginal canal and avoid the exposure of cervical tumor, regardless of the surgeon's skills or patient conditions. An intracorporeal colpotomy using the Gutclamper can contribute to the standardization of LRH.

Anatomical Description of Anterior Parametrium: A Probable Answer to Pelvic Recurrence Following Radical Hysterectomy

A prospective analysis of a retrospective data of patients with cervix carcinoma treated by minimal invasive surgery at high-volume gynecology oncology center analyzing that minimal access surgery is an acceptable treatment modality in cervix carcinoma. The study included 423 patients who underwent laparoscopic/robotic radical hysterectomy after pre-operative evaluation after taking their consent and obtaining ethical approval from the IRB. Post-operatively, patients were followed up at regular intervals for clinical examination and ultrasonography for a median range of 36 months. A PET scan was done only if there was any suspicious finding on clinical examination or ultrasonography. Patients with parametrial involvement, positive vaginal margins, and nodal involvement were treated with chemotherapy/radiotherapy. Four hundred twenty-three patients of cervix carcinoma were treated with minimal access surgery. Average duration of surgeries was 92 min. Median range of duration of post-operative follow-up was 36 months. None of the patients had positive resection margins indicating adequate parametrectomy with complete oncological clearance. On post-operative follow-up, only 2 patients had vaginal recurrence which is comparable to that observed in open surgery and no pelvic recurrence. With the understanding of the anatomical landmarks of the anterior parametrium and development of skills for adequate oncological clearance, minimal access surgery should be the preferred surgical modality in carcinoma of the cervix.

Meta-analysis of laparoscopic radical hysterectomy, excluding robotic assisted versus open radical hysterectomy for early stage cervical cancer

Recent evidence has shown an increase in recurrence and a decrease in overall survival in patients treated with laparoscopic radical hysterectomy (LRH) and robotic assisted radical hysterectomy (RRH) open techniques (ORH). In addition, several high quality trials were recently published regarding the laparoscopic treatment of early stage cervical cancer. We sought out to reassess the recurrence rates, overall survival, complications and outcomes associated with laparoscopic radical hysterectomy (LRH) techniques against open techniques (ORH) when robotic assisted techniques were excluded. We searched PubMed, Medline, Cochrane CENTRAL, SCOPUS, ClinicalTrials.Gov and Web of Science for relevant clinical trials and observational studies. We included all studies that compared with early stage cervical cancer receiving LRH compared with ORH. We included randomized clinical trials, prospective cohort, and retrospective cohort trials. We included studies that included LRH and RRH as long as data was available to separate the two arms. We excluded studies that combined LRH and RRH without supplying data to differentiate. Of 1244 total studies, we used a manual three step screening process. Sixty studies ultimately met our criteria. We performed this review in accordance with PRISMA guidelines. We analyzed continuous data using mean difference (MD) and a 95% confidence interval (CI), while dichotomous data were analyzed using odds ratio (OR) and a 95% CI. Review Manager and Endnote software were utilized in the synthesis. We found that when excluding RRH, the was no significant difference regarding 5-year overall Survival (OR = 1.24 [0.94, 1.64], (P = 0.12), disease free survival (OR = 1.00 [0.80, 1.26], (P = 0.98), recurrence (OR = 1.01 [0.81, 1.25], (P = 0.95), or intraoperative complications (OR = 1.38 [0.94, 2.04], (P = 0.10). LRH was statistically better than ORH in terms of estimated blood loss (MD = - 325.55 [- 386.16, - 264.94] (P < 0.001), blood transfusion rate (OR = 0.28 [0.14, 0.55], (P = 0.002), postoperative complication rate (OR = 0.70 [0.55, 0.90], (P = 0.005), and length of hospital stay (MD = - 3.64[- 4.27, - 3.01], (P < 0.001). ORH was superior in terms of operating time (MD = 20.48 [8.62, 32.35], (P = 0.007) and number of resected lymph nodes (MD = - 2.80 [- 4.35, - 1.24], (P = 0.004). The previously seen increase recurrence and decrease in survival is not seen in LRH when robotic assisted techniques are included and all new high quality is considered. LRH is also associated with a significantly shorter hospital stay, less blood loss and lower complication rate.Prospero Prospective Registration Number: CRD42022267138.

Comparison of long-term bowel symptoms after laparoscopic radical hysterectomy versus abdominal radical hysterectomy in patients with cervical cancer

INTRODUCTION AND HYPOTHESIS

The objective of this study was to compare the long-term bowel symptoms between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in patients with cervical cancer.

METHODS

A total of 207 patients who underwent radical hysterectomy (79 underwent LRH and 128 underwent ARH) at Peking University First Hospital from January 2010 to August 2020 were enrolled and their bowel symptoms were investigated using the Colorectal Anal Distress Inventory-8 (CRADI-8) of the Pelvic Floor Distress Inventory-20. The prevalence and severity of bowel symptoms were compared in the LRH and ARH groups, and multivariate analysis was performed to determine the factors associated with bowel symptoms.

RESULTS

There was no difference in the CRADI-8 scores between the two groups. However, the prevalence of straining at stool was significantly higher in the ARH group than in the LRH group (19.5% versus 1.3%, p<0.001), and the score was significantly higher in the ARH group than in the LRH group too (0.4 versus 0, p<0.001). The prevalence of incomplete defecation was significantly higher in the ARH group than in the LRH group (13.3% versus 3.8%, p=0.029), and the ARH group also had a significantly higher score than the LRH group (0.3 versus 0.1, p=0.028). Multivariate analysis showed that ARH and postoperative interval were independent risk factors for the development of straining at stool.

CONCLUSIONS

Patients with cervical cancer who underwent ARH may be more likely to develop symptoms related to constipation than those who underwent LRH. This finding has to be interpreted with caution owing to the study design.

Comparative single-center study between modified laparoscopic radical hysterectomy and open radical hysterectomy for early-stage cervical cancer

BACKGROUND

Since the release of the LACC trial results in 2018, the safety of laparoscopic radical hysterectomy (LRH) for cervical cancer has received huge attention and heated discussion. We developed modified laparoscopic radical hysterectomy (MLRH) incorporating a series of measures to prevent tumor spillage, which has been performed in our center since 2015.

OBJECTIVE

Present study retrospectively analyzed relevant indicators of MLRH and evaluated disease-free survival (DFS) primarily in the treatment of early cervical cancer compared with open surgery.

METHODS

Patients with 2014 International Federation of Gynecology and Obstetrics clinical stages 1B1 and 2A1 cervical cancer who underwent radical hysterectomy in the gynecological department of our hospital from October 2015 to June 2018 were enrolled retrospectively in this study. Patients were divided into two groups based on the surgical procedure: open radical hysterectomy (ORH) group (n = 336) and MLRH group (n = 302). Clinical characteristics, surgical indices, and survival prognosis were analyzed, including 2.5-year overall survival (OS) rate, 2.5-year DFS rate, recurrence rate, and recurrence pattern.

RESULTS

Compared to the ORH group, the MLRH group exhibited a longer operative time, longer normal bladder function recovery time, less intraoperative blood loss volume, and more harvested pelvic lymph nodes (P < 0.05). No significant differences were observed in postoperative complications, the 2.5-year OS, 2.5-year DFS, and recurrence rate between the two groups (P > 0.05); however, the recurrence pattern was significantly different (P < 0.05). The MLRH group mainly exhibited local single metastasis (7/11), whereas the ORH group mainly exhibited distant multiple metastases (14/16). Stratified analysis revealed that overall survival rate was higher in the MLRH group than in the ORH group in patients with stage 1B1 and middle invasion (P < 0.05).

CONCLUSION

MLRH does not show a survival disadvantage in the treatment of early-stage cervical cancer when compared with open surgery. In addition, MLRH shows a survival advantage in patients with stage 1B1 and middle 1/3 invasion. Considering this is a retrospective study, further prospective study is necessary for more sufficient data support.

