Is laparoscopically assisted radical vaginal hysterectomy for cervical carcinoma safe? A case control study with follow up

Effect of laparoscopic-assisted transvaginal hysterectomy on wound complications in patients with early stage cervical cancer: A meta-analysis

Laparoscopic-assisted vaginal radical hysterectomy (LARVH) and abdominal radical hysterectomy (ARH) have been widely applied to treat cervical carcinoma. But LARVH and ARH have not been fully investigated in treating cervical carcinoma after injury associated with injury. This research is intended to provide an up-to-date basis for comparing LARVH with ARH in early stage cervical carcinoma. Comparison between LARVH and ARH in cervical carcinoma was carried out through a combination of related research. Eligible articles from databases such as PubMed and Embase were screened using an established search strategy. This report covered the results of LARVH versus ARH in cervical carcinoma. The average difference and the 95% confidence interval (CI) were used for the combination of consecutive variables. The combination of categorical variables was performed with the odds ratio (OR) 95% confidence interval. Through the identification of 1137 publications, eight of them were chosen to be analysed. Among them, 363 were treated with LARVH and 326 were treated with ARH. Eight trials showed that LARVH was associated with a reduced risk of postoperative wound infection than ARH (OR, 0.23; 95% CI, 0.1-0.55, p = 0.0009). Five trials showed that there was no difference in the risk of postoperative bleeding after surgery (OR, 1.17; 95% CI, 0.42-3.29, p = 0.76). We also did not differ significantly in the duration of the surgery (OR, 1.79; 95% CI, -6.58 to 10.15, p = 0.68). So, the two surgical methods differ significantly only in the risk of postoperative wound infection.

A meta-analysis examining the impact of open surgical therapy versus minimally invasive surgery on wound infection in females with cervical cancer

A meta-analysis study was executed to measure the effect of minimally invasive surgery (MIS) and open surgical management (OSM) on wound infection (WI) in female's cervical cancer (CC). A comprehensive literature study till February 2023 was applied and 1675 interrelated investigations were reviewed. The 41 chosen investigations enclosed 10 204 females with CC and were in the chosen investigations' starting point, 4294 of them were utilizing MIS, and 5910 were utilizing OSM. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were utilized to compute the value of the effect of MIS and OSM on WI in female's CC and by the dichotomous approaches and a fixed or random model. The MIS had significantly lower WI (OR, 0.23; 95% CI, 0.15-0.35, p < 0.001) with no heterogeneity (I2 = 0%) and postoperative aggregate complications (PACs) (OR, 0.49; 95% CI, 0.37-0.64, p < 0.001) in females with CC and compared OSM. However, MIS compared with OSM in females with CC and had no significant difference in pelvic infection and abscess (PIA) (OR, 0.59; 95% CI, 0.31-1.16, p = 0.13). The MIS had significantly lower WI, and PACs, though, had no significant difference in PIA in females with CC and compared with OSM. However, care must be exercised when dealing with its values because of the low sample size of some of the nominated investigations for the meta-analysis.

Effect of minimally invasive surgery and laparotomy on wound infection and postoperative and intraoperative complications in the management of cervical cancer: A meta-analysis

We performed a meta-analysis to evaluate the effect of minimally invasive surgery and laparotomy on wound infection and postoperative and intraoperative complications in the management of cervical cancer. A systematic literature search up to July 2022 was performed and 10 231 subjects with cervical cancer at the baseline of the studies; 4307 of them were using the minimally invasive surgery, and 5924 were using laparotomy. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of minimally invasive surgery and laparotomy on wound infection and postoperative and intraoperative complications in the management of cervical cancer using the dichotomous methods with a random or fixed-effect model. The minimally invasive surgery had significantly lower wound infection (OR, 0.20; 95% CI, 0.13-0.30, P < .001), and postoperative complications (OR, 0.48; 95% CI, 0.37-0.64, P < .001) in subjects with cervical cancer compared laparotomy. However, minimally invasive surgery compared with laparotomy in subjects with cervical cancer had no significant difference in intraoperative complications (OR, 1.04; 95% CI, 0.80-1.36, P = 0.76). The minimally invasive surgery had significantly lower wound infection, and postoperative complications however, had no significant difference in intraoperative complications in subjects with cervical cancer compared with laparotomy. The analysis of outcomes should be with caution because of the low sample size of 22 out of 41 studies in the meta-analysis and a low number of studies in certain comparisons.

