Laparoscopic assisted radical vaginal hysterectomy versus radical abdominal hysterectomy-a randomised phase II trial: perioperative outcomes and surgicopathological measurements

Effects of tumor spillage prevention in laparoscopic radical hysterectomy for early-stage cervical cancer: a propensity score-matched analysis

OBJECTIVE

Minimally invasive radical hysterectomy has a worse prognosis than open surgery, but the reasons for the poor prognosis remain unclear. Tumor spillage occurs when the tumor is exposed to the surgical field and has been suggested to be related to a poor prognosis. This study aimed to compare the prognostic value of tumor spillage in laparoscopic radical hysterectomy and evaluate whether tumor spillage prevention improves oncological safety.

METHODS

We compared the prognosis of patients who underwent laparoscopic radical hysterectomy between December 2014 and November 2021 with or without tumor spillage prevention, including surgeries without prevention and those with failed prevention. Prevention consisted of vaginal cuff formation or closure of the vaginal canal with clips to prevent tumor exposure at the time of colpotomy. The primary endpoint was disease-free survival, which was adjusted using propensity scores to compare patients.

RESULTS

In total, 165 patients received tumor spillage prevention, and 61 did not or failed to receive such prevention. The median follow-up was 4.4 years. Patients who did not undergo prevention or failed prevention had significantly shorter disease-free survival than those who did (hazard ratio [HR]=3.54; 95% confidence interval [CI]=1.23-10.23). The same trend was observed after adjusting for propensity score matching. Patients who did not or failed to receive prevention were more likely to experience local recurrence (HR=4.01; 95% CI=1.13-14.24).

CONCLUSION

Tumor spillage prevention was associated with longer disease-free survival in laparoscopic radical hysterectomy.

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.

Comparison of 3D and 2D laparoscopy: Initial experience of perioperative outcomes and clinical assessment

INTRODUCTION

This study was designed to compare three-dimensional (3D) laparoscopy and conventional two-dimensional (2D) laparoscopy in surgical performance and clinical assessment during laparoscopic radical hysterectomy with pelvic lymphadenectomy (LRHND) for treating early-stage cervical cancer.

MATERIAL AND METHODS

In this study, we included 67 consecutive patients underwent LRHND for treating early-stage cervical cancer by the experienced laparoscopic surgeons between August 2018 and December 2020. amongst these patients, 32 patients underwent 3D laparoscopy (2D group) and 35 patients underwent 2D laparoscopy (2D group). Demographic data, clinical and surgical parameters were obtained from each patient. An end-of-operation questionnaire was administered regarding subjective perception of 3D laparoscopy system.

RESULTS

Patient characteristics, including age, BMI, FIGO stage, and histology, were comparable between the two groups. Compared with 2D imaging system, 3D system significantly shortened the operation time, especially bilateral lymph node dissection time. Blood loss was lower in 3D group compared with 2D group. There were no significant differences regarding pelvic nodes retrieved, incidence of complications, hospital stay, the recovery time of bowel, abdominal drainage fluid, hospitalization costs and visual symptoms. In addition, 3D system significantly improved depth perception and precision, and reduced surgical strain and eye strain for surgeon. No statistical difference was observed in visual symptoms and adverse events between the two groups. The surgeon was more willing to accept 3D laparoscopy.

CONCLUSION

The 3D laparoscopy is safe, feasible and comfortable, with obvious advantage in depth perception, precision and surgical strain. It triggered no increase in the complications and adverse events.

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.

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.

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

OPINION STATEMENT

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

Perioperative morbidity of different operative approaches in early cervical carcinoma: a systematic review and meta-analysis comparing minimally invasive versus open radical hysterectomy

Purpose

Radical hysterectomy and pelvic lymphadenectomy is the standard treatment for early cervical cancer. Studies have shown superior oncological outcome for open versus minimal invasive surgery, but peri- and postoperative complication rates were shown vice versa. This meta-analysis evaluates the peri- and postoperative morbidities and complications of robotic and laparoscopic radical hysterectomy compared to open surgery.

Methods

Embase and Ovid-Medline databases were systematically searched in June 2020 for studies comparing robotic, laparoscopic and open radical hysterectomy. There was no limitation in publication year. Inclusion criteria were set analogue to the LACC trial. Subgroup analyses were performed regarding the operative technique, the study design and the date of publication for the endpoints intra- and postoperative morbidity, estimated blood loss, hospital stay and operation time.