TRIAL REGISTRATION

Present research is a retrospective study. The study had retrospectively registered on Chinese Clinical Trial Registry ( http://www.chictr.org.cn/ ), and the registered number is ChiCTR1900026306.

The incidence of postoperative symptomatic lymphocele after pelvic lymphadenectomy between abdominal and laparoscopic approach: a systemic review and meta-analysis

OBJECTIVE

To evaluate the risks of symptomatic lymphocele after pelvic lymphadenectomy between the laparoscopic and abdominal approach in uterine cervical and endometrial cancer.

METHODS

We searched Ovid Medline, Ovid EMBASE, and the Cochrane library through April 2020. We selected the comparative studies contained information on symptomatic lymphoceles in postoperative complications. All articles searched were independently reviewed and selected by two researchers. A meta-analysis was performed using the Stata MP version 16.0 software package.

RESULTS

A total of 33 eligible clinical trials were ultimately enrolled in this meta-analysis. When all studies were pooled, the odds ratios (OR) of the laparoscopic approach for the risk of symptomatic lymphoceles compared to the abdominal approach was 0.58 [95% confidence interval (CI): 0.42-0.81, p = 0.022, I-squared = 0.0%]. The risk of postoperative symptomatic lymphoceles in the laparoscopic group tended to decrease over time in the cumulative meta-analysis. In the subgroup analysis, there was no evidence for an association between cancer type, quality of the study methodology, hysterectomy type, and postoperative symptomatic lymphoceles. However, in a recently published article, being overweight (body mass index ≥ 25) and studies conducted in oriental area were associated with a lower incidence of postoperative symptomatic lymphoceles.

CONCLUSION

Laparoscopic lymphadenectomy was associated with a significantly lower risk of postoperative symptomatic lymphoceles than abdominal lymphadenectomy (PROSPERO registration number: CRD 42,020,187,165).

The MEMORY Study: MulticentEr study of Minimally invasive surgery versus Open Radical hYsterectomy in the management of early-stage cervical cancer: Survival outcomes

OBJECTIVE

The Laparoscopic Approach to Cervical Cancer (LACC) trial found that minimally invasive radical hysterectomy compared to open radical hysterectomy compromised oncologic outcomes and was associated with worse progression-free survival (PFS) and overall survival (OS) in early-stage cervical carcinoma. We sought to assess oncologic outcomes at multiple centers between minimally invasive (MIS) radical hysterectomy and OPEN radical hysterectomy.

METHODS

This is a multi-institutional, retrospective cohort study of patients with 2009 FIGO stage IA1 (with lymphovascular space invasion) to IB1 cervical carcinoma from 1/2007-12/2016. Patients who underwent preoperative therapy were excluded. Squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinomas were included. Appropriate statistical tests were used.

RESULTS

We identified 1093 cases for analysis-715 MIS (558 robotic [78%]) and 378. OPEN procedures. The OPEN cohort had more patients with tumors >2 cm, residual disease in the hysterectomy specimen, and more likely to have had adjuvant therapy. Median follow-up for the MIS and OPEN cohorts were 38.5 months (range, 0.03-149.51) and 54.98 months (range, 0.03-145.20), respectively. Three-year PFS rates were 87.9% (95% CI: 84.9-90.4%) and 89% (95% CI: 84.9-92%), respectively (P = 0.6). On multivariate analysis, the adjusted HR for recurrence/death was 0.70 (95% CI: 0.47-1.03; P = 0.07). Three-year OS rates were 95.8% (95% CI: 93.6-97.2%) and 96.6% (95% CI: 93.8-98.2%), respectively (P = 0.8). On multivariate analysis, the adjusted HR for death was 0.81 (95% CI: 0.43-1.52; P = 0.5).

CONCLUSION

This multi-institutional analysis showed that an MIS compared to OPEN radical hysterectomy for cervical cancer did not appear to compromise oncologic outcomes, with similar PFS and OS.

Postsurgical urodynamic study of total laparoscopic nerve-sparing radical hysterectomy for uterine cervical cancer

AIM

To evaluate the impact on urodynamic results between the laparoscopic nerve-sparing radical hysterectomy (LRH) following a step-by-step procedure and abdominal nerve-sparing radical hysterectomy (ARH) for patients with uterine cervical cancer.

METHODS

This retrospective study enrolled 76 patients with cervical cancer: 35 in the LRH group and 41 in the ARH group. We analyzed their postoperative bladder function in a urodynamics study and examined the volume of resected pelvic nerves contained in parametrial sections using S-100 antibody staining.

RESULTS

Estimated blood loss and hospital stay after operation for the LRH group were significantly better than those in the ARH group (p < 0.0001). As well, the number of harvested lymph nodes was significantly higher in the LRH group (p = 0.044). There was no difference in perioperative complications between the two groups in this study. The 5-year disease-free survival rates and overall survival rates were 91.2% and 94.0% in the LRH group and 87.8% and 95.1% in the ARH group, both respectively. Although the median residual urine volume were no statistical differences between the LRH group and the ARH group, the recovery of postoperative bladder function (uroflowmetry) in the LRH group rapidly reached presurgery levels at 1 month, and the LRH group had a smaller number of s-100 antibody stained nerves contained the parametrial sections.

CONCLUSION

We demonstrated that LRH following a step-by-step procedure could achieve a higher level of prevention of damage to the bladder branch of the pelvic splanchnic nerve plexus and thus restore bladder function more rapidly.

Retrospective Comparison of Laparoscopic versus Open Radical Hysterectomy for Early-Stage Cervical Cancer in a Single Tertiary Care Institution from Lithuania between 2009 and 2019

Background and Objectives: A great debate within the academic arena was evoked by the LACC study, giving rise to doubt regarding the oncological outcomes of the laparoscopic approach for early-stage cervical cancer. This encouraged us to conduct a retrospective analysis of CC treatment surgical approaches applied to the patients at tertiary level Vilnius University Hospital Santaros Clinics, Vilnius, Lithuania, between 2009 and 2019. Materials and Methods: The retrospective study was carried out to evaluate the outcomes after 28 laparoscopic and 62 laparotomic radical hysterectomies for early cervical cancer in a single tertiary care institution performed during the period 2009–2019. For statistical analysis of patients’ parameters, SPSS v. 17.0 was applied, together with the Kaplan–Meier method with a long-rank test and the Cox proportional hazard regression model used for bi-variate analysis determining OS outcomes between MIS and open-surgery groups. Results: After computing data with the Cox regression model, there was no significant difference of the 36-months overall survival between laparoscopy and laparotomy groups, as opposed to the LACC study. Conclusions: Our tertiary institution faces a considerable challenge, and we acknowledge the limitations of the study and also feel a responsibility to follow the latest guidelines. Currently, it appears that the most substantial attention should be focused on the cessation of uterine manipulator use as well as laparoscopic technique learning curves.

Radical Hysterectomy for Cervical Cancer: the Right Surgical Approach

OPINION STATEMENT

Radical hysterectomy with pelvic lymph node assessment is the standard initial therapy for early-stage cervical cancer. Radical hysterectomy via laparotomy (an "open" approach) was first described more than 100 years ago and has been the standard for decades. Minimally invasive surgery (MIS) has been increasingly adopted by many surgeons due to its reported perioperative benefits. MIS was deemed safe for radical hysterectomy for many years based on multiple retrospective publications. Recently, the Laparoscopic Approach to Cervical Cancer (LACC) trial reported that patients randomized to MIS had inferior oncologic outcomes. The results of the LACC trial and subsequent retrospective studies led multiple professional societies to state that open radical hysterectomy should remain the gold standard surgical approach. We acknowledge that the open approach for radical hysterectomy is an appropriate option for all cervical cancer patients eligible for surgical treatment. However, considering the limitations of the LACC trial and the available data from other retrospective studies, we feel the MIS approach should not be simply abandoned. There may still be a role for MIS in cervical cancer surgery for properly and carefully selected cases and with detailed counseling; surgeons should analyze their own outcomes closely in order to perform such counseling. Modification of surgical technique and maintaining proper oncologic surgical principles are key for MIS to remain a viable option. Tumor manipulation and contamination should be avoided. Transcervical uterine manipulators should not be used. Cervical and tumor containment prior to colpotomy, as is performed during an open approach, is required. This will all require validation in future trials. We await the results of ongoing randomized trials to further inform us. A one-size-fits-all approach may be short-sighted; we may need to decide treatment strategy based on the notion of the right surgical approach for the right patient by the right surgeon.