Beyond Sentinel Lymph Node: Outcomes of Indocyanine Green-Guided Pelvic Lymphadenectomy in Endometrial and Cervical Cancer

BACKGROUND

The aim of our study was to compare the number of lymph nodes removed during indocyanine green (ICG)-guided laparoscopic/robotic pelvic lymphadenectomy with standard systematic lymphadenectomy in endometrial cancer (EC) and cervical cancer (CC).

METHODS

This is a multicenter retrospective comparative study (Clinical Trial ID: NCT04246580; updated on 31 January 2023). Women affected by EC and CC who underwent laparoscopic/robotic systematic pelvic lymphadenectomy, with (cases) or without (controls) the use of ICG tracer injection within the uterine cervix, were included in the study.

RESULTS

The two groups were homogeneous for age (p = 0.08), Body Mass Index, International Federation of Gynaecology and Obstetrics (FIGO) stages (p = 0.41 for EC; p = 0.17 for CC), median estimated blood loss (p = 0.76), median operative time (p = 0.59), and perioperative complications (p = 0.66). Nevertheless, the number of lymph nodes retrieved during surgery was significantly higher (p = 0.005) in the ICG group (n = 18) compared with controls (n = 16).

CONCLUSIONS

The accurate and precise dissection achieved with the use of the ICG-guided procedure was associated with a higher number of lymph nodes removed in the case of systematic pelvic lymphadenectomy for EC and CC.

Outcomes associated with different surgical approaches to radical hysterectomy: A systematic review and network meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of five different approaches to cervical cancer surgery.

METHODS

We conducted a systematic search for comparative studies on different radical hysterectomy types for cervical cancer in PubMed, Embase, the Cochrane Library, and Web of Science databases. All included observational studies used survival analyses to compare clinical outcomes of patients undergoing different radical hysterectomy types. All studies were assessed by the Newcastle-Ottawa Scale with scores of at least seven points. We extracted the relevant data and conducted a network meta-analysis to compare clinical outcomes among five surgical approaches.

RESULTS

Thirty studies (n = 11 353) were included. Robotic surgery had the lowest blood loss volume and hospitalization duration; open surgery had the shortest operative time. Vaginal assisted laparoscopic surgery was associated with the highest number of resected lymph nodes and lowest rate of perioperative complications. Survival outcomes and tumor recurrence outcomes were similar among the approaches.

CONCLUSION

The current approaches to cervical cancer surgery have comparable efficacies.

Laparo-assisted vaginal radical hysterectomy as a safe option for minimal invasive surgery in early stage cervical cancer: A systematic review and meta-analysis

BACKGROUND

Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery has been debated after the publication of a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC trial). It demonstrated poorer oncological outcomes for Minimal Invasive Surgery in ECC. However, the reasons are still an open debate. Laparo-Assisted Vaginal Hysterectomy (LAVRH) seems to be a logical option to Abdominal Radical Hysterectomy (ARH). This meta-analysis has the aim to prove it.

METHODS

Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the Pubmed database and Scopus database were systematically searched in January 2022 since early first publications. No limitation of the country was made. Only English article were considered. The studies containing data about Disease-free Survival (DFS) and/or Overall Survival (OS) and/or Recurrence Rate (RcR) were included.

RESULTS

18 studies fulfilled inclusion criteria. 8 comparative studies were enrolled in meta-analysis. Patients were analyzed concerning surgical approach (Laparo-Assisted Vaginal Radical Hysterectomy) and compared with ARH Oncological outcomes such as DFS and OS were considered. 3033 patiets were included. Meta-analysis highlighted a non-statistic significant difference between LARVH and ARH (RR 0.82 [95% CI 0.55-1.23] p = 0.34; I2 = 0%; p = 0.96). OS was feasible only for 3 studies (RR 1.14 [95% CI 0.28-4.67] p = 0.43; I2 = 0 p = 0.86). Data about the type of recurrences (loco-regional vs distant) were collected.