Results

27 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Meta-analysis showed no significant difference between robotic radical hysterectomy (RH) and laparoscopic hysterectomy (LH) concerning intra- and perioperative complications. Operation time was longer in both RH (mean difference 44.79 min [95% CI 38.16; 51.42]), and LH (mean difference 20.96 min; [95% CI − 1.30; 43.22]) than in open hysterectomy (AH) but did not lead to a rise of intra- and postoperative complications. Intraoperative morbidity was lower in LH than in AH (RR 0.90 [0.80; 1.02]) as well as in RH compared to AH (0.54 [0.33; 0.88]). Intraoperative morbidity showed no difference between LH and RH (RR 1.29 [0.23; 7.29]). Postoperative morbidity was not different in any approach. Estimated blood loss was lower in both LH (mean difference − 114.34 [− 122.97; − 105.71]) and RH (mean difference − 287.14 [− 392.99; − 181.28]) compared to AH, respectively. Duration of hospital stay was shorter for LH (mean difference − 3.06 [− 3.28; − 2.83]) and RH (mean difference − 3.77 [− 5.10; − 2.44]) compared to AH.

Conclusion

Minimally invasive radical hysterectomy appears to be associated with reduced intraoperative morbidity and blood loss and improved reconvalescence after surgery. Besides oncological and surgical factors these results should be considered when counseling patients for radical hysterectomy and underscore the need for new randomized trials.

Protective operative techniques in radical hysterectomy in early cervical carcinoma and their influence on disease-free and overall survival: a systematic review and meta-analysis of risk groups

Purpose

Radical hysterectomy with pelvic lymphadenectomy presents the standard treatment for early cervical cancer. Recently, studies have shown a superior oncological outcome for open versus minimal invasive surgery, however, the reasons remain to be speculated. This meta-analysis evaluates the outcomes of robotic and laparoscopic hysterectomy compared to open hysterectomy. Risk groups including the use of uterine manipulators or colpotomy were created.

Methods

Ovid-Medline and Embase databases were systematically searched in June 2020. No limitation in date of publication or country was made. Subgroup analyses were performed regarding the surgical approach and the endpoints OS and DFS.

Results

30 studies fulfilled the inclusion criteria. Five prospective, randomized-control trials were included. Patients were analyzed concerning the surgical approach [open surgery (AH), laparoscopic surgery (LH), robotic surgery (RH)]. Additionally, three subgroups were created from the LH group: the LH high-risk group (manipulator), intermediate-risk group (no manipulator, intracorporal colpotomy) and LH low-risk group (no manipulator, vaginal colpotomy). Regarding OS, the meta-analysis showed inferiority of LH in total over AH (0.97 [0.96; 0.98]). The OS was significantly higher in LH low risk (0.96 [0.94; 0.98) compared to LH intermediate risk (0.93 [0.91; 0.94]). OS rates were comparable in AH and LH Low-risk group. DFS was higher in the AH group compared to the LH group in general (0.92 [95%-CI 0.88; 0.95] vs. 0.87 [0.82; 0.91]), whereas the application of protective measures (no uterine manipulator in combination with vaginal colpotomy) was associated with increased DFS in laparoscopy (0.91 [0.91; 0.95]).

Conclusion

DFS and OS in laparoscopy appear to be depending on surgical technique. Protective operating techniques in laparoscopy result in improved minimal invasive survival.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00404-021-06082-y.

Comparison of survival outcomes between laparoscopic and abdominal radical hysterectomy for early-stage cervical cancer: A French multicentric study

OBJECTIVES

A recent randomized controlled trial has reconsidered the use of laparoscopy for treating patients with early-stage cervical cancer with radical hysterectomy (RH). We aimed to evaluate if surgical approach had an impact on surgical and oncological outcomes in these patients in a French setting.

METHODS

Data of 1706 patients with cervical cancer treated between 1996 and 2017 were extracted from maintained databases of 9 French University hospitals. Patients, with FIGO stage IA2 to IIB tumors, treated by radical hysterectomy were selected for further analysis. A propensity score matching was used with a ratio of 2:1 in favor of laparoscopic approach was used. The Kaplan Meier method was used to estimate the survival distribution.