A meta-analysis of survival after minimally invasive radical hysterectomy versus abdominal radical hysterectomy in cervical cancer: center-associated factors matter

Purpose

To explore the possible factors that contributed to the poor performance of minimally invasive surgery (MIS) versus abdominal surgery regarding progression-free survival (PFS) and overall survival (OS) in cervical cancer.

Methods

MEDLINE, EMBASE, Cochrane Library and Web of Science were searched (January 2000 to April 2021). Study selection was performed by two researchers to include studies reported oncological safety. Summary hazard ratios (HRs) and 95% confidence intervals (CIs) were combined using random-effect model. Subgroup analyses were stratified by characteristics of disease, publication, study design and treatment center.

Results

Sixty-one studies with 63,369 patients (MIS 26956 and ARH 36,049) were included. The overall-analysis revealed a higher risk of recurrence (HR 1.209; 95% CI 1.102–1.327) and death (HR 1.124; 95% CI 1.013–1.248) after MIS versus ARH expect in FIGO IB1 (FIGO 2009 staging) patients with tumor size less than 2 cm. However, subgroup analyses showed comparable PFS/DFS and OS in studies published before the Laparoscopic Approach to Cervical Cancer (LACC) trial, published in European journals, conducted in a single center, performed in centers in Europe and in centers with high sample volume or high MIS sample volume.

Conclusion

Our findings highlight possible factors that associated with inferior survival after MIS in cervical cancer including publication characteristics, center-geography and sample volume. Center associated factors were needed to be taken into consideration when evaluating complex surgical procedures like radical hysterectomy.

Cervical conization before primary radical hysterectomy has a protective effect on disease recurrence in early cervical cancer: A two-center matched cohort study according to surgical approach

OBJECTIVE

To ascertain whether cervical conization before radical hysterectomy (RH) has a protective effect on survival outcomes in early cervical cancer, taking into account the surgical approach.

METHODS

From cervical cancer cohorts of two institutions, we identified node-negative, margin-negative, parametria-negative, 2009 FIGO stage IB1 cervical cancer patients who received primary Type C RH between July 2006 and June 2020. Patients were divided into conization group (n = 144) and control group (n = 434). We conducted three independent 1:1 propensity score matching processes for histology, lymphovascular space invasion, cervical tumor size, and surgical approach (all patients, those who underwent open surgery, and those who underwent minimally invasive surgery [MIS]). Survival outcomes were compared.

RESULTS

Overall, the conization group had less cervical tumor size and received MIS more frequently (P = 0.010) and adjuvant treatment less often (P = 0.002) versus the controls. After matching, the conization group showed significantly better disease-free survival (DFS) versus control (3-year DFS rate, 94.2% vs. 86.3%; P = 0.012), but similar overall survival. Among the open RH matched patients (n = 96), no difference in DFS was observed between the conization and control groups (P = 0.984). In contrast, among the MIS RH matched patients (n = 192), the conization group showed significantly better DFS versus control (3-year DFS rate, 95.7% vs. 82.9%; P = 0.005). In multivariate analysis adjusting for cervical tumor size and adjuvant treatment, conization was identified as an independent favorable prognostic factor for DFS (adjusted HR, 0.318; 95% CI, 0.134-0.754; P = 0.009).

CONCLUSIONS

Preoperative cervical conization might reduce the disease recurrence rate in early cervical cancer patients who undergo primary MIS RH.

The incidence of urologic complications requiring urologic procedure in radical hysterectomy and difference between abdominal radical hysterectomy and laparoscopic radical hysterectomy

Objective

To evaluate the incidence of urologic complications requiring a urologic procedure during the perioperative period and compare the differences between abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH).

Methods

We identified all Korean women who underwent radical hysterectomy (RH) between January 2006 and December 2019 using the National Health Insurance Service database. Complications requiring surgical intervention-based urologic procedures between ARH and LRH were investigated.

Results

A total of 12,068 patients were classified into the ARH group and 8,837 patients were classified into the LRH group. Urologic complications requiring urologic procedures occurred in 1,546 of 20,905 patients (7.40%) who underwent RH. The most common urologic procedure was double-J insertion (R326, 5.18%), followed by bladder repair (R3550, 0.90%). There was no significant difference in urologic complications requiring urologic procedures between the ARH and LRH groups (odds ratio [OR]=1.027; 95% confidence interval [CI]=0.925–1.141; p=0.612). The incidence of bladder repair (R3550) was significantly higher in patients who underwent LRH (OR=1.620; 95% CI=1.220–2.171; p<0.001). Urologic complications requiring urologic procedures were statistically higher in the LRH group during the first half (OR=1.446; 95% CI=1.240–1.685; p<0.001), but more in the ARH group during the second half (OR=0.696; 95% CI=0.602–0.804; p<0.001) of the study period.

Conclusion

There was no difference of urologic complications between ARH and LRH with regard to urologic procedures. The incidence of urologic procedures decreases with time in patients who underwent LRH.

Previous studies have been insufficient to detect clinically significant difference in urologic complications between abdominal radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH). It is clinically more important to evaluate urologic complications that require urologic procedures rather than urologic complications alone. The incidence of urologic complications requiring urologic procedures related to radical hysterectomy was evaluated using data from the National Health Insurance Service. There was no difference in urologic complications between ARH and LRH.

Machine Learning Models to Predict Survival Outcomes According to the Surgical Approach of Primary Radical Hysterectomy in Patients with Early Cervical Cancer

Simple Summary

An increased risk of relapse and death from minimally invasive radical hysterectomy has been reported in some patients with early cervical cancer. Thus, the development of an intuitive and precise decision-aid tool, which estimates recurrence and mortality rates by surgical approach, is necessary. To develop models predicting survival outcomes according to the surgical approach, we collected clinicopathologic and survival data of patients with 2009 FIGO stage IB cervical cancer who underwent a radical hysterectomy. Using only variables that could be obtained preoperatively, we developed various models predicting the probability of 5-year progression-free survival and overall survival. Among them, hybrid ensemble models, combined with logistic regression and multiple machine learning models, achieved the best predictive performance. The developed models are expected to help physicians’ and patients’ decision making related to the surgical approach for primary radical hysterectomy.

Abstract

We purposed to develop machine learning models predicting survival outcomes according to the surgical approach for radical hysterectomy (RH) in early cervical cancer. In total, 1056 patients with 2009 FIGO stage IB cervical cancer who underwent primary type C RH by either open or laparoscopic surgery were included in this multicenter retrospective study. The whole dataset consisting of patients’ clinicopathologic data was split into training and test sets with a 4:1 ratio. Using the training set, we developed models predicting the probability of 5-year progression-free survival (PFS) and overall survival (OS) with tenfold cross validation. The developed models were validated in the test set. In terms of predictive performance, we measured the area under the receiver operating characteristic curve (AUC) values. The logistic regression models comprised of preoperative variables yielded AUCs of 0.679 and 0.715 for predicting 5-year PFS and OS rates, respectively. Combining both logistic regression and multiple machine learning models, we constructed hybrid ensemble models, and these models showed much improved predictive performance, with 0.741 and 0.759 AUCs for predicting 5-year PFS and OS rates, respectively. We successfully developed models predicting disease recurrence and mortality after primary RH in patients with early cervical cancer. As the predicted value is calculated based on the preoperative factors, such as the surgical approach, these ensemble models would be useful for making decisions when choosing between open or laparoscopic RH.