CONCLUSION

LARVH does not appear to affect DFS and OS in ECC patients. The proposed results seem to be comparable with the open approach group of the LACC trial, which today represents the reference standard for the treatment of this pathology. More studies will be needed to test the safety and efficacy of LARVH in the ECC.

Laparo-assisted vaginal radical hysterectomy as a safe option for Minimal Invasive Surgery in early stage cervical cancer: A systematic review and meta-analysis

BACKGROUND

Radical hysterectomy and pelvic lymphadenectomy are considered the standard treatment for early-stage cervical cancer (ECC). Minimal Invasive approach to this surgery has been debated after the publication of a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC trial). It demonstrated poorer oncological outcomes for Minimal Invasive Surgery in ECC. However, the reasons are still an open debate. Laparo-Assisted Vaginal Hysterectomy (LAVRH) seems to be a logical option to Abdominal Radical Hysterectomy (ARH). This meta-analysis has the aim to prove it.

METHODS

Following the recommendations in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, the Pubmed database and Scopus database were systematically searched in January 2022 since early first publications. No limitation of the country was made. Only English article were considered. The studies containing data about Disease-free Survival (DFS) and/or Overall Survival (OS) and/or Recurrence Rate (RcR) were included.

RESULTS

19 studies fulfilled inclusion criteria. 9 comparative studies were enrolled in meta-analysis. Patients were analyzed concerning surgical approach (Laparo-Assisted Vaginal Radical Hysterectomy) and compared with ARH Oncological outcomes such as DFS and OS were considered. 3196 patiets were included for the review. Meta-analysis of 1988 0f them highlighted a non-statistic significant difference between LARVH and ARH (RR 0.8 [95% CI 0.55-1.16] p = 0.24; I² = 0%; p = 0.98). OS was feasible only for 4 studies (RR 0.84 [95% CI 0.23-3.02] p = 0.79; I² = 0 p = 0.44). Sub-analysis for tumor with a maximum diameter greater than 2 cm was performed. Data about the type of recurrences (loco-regional vs distant) were collected.

CONCLUSION

LARVH does not appear to affect DFS and OS in ECC patients. The proposed results seem to be comparable with the open approach group of the LACC trial, which today represents the reference standard for the treatment of this pathology. More studies will be needed to test the safety and efficacy of LARVH in the ECC.

Comparison of the complications between minimally invasive surgery and open surgical treatments for early-stage cervical cancer: A systematic review and meta-analysis

BACKGROUND

This meta-analysis comprehensively compared intraoperative and postoperative complications between minimally invasive surgery (MIS) and laparotomy in the management of cervical cancer. Even though the advantages of laparotomy over MIS in disease-free survival and overall survival for management of gynecological diseases have been cited in the literature, there is a lack of substantial evidence of the advantage of one surgical modality over another, and it is uncertain whether MIS is justifiable in terms of safety and efficacy.

METHODS

In this meta-analysis, the studies were abstracted that the outcomes of complications to compare MIS (laparoscopic or robot-assisted) and open radical hysterectomy in patients with early-stage (International Federation of Gynecology and Obstetrics classification stage IA1-IIB) cervical cancer. The primary outcomes were intraoperative overall complications, as well as postoperative aggregate complications. Secondary outcomes included the individual complications. Two investigators independently performed the screening and data extraction. All articles that met the eligibility criteria were included in this meta-analysis.

RESULTS

The meta-analysis finally included 39 non-randomized studies and 1 randomized controlled trial (8 studies were conducted on robotic radical hysterectomy (RRH) vs open radical hysterectomy (ORH), 27 studies were conducted on laparoscopic radical hysterectomy (LRH) vs ORH, and 5 studies were conducted on all three approaches). Pooled analyses showed that MIS was associated with higher risk of intraoperative overall complications (OR = 1.41, 95% CI = 1.07-1.86, P<0.05) in comparison with ORH. However, compared to ORH, MIS was associated with significantly lower risk of postoperative aggregate complications (OR = 0.40, 95% CI = 0.34-0.48, P = 0.0143). In terms of individual complications, MIS appeared to have a positive effect in decreasing the complications of transfusion, wound infection, pelvic infection and abscess, lymphedema, intestinal obstruction, pulmonary embolism, deep vein thrombosis, and urinary tract infection. Furthermore, MIS had a negative effect in increasing the complications of cystotomy, bowel injury, subcutaneous emphysema, and fistula.