RESULTS

34 patients treated with laparotomy were matched with 61 patients treated by minimally invasive surgery (MIS). There was no difference regarding overall survival (91 % vs 81 %, p > 0.05) or disease-free survival (82 % vs 78 %, p > 0.05). There was no difference regarding surgical outcomes with no excess of postoperative complication in patients with MIS. Hospital stay was significantly longer in patients operated on laparotomy.

CONCLUSION

In our study, there was no evidence of a difference in survival between minimally invasive surgery and laparotomy in patients treated with radical hysterectomy for early-stage cervical cancer.

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.

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

Objective

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

Methods

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

Results

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

Conclusion

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

[Impact of the LACC study. A SFOG survey]

INTRODUCTION

The LACC (Laparoscopic Approach to Cervical Cancer Trial) study, released in 2018, described oncological findings in favour of open surgery compared to the minimally invasive pathway in the management of early stage cervical cancers. Our aim was to assess the impact of this study on surgical practices in France.

METHOD

Online questionnaire, consisting of 13 questions addressed to gynecology oncology french society (SFOG) surgeons.

RESULTS

Forty questionnaires were collected. The median annual number of radical hysterectomy was 5 (0-20). Prior to the study, 92.5 % of cervical cancer patients had radical hysterectomy by minimally invasive surgery. In case of laparoscopy or robot, the uterine manipulator was used in 67.6 % and the colpotomy was performed intra-abdominally (78.4 %). After the LACC study, 60 % changed their practice. Open surgery was favored by 75 % of those who modified their practice. Among those continuing to perform minimally invasive surgeries, the manipulator and the intracorporeal colpotomy were discontinued. One-third of surgeons have changed their surgical practice for endometrial cancer in parallel.

CONCLUSION

The results of the LACC study led to a change in surgical practices with an increase in open surgery and a stop in the use of the uterine manipulator and the laparoscopic/robotic intracorporeal colpotomy in the surgical management of early stage of cervical cancer.

Surgical and Oncological Outcome of Total Laparoscopic Radical Hysterectomy versus Radical Abdominal Hysterectomy in Early Cervical Cancer in Singapore

Introduction:

The Wertheim's radical abdominal hysterectomy (RAH) has been the traditional surgical approach for operable Stage IB cervical cancer in Singapore whereas total laparoscopic radical hysterectomy (TLRH) was introduced only in 2009. In this study, we aimed to compare the long-term surgical outcome between the two routes of surgery in our center.

Methods:

This is a prospective study performed in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases.

Results:

From November 2009 to December 2014, 51 TLRHs and 85 RAHs were performed. Median blood loss in the TLRH group was significantly lower than in the RAH group (300 vs. 500 mL; P = 0.002) as was median hospital stay (5 vs. 6 days; P = 0.001). Operative time was significantly higher in the TLRH group (262 vs. 228 min; P < 0.001). There was no significant difference in bladder recovery. Intraoperative complications were encountered in 2 (3.9%) TLRH patients and 1 (1.2%) RAH patient. Postoperative complications occurred in 3 (5.9%) TLRH patients and 8 (9.4%) RAH patients. With a median follow-up of 117 (range 1.6–314.6) weeks in the TLRH group and 143.3 (range 0.4–304.7) weeks in the RAH group, 9 (17.6%) TLRH patients and 7 (8.2%) RAH patients had recurrence. There was no significant difference in the overall 3-year survival between the TLRH group and the RAH group for tumor size ≤2 cm (100.0% vs. 97.0%; P = 0.37). However, there was a trend toward lower survival for the TLRH group for tumor size >2 cm (61.9% vs. 85.4%; P = 0.06).

Conclusion:

The results of our study suggest that with appropriate patient selection, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore, especially in women with small tumors ≤2 cm but should be used with caution in women with larger tumors.

Less Is More: Minimally Invasive and Quality Surgical Management of Gynecologic Cancer

Surgery is a cornerstone of gynecologic oncology. Minimally invasive techniques have been adopted rapidly, in lieu of open approaches, in cervical and endometrial cancer staging. In addition, nodal assessment has undergone significant changes with the introduction of SLN biopsies. The movement toward less is more has also been seen with perioperative and postoperative care and the advent of ERAS protocols, which attempt to maintain normal physiology with the goal of improving functional recovery. It is imperative that new technology be critically evaluated to ensure that oncologic outcomes are not compromised.