Minimally invasive surgery and abdominal radical hysterectomy in patients with early-stage cervical cancer: A meta-analysis

OBJECTIVE

To compare risk of recurrence and death related to minimally invasive surgery (MIS) and abdominal radical hysterectomy (ARH) in early-stage cervical cancer (CC) patients.

METHODS

All relevant literatures in databases were retrieved from the built time of databases to October 2020. Observational studies comparing MIS and ARH in early-stage CC patients were involved. Newcastle-Ottawa Scale was used for quality assessment, including studies with a score of at least 6. Main outcomes involved overall survival (OS) and disease-free survival (DFS).

RESULTS

Twenty-two studies were involved, including 14 894 patients, among which 7213 (48.6%) underwent MIS. The OS (hazard ratio [HR] 1.23, 95% confidence interval [CI] 1.03-1.43) and DFS (HR 1.25, 95% CI 1.07-1.42) of patients undergoing MIS was obviously shortened compared with those of patients undergoing ARH. Subgroup analysis revealed that OS (HR 1.42, 95% CI 1.10-1.74) and DFS (HR 1.46, 95% CI 1.18-1.74) of patients with a tumor ≥2 cm in diameter were significantly reduced by MIS.

CONCLUSION

Overall survival and DFS after MIS for early-stage CC treatment were worse than those after ARH, especially for patients with a tumor ≥2 cm in diameter.

Lymph-Vascular Space Invasion in Patients with Stages IA2-IIA2 Cervical Cancer Treated with Laparoscopic versus Open Radical Hysterectomy

Objective

To explore the relationship between laparoscopic radical hysterectomy (LRH) and cervical cancer lymph-vascular space invasion (LVSI) by comparing the prevalence of LVSI in cervical cancer patients who underwent LRH versus open radical hysterectomy (ORH).

Methods

The study participants were 1087 cervical cancer patients (FIGO 2009 stages IA2-IIA2) with pathologically confirmed with or without LVSI who underwent radical hysterectomy at Shengjing Hospital of China Medical University from 2013 through 2018. The patients were divided according to the type of surgical procedure into an LRH group (n=148) and an ORH group (n=939).

Results

In the LRH group, 31.76% of patients (47/148) had LVSI-positive tumors compared to 33.23% of patients (312/939) in the ORH group; the difference was not significant (p=0.724). No between-group differences in LVSI prevalence according to lymph node metastasis, interstitial infiltration depth, differentiation degree, and parametrial infiltration were found. However, the number of LVSI-positive patients whose cervical cancer lesions >4 cm (stage I B2 and II A2) was significantly higher in the LRH group than in the ORH group (Odds Ratio [OR] 0.333, 95% confidence interval [CI] 0.157–0.706, p=0.005). The 3-Year disease-free survival (DFS) in the LRH group is lower than that in the ORH group (94.75% vs 97.27%), but there was no significance (P=0.187). Furthermore, the percentage of LVSI-positive tumors in patients with lymph node metastases was significantly higher than those without lymph node metastases (OR 2.897, 95% CI 2.129–3.942, p=0.000). The 3-Year DFS were 98.22% in the LVSI negative patients and 93.78% in the LVSI positive patients, the difference was significant (P=0.002).

Conclusion

A higher risk of lymph node metastasis and a lower 3-Year DFS was found in the LVSI-positive patients. In case of LVSI, it would be dangerous to treat patient in laparoscopy, especially in case of cervical cancer lesions >4cm.

Comparison of survival outcomes between laparoscopic surgery and abdominal surgery for radical hysterectomy as primary treatment in patients with stage IB2/IIA2 cervical cancer

OBJECTIVE

To investigate the long-term oncological outcomes of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for the treatment of stage IB2/IIA2 cervical cancer without preoperative adjuvant therapy.

METHODS

We conducted a multicenter, retrospective, case-matching study. The differences in overall survival (OS) and disease-free survival (DFS) between the LRH and ARH were compared under the conditions of real-world study and case-control matching (1:1 matching).

RESULTS

There was no significant difference in the outcomes of LRH (n = 580) and ARH (n = 1653) in 5-year OS and DFS (OS: 80.6% vs. 86.1%, p = 0.421; DFS: 78.6% vs. 80.7%, p = 0.376). After 1:1 matching, there was no difference in 5-year OS and DFS between LRH (n = 554) and ARH (n = 554) (OS: 80.4% vs. 84.5%, p = 0.993; DFS: 79.0% vs. 78.8%, p = 0.695). Before and after matching, the surgical approach was not an independent risk factor for 5-year OS and DFS, and postoperative adjuvant therapy affected patient prognosis. Further subgroup analysis suggested that there was no difference in LRH (n = 313) and ARH (n = 1092) in 5-year OS or DFS in patients who underwent standard postoperative adjuvant therapy (OS: 83.0% vs. 87.7%, p = 0.992; DFS: 79.0% vs. 82.5%, p = 0.323). After 1:1 pairing, the 5-year OS and DFS in LRH (n = 295) and ARH (n = 295) showed no difference. Before and after matching, the surgical approach was not an independent risk factor affecting the 5-year OS and DFS.

CONCLUSIONS

There was no difference in the oncological outcomes between laparoscopic and abdominal surgery in patients with stage IB2/IIA2 cervical cancer without preoperative adjuvant therapy.

CLINICAL TRIALS

The ethical approval number is NFEC-2017-135, and the clinical research registration number is CHiCTR1800017778 (International Clinical Trials Registry Platform Search Port, http://apps.who.int/trialsearch/).

Minimal-invasive or open approach for surgery of early cervical cancer: the treatment center matters

PURPOSE

The aim of the study was to compare recurrence-free survival (RFS) and overall survival (OS) of patients with early stage cervical cancer in dependence of surgical approach and treatment center.

PATIENTS AND METHODS

A population-based cohort study including women with early stage IA1-IIB2 cervical cancer treated by radical hysterectomy between January 2010 and December 2015 was performed.

RESULTS

The median follow-up time was 5.6 years. After exclusions, 413 patients were eligible for analysis: 111 (26.9%) underwent minimal-invasive surgery (MIS) and 302 (73.1%) open surgery. Both treatment groups were well balanced regarding the clinical and pathological characteristics. The mean age of the patients was 51.0 years. MIS was associated with improved RFS and OS compared with the open surgery. The 5-year RFS rates were 89.2% in the MIS group and 73.4% in the open surgery group (p = 0.004). The 5-year OS rates were 93.7% in the MIS group and 81.8% in the open surgery group (p = 0.016). After adjustment for other prognostic covariates, the MIS was further associated with improved RFS (HR = 0.45, 95% CI 0.24-0.86; p = 0.015) but not with OS. Nevertheless, after adjustment for treatment center, the surgical approach was not associated with significant difference in RFS (HR = 0.61, 95% CI 0.31-1.19; p = 0.143). Overall survival of patients treated in university cancer centers was significantly increased compared to patients treated in non-university cancer centers. The treatment center remains a strong prognostic factor regarding RFS (HR = 0.49, 95% CI 0.28-0.83; p = 0.009) and OS (HR = 0.50, 95% CI 0.26-0.94; p = 0.031).

CONCLUSIONS

The treatment center but not the surgical approach was associated with the survival of patients treated with radical hysterectomy for early stage cervical cancer.

Survival After Minimally Invasive vs Open Radical Hysterectomy for Early-Stage Cervical Cancer: A Systematic Review and Meta-analysis

Importance

Minimally invasive techniques are increasingly common in cancer surgery. A recent randomized clinical trial has brought into question the safety of minimally invasive radical hysterectomy for cervical cancer.

Objective

To quantify the risk of recurrence and death associated with minimally invasive vs open radical hysterectomy for early-stage cervical cancer reported in observational studies optimized to control for confounding.