CONCLUSIONS

Our meta-analysis demonstrates that MIS is superior to laparotomy, with fewer postoperative overall complications (wound infection, pelvic infection and abscess, lymphedema, intestinal obstruction, pulmonary embolism, and urinary tract infection). However, MIS is associated with a higher risk of intraoperative aggregate complications (cystotomy, bowel injury, and subcutaneous emphysema) and postoperative fistula complications.

Clinical determinants of vaginal and abdominal hysterectomy for benign conditions at the University Teaching Hospital, Yaounde-Cameroon

Background:

Little is known about training and the practice of vaginal hysterectomy in many sub-Saharan Africa countries.

Objective:

The aim of this study was to identify the clinical determinants of choice of hysterectomy route for benign conditions at the University Teaching Hospital in Yaoundé, Cameroon (UTHYC).

Methods:

This was a retrospective cross-sectional study at the UTHYC from January 1, 2000 to December 31, 2008. Non-emergency hysterectomies for benign conditions were divided into two surgical approaches: vaginal and abdominal. Patients’ files and registers were used for data collection. Variables of interest were socio-demographic, reproductive health, and clinical characteristics, including indications and surgical route. Analysis was performed using Epi-Info version 3.5.1. Logistic regression analysis was conducted to determine the association between clinical variables and surgical routes. Odds ratios with their 95% confidence intervals (CI) were calculated. The level of significance was set up at P < 0.05.

Results:

One hundred and sixty-three women who underwent hysterectomy for benign conditions were included in the study. Thirty-seven (22.7%) were by vaginal route and 126 (77.3%) by abdominal route. Indications for hysterectomy were: cervical premalignant lesions, symptomatic uterine fibroids, prolapsed uterus, endometrial hyperplasia, recurrent cervical condyloma, and dysfunctional uterine bleeding. All 61 women with estimated uterine size of more than 12 weeks were operated on by abdominal route. At bivariate analysis, compared to women who had vaginal hysterectomy, factors associated with the choice of abdominal route were secondary/tertiary level of formal education, previous history of laparotomy/caesarean section, premenopausal status, age less than 50 years, and symptomatic uterine fibroids as surgical indication. At multivariate analysis, factors remaining independently associated with the choice of abdominal route were: age <50 years (AOR: 2.99 [1.9–4.71]), P < 0.001); previous laparotomy/cesarean section (AOR: 2.95[2.13–4.08], P = 0.001); premenopausal status (AOR: 1.55 [1.06–2.25]; P = 0.001); and myoma as surgical indication (AOR: 7.49.4[3.2–14.4]; P = 0.0001).

Conclusion:

Less than a quarter of hysterectomies for benign conditions were performed vaginally. All patients with uterine sizes larger than 12 weeks had laparotomy. The determinants of the choice of the abdominal route included age less than 50 years, previous laparotomy/caesarean section, premenopausal status, and fibroid as surgical indication.

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.

Comparison of laparoscopic-assisted radical vaginal hysterectomy and abdominal radical hysterectomy in patients with early stage cervical cancer: A retrospective study

BACKGROUND

The aim of this study was to compare the safety and survival outcomes of early stage cervical cancer patients treated by laparoscopically assisted radical vaginal hysterectomy (LARVH) versus abdominal radical hysterectomy (ARH).

METHODS

Since March 2008 to July 2012, the patients with early stage cervical cancer undergoing LARVH or ARH in Beijing hospital have been entered into this study. Statistical analysis used Statistical Product and Service Solutions (SPSS) and significance was defined as P < .05.