Profile of treatment-related complications in women with clinical stage IB-IIB cervical cancer: A nationwide cohort study in Japan

OBJECTIVE

To examine clinico-pathological factors associated with surgical complications and postoperative therapy for clinical stage IB-IIB cervical cancer.

METHODS

This nationwide multicenter retrospective study examined women with clinical stage IB-IIB cervical cancer who underwent radical hysterectomy plus pelvic and/or para-aortic lymphadenectomy between 2008-2009 at 87 institutions of the Japanese Gynecologic Oncology Group (n = 693). Multivariate models were used to identify independent predictors of perioperative grade 3-4 complications and bladder dysfunction.

RESULTS

The overall intraoperative and postoperative complication rates were 3.3% and 9.8%, respectively. Clinical stage was not associated with perioperative complications (P = 0.15). Radiotherapy-based adjuvant therapy was significantly associated with an increased risk of postoperative complications (radiotherapy alone: adjusted-odds ratio [OR] 3.19, 95% confidence interval [CI] 1.46-6.99, P = 0.004; radiotherapy plus chemotherapy: adjusted-OR 3.26, 95%CI 1.66-6.41, P = 0.001), whereas chemotherapy was not (P = 0.45). Nerve-sparing surgery significantly reduced the risk of postoperative bladder dysfunction (adjusted-OR 0.57, 95%CI 0.37-0.90, P = 0.02) whereas adjuvant chemotherapy increased the risk of bladder dysfunction (adjusted-OR 2.06, 95%CI 1.16-3.67, P = 0.01). Among women receiving adjuvant chemotherapy, nerve-sparing radical hysterectomy significantly reduced the risk of bladder dysfunction (15.0% versus 32.9%, OR 0.31, 95%CI 0.14-0.68, P = 0.004). After propensity score matching, survival outcomes were similar with both types of adjuvant therapy (radiotherapy-based versus chemotherapy, P>0.05).

CONCLUSION

Our study highlighted two distinct complication profiles of adjuvant therapy after radical hysterectomy for clinical stage IB-IIB cervical cancer, with radiotherapy increasing grade 3-4 adverse events and chemotherapy increasing bladder dysfunction. In this setting, nerve-sparing surgery may be useful if chemotherapy is being considered for adjuvant therapy.

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.

Early Cervical Cancer: Current Dilemmas of Staging and Surgery

PURPOSE OF REVIEW

Advances in cervical cancer screening and treatment have resulted in high cure rates in developed countries for early-stage disease. Current research focuses on minimizing morbidity and maximizing quality of life.

RECENT FINDINGS

Imaging has been disappointing in identifying small volume metastases. Sentinel lymph node biopsy represents a significant advantage with high sensitivity, low false negative rates, reduced morbidity, and equivalent survival in recent studies compared to pelvic lymphadenectomy. Non-radical surgical options are currently being investigated for early cervical cancer in a number of large prospective studies in patients at low risk for metastases. Evidence suggests that sentinel lymph node biopsy and non-radical surgery are safe approaches for the staging and management of early cervical cancer in appropriately selected patients with the potential to significantly reduce treatment-related morbidity.

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.

Early catheter removal following laparoscopic radical hysterectomy for cervical cancer: assessment of a new bladder care protocol

Evidence to support prolonged catheterisation after radical hysterectomy is lacking. We sought to assess feasibility of a new protocol of early post-operative catheter removal following laparoscopic radical hysterectomy for cervical cancer. A retrospective review of post-operative bladder care in patients who underwent laparoscopic radical hysterectomy for cervical cancer was carried out. The post-operative bladder care protocol recommended catheter removal after 24-72 hours. Three consecutive post-void residual scans of less than 150 millilitres (ml) were considered evidence of normal voiding function. First line management of voiding dysfunction was clean intermittent self-catheterisation (CISC). Ninety-eight patients underwent laparoscopic radical hysterectomy for cervical cancer of whom 78 patients had catheter removal 24-72 hours post-operatively. The incidence of post-operative voiding dysfunction in this group was 44%, of whom 88% were managed with CISC and 82% regained normal voiding function. Average hospital stay was 4.2 days. The overall rate of long-term voiding dysfunction was 6%. Early catheter removal after laparoscopic radical hysterectomy appears to be both feasible and effective and compliments the ethos of enhanced patient recovery.