Data Sources

Ovid MEDLINE, Ovid Embase, PubMed, Scopus, and Web of Science (inception to March 26, 2020) performed in an academic medical setting.

Study Selection

In this systematic review and meta-analysis, observational studies were abstracted that used survival analyses to compare outcomes after minimally invasive (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics 2009 stage IA1-IIA) cervical cancer. Study quality was assessed with the Newcastle-Ottawa Scale and included studies with scores of at least 7 points that controlled for confounding by tumor size or stage.

Data Extraction and Synthesis

The Meta-analysis of Observational Studies in Epidemiology (MOOSE) checklist was used to abstract data independently by multiple observers. Random-effects models were used to pool associations and to analyze the association between surgical approach and oncologic outcomes.

Main Outcomes and Measures

Risk of recurrence or death and risk of all-cause mortality.

Results

Forty-nine studies were identified, of which 15 were included in the meta-analysis. Of 9499 patients who underwent radical hysterectomy, 49% (n = 4684) received minimally invasive surgery; of these, 57% (n = 2675) received robot-assisted laparoscopy. There were 530 recurrences and 451 deaths reported. The pooled hazard of recurrence or death was 71% higher among patients who underwent minimally invasive radical hysterectomy compared with those who underwent open surgery (hazard ratio [HR], 1.71; 95% CI, 1.36-2.15; P < .001), and the hazard of death was 56% higher (HR, 1.56; 95% CI, 1.16-2.11; P = .004). Heterogeneity of associations was low to moderate. No association was found between the prevalence of robot-assisted surgery and the magnitude of association between minimally invasive radical hysterectomy and hazard of recurrence or death (2.0% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -3.4% to 7.7%]) or all-cause mortality (3.7% increase in the HR for each 10-percentage point increase in prevalence of robot-assisted surgery [95% CI, -4.5% to 12.6%]).

Conclusions and Relevance

This systematic review and meta-analysis of observational studies found that among patients undergoing radical hysterectomy for early-stage cervical cancer, minimally invasive radical hysterectomy was associated with an elevated risk of recurrence and death compared with open surgery.

A retrospective assessment of the safety and efficacy of laparoscopic radical hysterectomy in Japan during the early years following its introduction: a Japanese Gynecologic Oncology Group study (JGOG1081S)

OBJECTIVE

To evaluate the safety and efficacy of laparoscopic radical hysterectomy (LRH) for cervical cancer, in terms of morbidity and short-term oncologic outcome following LRH's introduction into Japan.

METHODS

We conducted a retrospective analysis of patients with early-stage cervical cancer (FIGO staging IA2, IB1, and IIA1) who underwent LRH from Dec 2014 to Dec 2016. We assessed the morbidity, overall survival (OS) and recurrence-free survival (RFS), and prognostic factors for RFS.

RESULTS

A total of 251 patients were included from 22 facilities across Japan. There were 8 cases of stage IA2 cervical cancer, 226 of IB1, and 17 of IIA1. The median operating time was 343 min and the median blood loss was 190 ml. Two patients (0.8%) had a postoperative complication with a Clavien-Dindo classification of grade 3 or higher. After a median follow-up time of 15.6 months, the 2-year RFS was 87.4%, and the 2-year OS was 97.8%. When the 2-year RFS rate was compared with whether the patient pathologically had tumors of less than 2 cm, versus 2 cm or more, the RFS was 95.8% and 80.4%, respectively. Multivariate analysis found that tumor size and the route of lymph node removal were independent prognostic factors for recurrence.

CONCLUSION

When LRH was first introduced into Japan, we found that the route of lymph node removal was an independent prognostic factor for recurrence in addition to large tumors (≥ 2 cm). Our results suggest that prognosis may be secured by paying attention to the lymph node removal route.

Comparison of abdominal and minimally invasive radical hysterectomy in patients with early stage cervical cancer

PURPOSE

The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer.

METHODS

A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach.

RESULTS

In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252).

CONCLUSION

In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Survival after Laparoscopic versus Abdominal Radical Hysterectomy in Early Cervical Cancer: A Randomized Controlled Trial

BACKGROUND

Previous studies have reported the safety of laparoscopic radical hysterectomy for treatment of early cervical cancer, as option to laparotomy. This study aims to compare overall survival between laparoscopic versus abdominal radical hysterectomy for early cervical cancer.

METHODS

A single-center randomized controlled trial enrolled 30 patients with clinically staged IA2 cervical cancer and lymphovascular invasion, IB and IIA, who underwent laparoscopic radical hysterectomy (16) or abdominal radical hysterectomy (14).

RESULT

The mean overall survival time was 74.74 months (CI 95%: 54.15-95.33) for LRH 91.67 months (CI 95%: 74.97-108.37) for ARH (log-rank test = 0.30). The mean disease-free survival time was 81.07 months (CI 95%: 60.95-101.19) for LRH and 95.82 months (CI 95%: 80.18-111.47) for ARH (log-rank test = 0.371). The overall survival hazard ratio was 2.05 (CI 95%: 0.51-8.24), and the disease-free hazard ratio was 2.13 (CI 95%: 0.39-11.7).

CONCLUSION

Our study suggests a non-significant trend of worse outcomes for LRH. In light of recent controversy and need for prospective studies, further studies in different populations are required for definite conclusions and until then, patients should be aware of risks and benefits, survival data and quality of life outcomes related to both surgical techniques.

Comparison of Survival Outcomes after Laparoscopic Radical Hysterectomy versus Abdominal Radical Hysterectomy in Patients with Cervical Cancer

OBJECTIVE

A meta-analysis was performed to compare survival outcomes including disease-free survival (DFS) between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in patients with cervical cancer.

DATA SOURCES

We searched PubMed, EMBASE, Google scholar, and the Cochrane library for studies published between December 2004 and May 2020. Manual searches of related articles and relevant bibliographies of published studies were also performed.

METHODS OF STUDY SELECTION

Two researchers independently extracted the data. Studies with survival outcome information were included.

TABULATION, INTEGRATION, AND RESULTS

A total of 36 eligible clinical trials were included in this meta-analysis. When all studies were pooled, the hazard ratio (HR) of LRH for the risk of DFS and overall survival (OS) compared with ARH was 1.24 (95% confidence interval [CI], 1.09-1.41; p = .001; I² = 37.5%) and 1.27 (95% CI, 1.04-1.56; p = .020; I² = 45.5%), respectively. In a subgroup analysis, significant harmful effects of DFS in patients with LRH increased in studies using the HR presented by the article (HR, 1.41; 95% CI, 1.21-1.64; p <.001), matched retrospective design (HR, 1.49; 95% CI, 1.19-1.88; p = .001), large-scale studies (HR, 1.34; 95% CI, 1.16-1.55; p <.001), and studies published after the Laparoscopic Approach to Cervical Cancer trial (HR, 1.46; 95% CI, 1.25-1.71; p <.001). However, LRH did not affect DFS (HR, 1.04; 95% CI, 0.59-1.81; p = .898) or OS (HR, 0.57; 95% CI, 0.31-1.05; p = .073) of patients with cervical cancer with cervical masses <2 cm.

CONCLUSION

This meta-analysis demonstrated that LRH was associated with higher recurrence rates than ARH. However, LRH showed similar recurrence and OS among patients with cervical masses <2 cm (Centre for Reviews and Dissemination 42020191713).

Does a pre-operative conization improve disease-free survival in early-stage cervical cancer?

PURPOSE

Ever since the recent findings showing the lack of benefit of minimally invasive surgery (MIS) versus open surgery in early-stage cervical cancer, gynecologists have tried to explain these results. The primary objective of our study was to assess the impact of pre-operative conization on disease-free survival (DFS) in early-stage cervical cancer. The secondary objective was to analyze the peri-operative morbidity associated with a pre-operative conization.