RESULT

Forty-two patients were included in LARVH group and 35 patients in ARH group. Both groups were similar with respect to age, body mass index (BMI), histological diagnosis, and stage. There were no differences in operative time, vaginal length, and postoperative complications, but blood loss, rate of transfusion, length of catheterized, and length of hospital stay were significantly less in LARVH. Number of lymph node retrieved was less than ARH. No differences were seen regarding recurrence rate, length of disease free survival, overall survival, and mortality rate after a median follow up of 58.5 and 48.5 months.

CONCLUSION

LARVH is a suitable alternative to ARH for early-stage cervical cancer, which shows less blood loss, shorter catheterized and hospital stay, and similar survival outcomes.

Laparoscopically Assisted Radical Vaginal Hysterectomy for Early-Stage Cervical Cancer: A Systemic Review and Meta-Analysis

OBJECTIVE

The aim of this study was to compare intraoperative and short-term postoperative outcomes and recurrence of laparoscopically assisted radical vaginal hysterectomy (LARVH) to abdominal radical hysterectomy (ARH) in the treatment of early-stage cervical cancer.

METHODS

A search of PubMed, EMBASE, and Cochrane library search trial (central) databases was conducted from database inception through December 2015. We included studies comparing surgical approaches with radical hysterectomy (LARVH vs ARH) in women with stages IA1 to IIB cervical cancer. Outcomes included blood loss, operative time, number of lymph nodes retrieved, intraoperative complications, hospital stay, and prognosis.

RESULT

Seven studies were included (4 prospective cohort studies and 3 case control studies) enrolling 794 women; 349 women were treated by LARVH, and 445 were treated by ARH. Laparoscopically assisted radical vaginal hysterectomy was associated with less blood loss (weight mean difference [WMD], -237.45; 95% confidence interval [CI], -453.42 to -21.47), wound-related complications (odds ratio, 0.17; 95% CI, 0.05-0.61), shorter hospital stay (WMD, -2.01; 95% CI, -2.52 to -1.51), and longer operative time (WMD, 48.95; 95% CI, 42.08 to 55.82) versus ARH. Laparoscopically assisted radical vaginal hysterectomy was comparable with ARH in number of lymph nodes retrieved, urinary-related complications, rectal injury, lymphedema, and all prognosis indicators.

CONCLUSIONS

The evidence suggests that LARVH is superior to ARH with lower blood loss, less wound-related complications, and shorter hospital stay. Laparoscopically assisted radical vaginal hysterectomy and ARH seem equivalent in number of lymph nodes retrieved, urinary-related complications, rectal injury, lymphedema, and prognosis.

Minimally Invasive Surgical Management of Early-Stage Cervical Cancer: An Analysis of the Risk Factors of Surgical Complications and of Oncologic Outcomes

Objectives

The objective of this study was to evaluate the morbidity and the oncologic outcomes of laparoscopic radical hysterectomy in treating early-stage cervical cancer.

Methods

We included all patients with early-stage cervical cancer (IA, IB1, IIA1, and IIB), as assessed by the Federation International of Gynecology and Obstetrics staging criteria, undergoing laparoscopic radical hysterectomy from January 1999 to December 2013 in our center. Morbidity was classified according to the Clavien and Dindo classification.

Results

A total of 170 patients were included in which 7 patients were in stage IA2, 150 in IB1, 2 in IIA, and 7 in IIB. The mean operation time was 256 minutes (67–495 minutes). Fourteen severe perioperative complications (8.2%) occurred, in which 5 patients (2.9%) required conversion to an open procedure: 3 bowel injuries, 3 hemorrhages, 2 ureteral injuries, 3 bladder injuries, 2 severe adhesions, and 1 intolerance to the Trendelenburg position. Fourteen patients (8.2%) presented with 1 severe postoperative complication (grade III or more). Two factors appeared as independent risk factors for perioperative and/or postoperative complications: the tumor size (odds ratio, 1.128; 95% confidence interval, 1.054–1.207) and operative time (odds ratio, 1.0116; 95% confidence interval, 1.003–1.020). In a median follow-up of 47.7 months, the 5-year overall survival was 94.1% (range, 88.1%–97.3%), and the 5-year disease-free survival was 88.8% (range, 81.0%–92.6%).