METHODS

All patients undergoing a surgical management for early-stage squamous carcinoma or adenocarcinoma cervical cancer (IA1, IA2, IB1 and IB2 FIGO 2018) at a French university hospital from 2004 to 2018 were retrospectively included. We examined the association between conization and DFS using a Cox regression model. We also analyzed the morbidity associated with pre-operative conization.

RESULTS

48.4% (44/91) of the patients had a pre-operative conization (defined by a conization up to 90 days prior to surgery). 86.8% underwent MIS. There was a non-significant increase in the DFS with one patient presenting a recurrence in the conization group (2.3%) and six (12.8%) in the no conization group (log rank = 0.09). In univariate analysis, conization, definitive FIGO stage and pre-operative tumor size were associated with DFS (p < 0.2). Only pre-operative tumor size was significantly associated with DFS in multivariate analysis. There was a non-significant increase of adverse events in the conization group (43.2% in the conization group versus 23.4%, p = 0.06).

CONCLUSION

Conization, through a reduction of tumor size, could improve DFS. Carefully selected patients could still benefit from minimally invasive surgery.

Survival After Minimally Invasive vs. Open Radical Hysterectomy for Cervical Cancer: A Meta-Analysis

Background: The comparison of survival outcomes between minimally invasive surgery and open surgery for cervical cancer patients remains controversial. We evaluated the survival outcomes of cervical cancer patients who underwent different surgical approaches.

Methods: A literature search was performed in PubMed, Embase, and Cochrane databases up to February 2020, using the MESH terms “minimally invasive surgical procedures” and “Uterine Cervical Neoplasms.” Included were all original comparative studies and trials both published and unpublished in English that were related to minimally invasive surgery and open surgery for cervical cancer patients with International Federation of Gynecology and Obstetrics (FIGO) 2009 stage < IIB. Begg's and Egger's regressions were used to evaluate publication bias.

Results: This meta-analysis included 28 studies enrolling 18,961 patients with cervical cancer. The overall analyses indicated that cervical cancer patients with FIGO 2009 stage < IIB who underwent minimally invasive surgery had a lower rate of OS (HR = 1.43, 95% CI = 1.06–1.92, P = 0.019) and DFS (HR = 1.50, 95% CI = 1.21–1.85, P < 0.001) than those who underwent open surgery. Moreover, minimally invasive surgery could lower OS (HR = 2.30, 95% CI = 1.50–3.52, P < 0.001) and DFS (HR = 1.94, 95% CI = 1.36–2.76, P < 0.001) of cervical cancer patients with FIGO 2009 stage ≤ IB1 compared to open surgery. However, there were no significant differences in OS (HR = 1.07, 95% CI = 0.65–1.76, P = 0.801) and DFS (HR = 1.20, 95% CI = 0.65–2.19, P = 0.559) in patients with tumors < 2 cm between the two groups.

Conclusions: Minimally invasive radical hysterectomy was associated with poor survival outcomes compared to open surgery. Patients with FIGO 2009 stage ≤ IB1 cervical cancer who underwent minimally invasive surgery have lower OS and DFS rates than those who underwent open surgery. Therefore, open surgery should be performed for cervical cancer patients. However, patients with tumors < 2 cm might take the most advantage of minimally invasive surgery without increasing poor prognosis. There are some limitations in the meta-analysis, which needs further high-quality multicenter studies to confirm and update our findings.

Identification of Prognostic miRNA Signature and Lymph Node Metastasis-Related Key Genes in Cervical Cancer

Background

miRNAs and genes can serve as biomarkers for the prognosis and therapy of cervical tumors whose metastasis into lymph nodes is closely associated with disease progression and poor prognosis.

Methods

R software and Bioconductor packages were employed to identify differentially expressed miRNAs (DEMs) from The Cancer Genome Atlas (TCGA) database. GEO2R detected differentially expressed genes (DEGs) in the GSE7410 dataset originating from the Gene Expression Omnibus (GEO). A Cox proportional hazard regression model was established to select prognostic miRNA biomarkers. Online tools such as TargetScan and miRDB predicted target genes, and overlapping DEGs and target genes were defined as consensus genes. Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment and Gene Ontology (GO) function annotations were performed to discern the potential functions of consensus genes. STRING and Cytoscape screened key genes and constructed a regulatory network.

Results

A combination of four miRNAs (down-regulated miR-502 and miR-145, up-regulated miR-142 and miR-33b) was identified as an independent prognostic signature of cervical cancer. A total of 94 consensus genes were significantly enriched in 7 KEGG pathways and 19 GO function annotations including the cAMP signaling pathway, the plasma membrane, integral components of the plasma membrane, cell adhesion, etc. The module analysis suggested that CXCL12, IGF1, PTPRC CDH5, RAD51B, REV3L, and WDHD1 are key genes that significantly correlate with cervical cancer lymph node metastasis.

Conclusions

This study demonstrates that a four-miRNA signature can be a prognostic biomarker, and seven key genes are significantly associated with lymph node metastasis in cervical cancer patients. These miRNAs and key genes have the potential to be therapeutic targets for cervical cancer. Among them, two miRNAs (miR-502 and miR-33b) and two key genes (PTPRC and CDH5) were first reported to be potential novel biomarkers for cervical cancer. The current study further characterizes the progression of lymph node metastasis and mechanism of cervical tumors; therefore, it provides a novel diagnostic indicator and therapeutic targets for future clinical treatments.

Comparison of urologic complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy: A nationwide study from the National Health Insurance

OBJECTIVE

This study aimed to assess the risks of intraoperative and postoperative urologic complications between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH).

METHODS

Using the database of the National Health Insurance Service (NHIS) and Health Insurance Review & Assessment (HIRA), we identified all Korean women who underwent radical hysterectomy between 2006 and 2018. Intraoperative and postoperative urologic complications were compared between the ARH and LRH groups.

RESULTS

A total of 11,399 patients were identified to ARH and 8435 patients to LRH. Urologic complications occurred in 292 of 19,774 patients (1.48%) who underwent radical hysterectomy. LRH was associated with higher complication rates than ARH, although with a borderline significance (OR: 1.23; 90% CI: 1.02-1.51, p = 0.066). There was no difference in intraoperative urologic complications between the ARH and the LRH groups (OR: 1.1 95% CI: 0.86-1.43, p < 0.435). The incidence of postoperative urologic complications was significantly higher in the LRH group (OR: 2.01; 95% CI: 1.18-3.47, p = 0.009). In terms of postoperative urologic complications, the risk of ureterovaginal fistula was not significant between the two groups (OR: 1.53; 95% CI: 0.54-4.24, p = 0.403), whereas the risk of vesicovaginal fistula was significantly higher in the LRH group (OR: 2.24; 95% CI: 1.09-4.58, p = 0.028). There were no significant differences in the overall and urinary tract-specific complications between ARH and LRH in groups under 40 years of age and during the second half (2013-2018), with 2012 as the boundary.

CONCLUSION

Among specific urologic complications, the incidence of vesicovaginal fistula was significantly higher in the LRH group than in the ARH group.

Comparison of laparoscopic and open radical hysterectomy in cervical cancer patients with tumor size ≤2 cm

OBJECTIVE

There is recent evidence that demonstrates worse oncologic outcomes associated with minimally invasive radical hysterectomy when compared with open radical hysterectomy, particularly in patients with tumors >2 cm. The aim of our study was to retrospectively evaluate the oncological outcomes between laparoscopic and open radical hysterectomy in International Federation of Gynecology and Obstetrics(FIGO) 2009 stage IB1 (FIGO 2009) cervical cancer patients with tumor size ≤2 cm.

METHODS

A retrospective review of medical records was performed to identify patients who underwent either laparoscopic or open radical hysterectomy during January 2010 and December 2018. Inclusion criteria were: (1) histologically confirmed cervical cancer including all histological types; (2) FIGO 2009 stage IB1; (3) tumor size ≤2 cm (determined by pelvic examination, magnetic resonance imaging or transvaginal ultrasound); (4) had undergone radical hysterectomy (type II or III) with pelvic and/or para-aortic lymphadenectomy as primary surgical treatment; (5) had follow-up information. Patients with FIGO 2009 stage IA1 or IA2, tumor size >2 cm, or who received neo-adjuvant chemotherapy before surgery, those with cervical cancer incidentally found after simple hysterectomy, or with insufficient data were excluded. Concurrent comparison between the laparoscopic and open cohorts was made for disease-free survival and overall survival.

RESULTS

A total of 325 cervical cancer patients were included; of these, 129 patients underwent laparoscopic surgery and 196 patients had open surgery. The median follow-up times were 51.8 months (range 2-115) for laparoscopic surgery and 49.5 months (range 3-108) for open surgery. Patients in the laparoscopic group had significantly worse 5 year disease-free survival than those in the open group (90.4% vs 97.7%; p=0.02). There was no significant difference in 5 year overall survival between groups (96.9% vs 99.4%, p=0.33). The Cox proportional hazards regression analysis indicated that laparoscopic surgery was associated with lower disease-free survival compared with open surgery (adjusted hazard ratio 4.64, 95% CI 1.26 to 17.06; p=0.02). In patients with non-squamous cell carcinoma or with grade II-III, laparoscopic surgery had a significantly worse 5 year disease-free survival compared with the open surgery group (74% vs 100%, p=0.01, and 88.8% vs 98.0%, p=0.02, respectively).

CONCLUSION

Laparoscopic radical hysterectomy was associated with worse disease-free survival for stage IB1 (FIGO 2009) cervical cancer patients with tumor size ≤2 cm compared with open radical hysterectomy. Further studies may shed additional light on the impact of minimally invasive surgery in this low-risk patient population.

Laparoscopic versus abdominal radical hysterectomy for stage IB1 cervical cancer patients with tumor size ≤ 2 cm: a case-matched control study

BACKGROUND

To investigate the survival outcomes of stage IB1 cervical cancer patients with tumor size ≤ 2 cm who underwent laparoscopic or abdominal radical hysterectomy.

METHODS

We retrospectively analyzed stage IB1 cervical cancer patients with a tumor size ≤ 2 cm who underwent laparoscopic or abdominal radical hysterectomy in China between 2004 and 2016. A real-world study (RWS) and 1:1 matching was used in the study.

RESULTS

After 1:1 matching, laparoscopic (n = 926) and abdominal radical hysterectomy (n = 926) had similar 5-year overall survival and disease-free survival rates in stage IB1 cervical cancer with a tumor size ≤ 2 cm. Subsequently, in cervical squamous carcinoma with tumor size ≤ 2 cm, the laparoscopic and abdominal groups (724 cases, respectively) showed comparable 5-year overall survival and disease-free survival rates. Finally, in cervical adenocarcinoma or adenosquamous carcinoma with tumor size ≤ 2 cm, the laparoscopic group (n = 174) had a similar 5-year overall survival rate but a lower disease-free survival rate compared to those of the abdominal group (disease-free survival: 89.9% vs. 98.0%, respectively, P = 0.006; hazard ratio (HR), 5.094; 95% confidence interval (CI), 1.400-18.535; P = 0.013; n = 174). The RWS results were similar to the 1:1 matching results.

CONCLUSIONS

Patients with squamous cell carcinoma in stage IB1 cervical cancer with tumor size ≤ 2 cm might be suitable for laparoscopic surgery, while patients with adenocarcinoma or adenosquamous carcinoma with tumor size ≤ 2 cm are not candidates for laparoscopic surgery.

Laparoscopic radical hysterectomy has higher risk of perioperative urologic complication than abdominal radical hysterectomy: a meta-analysis of 38 studies

OBJECTIVE

A meta-analysis was performed to assess risks of intraoperative and postoperative urologic complications in laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH).

METHODS

We searched Pubmed, EMBASE, and Cochrane library for studies published up to December, 2018. Manual searches of related articles and relevant bibliographies of published studies were also performed. Two researchers independently performed data extraction. Inclusion criteria of studies were: (1) had information of perioperative complications, and (2) had at least ten patients per group.

RESULTS

A total of 38 eligible clinical trials were collected. Intraoperative and postoperative urologic complications were reported by 34 studies and 35 studies, respectively. When all studies were pooled, odd ratios (OR) of LRH for the risk of intraoperative urologic complications compared to abdominal radical hysterectomy (ARH) was 1.40 [95% confidence interval (CI) 1.05-1.87]. The OR of LRH for postoperative complication risk compared to ARH was 1.35 [95% CI 1.01-1.80]. However, significant adverse effects of intraoperative urologic complications in LRH were not observed among articles published after 2012 (OR 1.12, 95% CI 0.77-1.62) in cumulative meta-analysis or subgroup analysis. The incidence of bladder injury was statistically higher than that of ureter injury (p = 0.001). In subgroup analysis, obesity and laparoscopic type (laparoscopic assisted vaginal radical hysterectomy) were associated with intraoperative urologic complications.

CONCLUSION

LRH is associated with significantly higher risk of intraoperative and postoperative urologic complications than abdominal 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.

Feasibility and outcome of total laparoscopic radical hysterectomy with no-look no-touch technique for FIGO IB1 cervical cancer

Objectives

Intraoperative tumor manipulation and dissemination may possibly compromise survival of women with early-stage cervical cancer who undergo minimally-invasive radical hysterectomy (RH). The objective of the study was to examine survival related to minimally-invasive RH with a “no-look no-touch” technique for clinical stage IB1 cervical cancer.

Methods

This retrospective study compared patients who underwent total laparoscopic radical hysterectomy (TLRH) with no-look no-touch technique (n=80) to those who underwent an abdominal radical hysterectomy (ARH; n=83) for stage IB1 (≤4 cm) cervical cancer. TLRH with no-look no-touch technique incorporates 4 specific measures to prevent tumor spillage: 1) creation of a vaginal cuff, 2) avoidance of a uterine manipulator, 3) minimal handling of the uterine cervix, and 4) bagging of the specimen.

Results

Surgical outcomes of TLRH were significantly superior to ARH for operative time (294 vs. 376 minutes), estimated blood loss (185 vs. 500 mL), and length of hospital stay (14 vs. 18 days) (all, p<0.001). Oncologic outcomes were similar between the 2 groups, including disease-free survival (DFS) (p=0.591) and overall survival (p=0.188). When stratified by tumor size (<2 vs. ≥2 cm), DFS was similar between the 2 groups (p=0.897 and p=0.602, respectively). The loco-regional recurrence rate following TLRH was similar to the rate after ARH (6.3% vs. 9.6%, p=0.566). Multiple-pelvic recurrence was observed in only 1 patient in the TLRH group.

Conclusion

Our study suggests that the no-look no-touch technique may be a useful surgical procedure to reduce recurrence risk via preventing intraoperative tumor spillage during TLRH for early-stage cervical cancer.

Effect of laparoscopic versus abdominal radical hysterectomy on major surgical complications in women with stage IA-IIB cervical cancer in China, 2004-2015

OBJECTIVES

To report the trends in surgical approaches and compare the major surgical complication rates of laparoscopic and abdominal radical hysterectomy for cervical cancer.

METHODS

From the major surgical complications of cervical cancer in China (MSCCCC) database, we obtained the demographic, clinical, treatment hospital and complication data of patients with cervical cancer who underwent radical hysterectomy from 2004 to 2015 at 37 hospitals. The patients were assigned to the laparoscopic and abdominal surgery groups. The differences in the complication rates were analyzed using univariate and multivariable logistic regression models.