Conclusions

The laparoscopic approach was favorable for both perioperative and postoperative morbidity. With the advantage of minimal invasiveness, laparoscopic treatment by experienced surgeons is an alternative for early-stage cervical cancer with correct long-term survival outcomes. Mini-invasive surgery could be the standard in early-stage cervical cancer.

Surgical management of cervical carcinoma

Surgical management for cervical carcinoma uses a wide variety of procedures for all stages of disease, ranging from the most conservative excisional biopsy to aggressive extirpative surgery with sophisticated reconstruction. Innovative surgical procedures have given fertility-sparing treatment options to women of reproductive age, and refinement and use of minimally invasive surgical approaches have minimized operative morbidity without sacrificing outcomes. Conservative staging procedures are being evaluated to improve survival in locally advanced disease. There have been many breakthroughs in the treatment of cervical carcinoma over recent years, which have improved not only survival but also the quality of ensuing life for women afflicted by this disease.

From laparoscopic assisted radical vaginal hysterectomy to vaginal assisted laparoscopic radical hysterectomy

Radical hysterectomy with pelvic lymphadenectomy is the standard surgical treatment for patients with early stage cervical cancer. The majority of radical hysterectomies are performed with the open technique. However, laparoscopic, combined laparoscopic and vaginal, and robotic-assisted approaches may also be used. Compared with the abdominal radical hysterectomy (ARH), laparoscopic techniques are associated with less blood loss, shorter hospital stay, better cosmesis, and faster recovery. A further breakthrough in laparoscopic technique can only be made if safety and oncological clearance are comparable with ARH. We describe the technique and results of laparoscopic assisted radical vaginal hysterectomy and the transition to vaginal assisted laparoscopic radical hysterectomy.

Comparative evaluation of surgical stress of laparoscopically assisted vaginal radical hysterectomy and lymphadenectomy and laparotomy for early-stage cervical cancer

The aim of this study was to objectively evaluate the benefits of laparoscopically assisted vaginal radical hysterectomy and lymphadenectomy for early-stage cervical cancer. Clinical data were prospectively collected from patients with IA-IIB cervical cancer who underwent laparoscopically assisted vaginal radical hysterectomy (n1=33) and laparotomy (n2=30). Peripheral blood samples were obtained prior to surgery and at 1 and 2 h into the operation, as well as on days 1, 4 and 7 following surgery to measure serum interleukin-6, C-reaction protein and cortisol. Results showed that there was no conversion to laparotomy in the laparoscopy group. The average blood loss was 317.23±217.20 ml (laparoscopy group) and 872.58±693.16 ml (laparotomy group). No significant difference was found in the number of resected pelvic lymph nodes (19.74±7.43 in the laparoscopy group and 20.35±6.62 in the laparotomy group). At days 1 and 7 after surgery, the serum IL-6 level was significantly different in the laparoscopy and laparotomy groups (day 1: laparoscopy group 17.14±16.53 pg/ml and laparotomy group 34.32±20.97 pg/ml, p=0.001; day 7: laparoscopy group 6.7±7.21 pg/ml and laparotomy group 17.54±16.47 pg/ml, p=0.001). The serum CRP level was significantly different at days 1 and 7 after the operation (day 1: laparoscopy group 7024.72±949.12 ng/ml and laparotomy group 7586.61±869.42 ng/ml, p=0.018; day 7: laparoscopy group 4357.71±2108.85 ng/ml and laparotomy group 6967.96±995.02 ng/ml, p<0.001). A significant difference was noted in the serum cortisol level at day 4 after the operation (122.29±65.17 ng/ml in the laparoscopy group and 186.76±68.61 ng/ml in the laparotomy group, p<0.001). In conclusion, the differences in clinical data and the various parameters pertinent to surgical stress evaluated in this study suggest that laparoscopic surgery for cervical cancer causes less postoperative stress than conventional open surgery.

Place of Schauta's radical vaginal hysterectomy

Women affected by early stage invasive cancer of the cervix are usually treated by surgery. Radical abdominal hysterectomy with pelvic lymphadenectomy is the most widely used technique. Because the morbidity of the abdominal approach can be important, the radical vaginal hysterectomy has gained acceptance in gynaecologic oncology. New instrumentation in laparoscopy also opens the possibility of treating cervical cancer by laparoscopically assisted vaginal radical hysterectomy and also total laparoscopic radical hysterectomy. Before these techniques become widely accepted, it has to be shown that safety and efficacy are comparable with the 'standard' abdominal approach. In this chapter, we review the technique of radical vaginal hysterectomy with pelvic lymphadenectomy and evaluate results of published studies, comparing the abdominal, vaginal and laparoscopic approaches.

Total laparoscopic radical hysterectomy for treatment of uterine malignant tumors: analysis of short-term therapeutic efficacy

To investigate the efficacy and the clinical value of total laparoscopic radical hysterectomy (TLRH) for the treatment of uterine malignancies, we performed a retrospective review of 87 patients with cervical cancer and 23 patients with endometrial carcinoma who underwent TLRH at Union hospital between June 2008 and September 2009. Data collected included operative time, estimated blood loss, lymph node count, time for the recovery of normal temperature and time to resumption of normal bladder function, intraoperative and postoperative complications. The procedure was completed laparoscopically in 108 patients. Two patients were converted to laparotomy due to common iliac vein injury. The mean overall operative time was 200.6+/-38.6 min; the mean operative blood loss was 280.5+/-128.3 mL; he mean number of pelvic lymph nodes that were resected wa26. 0+/-5.8. The time for recovery of normal temperature and the normal bladder function after the operation was 5.8+/-2.9 d and 15.2+/-4.3 d. There were 2 (1.8%) common iliac vein injuries during the operation and 10 (9.1%) bladder retentions post operation. It was concluded that TLRH is feasible, minimally invasive and provides promise for the treatment of uterine malignancies.

Effectiveness of vaginal hysterectomy for benign conditions in semi-urban hospital: report from Maroua-Cameroon

We assessed the effectiveness of vaginal hysterectomy for benign uterine conditions in Northern Cameroon. This is a case series study of 29 elective vaginal hysterectomies carried out between February 2005 and June 2007 in Maroua, Cameroon. Hysterocele was found as the only or associated indication in 17 (58.6%) patients, symptomatic uterine fibroids in 4 (13.8%) and other indications in 8 (27.6%) patients. The mean duration of the operation was 132 minutes and the mean blood loss at surgery was 150 ml. Twenty-five of the 28 (89.3%) women had less than seven days of hospitalisation. There was a negative correlation (r = −0.45, P = 0.015) between duration of the surgery and the order of operation. One urinary tract and one wound infection were observed. Two patients had conversion to laparotomy. This study has shown that vaginal hysterectomy is a safe and feasible method of hysterectomy in a semi-urban hospital.

New developments in the surgical therapy of cervical carcinoma

For almost a century abdominal radical hysterectomy has been the standard surgical treatment of early-stage macroscopic carcinoma of the uterine cervix. The excessive parametrial resection of the original procedures of Wertheim, Okabayashi, and Meigs has later been "tailored" to tumor extent. Systematic pelvic and eventually periaortic lymph node dissection is performed to identify and treat regional disease. Adjuvant (chemo)radiation therapy is liberally added to improve locoregional tumor control when histopathological risk factors are present. The therapeutic index of the current surgical treatment, particularly if combined with radiation, appears to be inferior to that of primary chemoradiation as an oncologically equivalent therapeutic alternative. Several avenues of new conceptual and technical developments have been used since the 1990s with the goal of improving the therapeutic index. These are: surgical staging, including sentinel node biopsy and nodal debulking; minimal access and recently robotic radical hysterectomy; fertility-preserving surgery; nerve-sparing radical hysterectomy; total mesometrial resection based on developmentally defined surgical anatomy; and supraradical hysterectomy. The superiority of these new developments over the standard treatment remains to be demonstrated by controlled prospective trials. Multimodality therapy including surgery for locally advanced disease represents another area of clinical research. Both neoadjuvant chemotherapy followed by radical surgery, with or without adjuvant radiation, and completion surgery after (chemo)radiation are feasible and have to be compared to primary chemoradiation as the new nonsurgical treatment standard. Surgical treatment of postirradiation persisting or recurrent cervical carcinoma has been traditionally limited to pelvic exenteration for central disease. Applying the principle of developmentally derived anatomical compartments increases R0 resectability. The laterally extended endopelvic resection allows even the extirpation of a subset of visceral pelvic side wall tumors with clear margins. Many questions regarding the indication for these "ultraradical" operations, the surgery of irradiated tissues, and the optimal reconstructive procedures are still open and demand multi-institutional controlled trials to be answered.