RESULTS

We identified a total of 18447 patients; 5491 (29.8%) underwent laparoscopic surgery and 12956 (70.2%) underwent abdominal surgery. The proportion of laparoscopic surgery rose from 0.35% in 2004 to 49.31% in 2015. In the multivariate analysis, the laparoscopic group had increased odds of intraoperative and postoperative complications (OR = 3.88, 95% CI = 2.47-6.11; OR = 1.42, 95% CI = 1.11-1.82). A more detailed analysis showed that laparoscopic surgery was associated with increased rates of intraoperative ureteral injury (OR = 3.83, 95% CI = 2.11-6.95), bowel injury (OR = 14.83, 95% CI = 1.32-167.25), vascular injury (OR = 3.37, 95% CI = 1.18-9.62), postoperative vesicovaginal fistula (OR = 4.16, 95% CI = 2.08-8.32), ureterovaginal fistula (OR = 4.16, 95% CI = 2.08-8.32), rectovaginal fistula (OR = 8.04, 95% CI = 1.63-39.53), and chylous leakage (OR = 10.65, 95% CI = 1.18-95.97), while abdominal surgery was more likely to cause bowel obstruction (OR = 0.55, 95% CI = 0.35-0.87). The two groups had similar rates of bladder injury, obturator nerve injury, pelvic hematoma, rectovaginal fistula and venous thromboembolism (P > 0.05).

CONCLUSION

Laparoscopic surgery was associated with more major surgical complications, especially intraoperative ureteral injury and postoperative fistula, than abdominal surgery among women with cervical cancer.

Impact of laparoscopic radical hysterectomy on survival outcome in patients with FIGO stage IB cervical cancer: A matching study of two institutional hospitals in Korea

OBJECTIVE

To compare survival outcomes of primary laparoscopic radical hysterectomy (LRH) and open radical hysterectomy (ORH) in patients with FIGO stage IB cervical cancer.

METHODS

We retrospectively identified stage IB1-IB2 cervical cancer patients who received either LRH (n = 343) or ORH (n = 222) at two tertiary institutional hospitals between 2000 and 2018. To adjust for confounders, we conducted Mahalanobis distance-based sample matching for stage, histology, cervical mass size, parametrial invasion, and lymph node metastasis. Then, survival outcomes were compared between the matched groups. Through the independent matching processes, we narrowed the study population to stage IB1 patients and stage IB1 patients with tumor size ≤2 cm on pre-operative MRI.

RESULTS

After matching, LRH group showed poorer progression-free survival (PFS) than ORH group (3-year: 85.4% vs. 91.8%; P = 0.036), whereas no significant difference in overall survival (OS) was found. Regarding recurrence patterns, no significant differences in the incidences of pelvic, retroperitoneal lymph node and abdominal recurrences, or distant metastasis were observed between the two groups. Among the matched patients with stage IB1 who had cervical mass size ≤2 cm, the LRH and ORH groups showed similar PFS (3-year: 90.0% vs. 93.1%; P = 0.8) and OS (5-year: 98.6% vs. 96.4%; P = 0.6).

CONCLUSIONS

Despite the retrospective design, our matched cohort study suggests that ORH might be preferable for the surgical treatment of FIGO stage IB cervical cancer. However, in stage IB1 patients with tumor size ≤2 cm, LRH might be applicable, as equivalent outcomes were found regardless of the surgical approach. Further prospective studies are warranted.

Impact of hospital care volume on clinical outcomes of laparoscopic radical hysterectomy for cervical cancer: A systematic review and meta-analysis

BACKGROUND

In cervical cancer, the impact of hospital volume of laparoscopic radical hysterectomy (LRH) has not been investigated systematically as in ovarian cancer.The aim of this study was to investigate the impact of hospital care volume of LRH on treatment outcomes of patients with cervical cancer.

METHODS

The PubMed, Embase, and Cochrane Library databases were searched with the terms "cervical cancer," "radical hysterectomy," and "laparoscopy." The selection criteria included studies presenting operative outcomes and/or perioperative complications of LRH from high-volume hospitals (HVHs) (≥15 cases/year) and low-volume hospitals (LVHs) (<15 cases/year). Fifty-nine studies including 4367 cases were selected. Linear regression analysis weighted by the average annual case number in each study was performed to evaluate differences between the groups.

RESULTS

In HVH, a higher number of lymph nodes (24.5 vs 21.1; P = .037) were retrieved by LRH in older women (48.4 vs 44.5 years; P = .010) with tendencies of shorter operation time (224.4 vs 256.4 minutes; P = .096) and less blood loss (253.1 vs 322.2 mL; P = .080). Compared with LVH, HVH had fewer patients with stage IA disease (13.8 vs 24.4%; P = .003) and more patients with stage IIA disease (15.3 vs 7.1%; P = .052) with comparable 5-year overall survival (93.1 vs 88.6%; P = .112).

CONCLUSION

HVH is a prognostic factor for operative outcome and perioperative complications in patients with cervical cancer undergoing LRH. The exact effect of hospital volume on survival outcome needs to be evaluated.

Comparative Effectiveness of Abdominal versus Laparoscopic Radical Hysterectomy for Cervical Cancer in the Postdissemination Era

Purpose

Despite the benefits of minimally invasive surgery for cervical cancer, there are a lack of randomized trials comparing laparoscopic radical hysterectomy and abdominal radical hysterectomy. We compared morbidity, cost of care, and survival between abdominal radical hysterectomy and laparoscopic radical hysterectomy for cervical cancer.

Materials and Methods

We used the Korean nationwide database to identify women with cervical cancer who underwent radical hysterectomy from January 1, 2011 to December 31, 2014. Patients who underwent abdominal radical hysterectomy were compared to those who underwent laparoscopic radical hysterectomy. Perioperative morbidity, the use of adjuvant therapy, and survival were evaluated after propensity score balancing.

Results

We identified 6,335 patients, including 3,235 who underwent abdominal radical hysterectomy and 3,100 who underwent laparoscopic radical hysterectomy. The use of laparoscopic radical hysterectomy increased from 46.1% in 2011 to 51.8% in 2014. Patients who were younger, had a more recent year of diagnosis, and were treated in the metropolitan area were more likely to undergo a laparoscopic procedure (p < 0.001). Compared to abdominal radical hysterectomy, laparoscopic radical hysterectomy was associated with lower rates of complication, fewertransfusions, a shorter hospital stay, less adjuvant therapy, and reduced total medical costs (p < 0.001). Laparoscopic surgery was associated with a better overall survival than abdominal operation (hazard ratio, 0.74; 95% confidence interval, 0.64 to 0.85).

Conclusion

In the postdissemination era, laparoscopic radical hysterectomy was associated with more favorable morbidity profiles, a lower cost of care, and comparable survival than abdominal radical hysterectomy.

MicroRNA-221-3p, a TWIST2 target, promotes cervical cancer metastasis by directly targeting THBS2

MicroRNAs have implicated in the relapse and metastasis of cervical cancer, which is the leading cause of cervical cancer-related mortality. However, the underlying molecular mechanisms need further elucidation. Our present study revealed that miR-221-3p is transcriptionally promoted in metastatic cervical cancer tissues compared with non-metastatic cervical cancer tissues. Forced overexpression of miR-221-3p facilitated EMT and promoted cell migration and invasion in vitro and lymphatic metastasis in vivo. Twist homolog 2 (TWIST2) was found to be a key transcription factor binding to the promoter of miR-221-3p. Inhibitors of miR-221-3p drastically reduced the induction of EMT and decreased cell migration and invasion mediated by TWIST2. By combined computational and experimental approaches, THBS2 was recognized to be an important downstream target gene of miR-221-3p. In cervical cancer tissues, especially with lymphatic metastasis, miR-221-3p and TWIST2 were increased and THBS2 was decreased, suggesting that TWIST2 induces miR-221-3p expression and consequently suppresses its direct target THBS2 in lymphatic metastasis CC. Our findings uncover a mechanistic role for miR-221-3p in lymph node metastasis, suggesting that miR-221-3p is upregulated by the transcription factor TWIST2 and downregulates its target THBS2, which may potentially promote lymph node metastasis in cervical cancer.