The outcome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: a prospective analysis of 295 patients

OBJECTIVES

Cervical carcinoma is likely to become one of the most important indications for laparoscopic radical surgery. The laparoscopic technique combines the benefits of a minimally invasive approach with established surgical principles. In our institution, the laparoscopic radical hysterectomy and transperitoneal approach for lymphadenectomy have become the standard techniques for invasive cervical cancer. We report the indications, techniques, results, and oncological outcome in a single center experience.

METHODS

Between February 2001 and June 2007 we performed laparoscopic radical hysterectomies for cervical cancer in 295 patients. Their initial techniques, operation data, complications, postoperative course, oncological outcome, and survival were evaluated.

RESULTS

Out of 295 procedures, 290 were successful. Para-aortic lymphadenectomy was performed in 156 patients (52.9%), and pelvic lymphadenectomy was performed in all 295 patients. The median blood loss was 230 mL (range, 50-1200 mL). The mean operation time was 162 min (range, 110-350), which included the learning curves of 3 surgeons. In 5 cases (1.7%), conversion to open surgery was necessary due to bleeding (3 cases), bowel injury (1 case), and hypercapnia (1 case). Other major intraoperative injuries occurred in 12 patients (4.1%). Positive lymph nodes were detected in 80 cases (27.1%), lymphovascular space invasion in 54 cases (18.3%), and surgical margins were negative for tumor in all patients. The mean hospital stay was 10.3 days. Postoperative complications occurred in 10.8% patients, ureterovaginal fistula in 5 cases, vesicovaginal fistula in 4, ureterostenosis in 3 cases, deep venous thrombosis in 9 cases, lymphocyst in 4 cases, lymphedema in 5 cases, and 1 case with trocar insertion site metastasis. Other medical problems included 47 cases (15.9%) of bladder dysfunction and 62 cases (21.0%) of rectum dysfunction or constipation. The median follow-up was 36.45 months (range, 8-76 months). Recurrences or metastasis occurred in 48 patients (16.3%). Of these patients, 43 (14.6%) have died of their disease, and 5 (1.7%) are alive with disease. The overall disease-free survival was 95.2% for Ia, 96.2% for Ib, 84.5% for IIa, 79.4% for IIb, 66.7% for IIIa, and 60.0% for IIIb.

CONCLUSION

Laparoscopic radical hysterectomy is a routine, effective treatment for patients with Ia2-IIb cervical carcinoma. With more experience it is envisaged that IIb stage patients can be managed safely offering all the benefits of minimal surgery to the patients. Although no long-term follow-up is available, our follow-up data for up to 76 months confirm the effectiveness of laparoscopic radical hysterectomy in terms of surgical principles and oncological outcome.

Advances in Surgical Treatment of Cervical Cancer

Radical hysterectomy has been the standard surgical treatment for cervical cancer, achieving a good survival outcome. However, it is a major operation that has considerable potential long-term morbidity. With good prognosis achieved in most early cervical cancers, there is a trend towards more emphasis on maintaining good quality of life post-treatment. Many women diagnosed with cervical cancer are young, and fertility-sparing surgery such as trachelectomy would preserve their reproductive potential. Minimally invasive surgery, such as laparoscopic radical hysterectomy, can potentially improve post-operative recovery and cosmetic results while maintaining oncological safety. Sentinel lymph nodes assessment can minimize unnecessary systematic pelvic lymphadenectomy. Radicality of the hysterectomy may also be reduced in selected individuals with good prognostic factors, thus minimizing long-term pelvic floor dysfunction. This review aims to give a broad overview of the current status of these new trends in surgical management for cervical cancer.