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.

Surgical Treatment of Early-Stage Cervical Cancer

Surgical treatment of cervical cancer has been a cornerstone in the management of this malignancy for more than 100 years. Today, for early-stage and low-risk cervical cancer, surgery is still considered the gold standard. If the preoperative assessment of the tumor reveals a situation prompting postoperative adjuvant radiochemotherapy, the latter should be planned as the primary treatment option, being preceded by staging laparoscopy including pelvic and paraaortic lymph node dissection. As an alternative to the open approach, the definitive surgical treatment should be either performed laparoscopically, or be laparoscopic-assisted, or laparoscopically robotic-assisted.

Prognostic and Safety Roles in Laparoscopic Versus Abdominal Radical Hysterectomy in Cervical Cancer: A Meta-analysis

Objective: Studies comparing the prognostic results between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in cervical cancer reported contradictory results. We aimed to evaluate the prognostic and safety roles of LRH by pooling studies in a meta-analysis.

Materials and Methods: Original articles were searched in PubMed, EMBASE, and the Cochrane Library. The survival results (5-year disease-free survival [DFS], 5-year overall survival [OS], and recurrence rate [RR]), safety parameters (intra-, peri-, and postoperative complication rates and postoperative bowel or bladder recovery days), efficiency parameters (pelvic/para-aortic lymph nodes removed), and other parameters (operative time, estimated blood loss, and hospital of stay) between the two approaches were reviewed.

Results: For the 2922 cases identified, DFS, OS, and RR did not differ in balanced prognostic factors, including lymph node metastasis, Stage IIB or above, non–squamous cancer histology, grade G3, lymphovascular space invasion, tumor size ≥4 cm, and positive parametrial and vaginal margin rates. Meanwhile, LRH was associated with higher complication rates and a shorter time to the recovery of bowel or bladder function than for ARH. The number of removed pelvic or para-aortic lymph nodes did not significantly differ. Other parameters showed LRH was associated with a longer operative time, less blood loss, and a shorter length of hospital stay. The survival and prognostic results did not differ in balanced prognostic factors.

Conclusions: LRH is safe and has lower operative complication rates than ARH.

Non-compliance with randomised allocation and missing outcome data in randomised controlled trials evaluating surgical interventions: a systematic review

Background

Randomised controlled trials are widely acknowledged as the gold standard in medical research although their validity can be undermined by non-compliance with the randomly allocated treatment and missing data. Due to the nature of the intervention, surgical trials face particular threat to compliance and data collection. For example, ineligibility for the intervention may only become apparent once the operation has commenced. It is unclear how such cases are reported and handled.

Objective

The objective was to assess non-compliance and missing data in reports of trials of surgical interventions.

Methods

Searches for reports of trials involving at least one surgical procedure and published in 2010 were carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE^®). Data on missing data, non-compliance and methods of handling missing data were extracted from full texts. Descriptive data analyses were carried out on the data.

Results

Forty-five (55 %) studies reported non-compliance with treatment allocation and 52 (63 %) reported primary outcome missing data. The median levels of non-compliance and missing data were 2 % [IQR (0, 5), range (0–29)] and 6 % [IQR (0, 15), range (0–57)], respectively. Fifty-two (63 %) studies analysed as randomised, 17 (21 %) analysed per protocol and 3 (4 %) analysed as treated. Complete case analysis was the most common method used to deal with missing data, 35/52 (67 %).

Conclusions

The reporting of non-compliance to allocation and the handling of missing data were typically suboptimal. There is still room for improvement on the use of the CONSORT statement particularly in accounting for study participants. Transparency in reporting would facilitate evidence synthesis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-015-1364-9) contains supplementary material, which is available to authorized users.

The surgical management of cervical cancer: an overview and literature review

IMPORTANCE

Surgery has evolved into the standard therapy for nonbulky carcinoma of the cervix. The mainstay of surgical management is radical hysterectomy; however, less radical procedures have a small but important role in the management of cervical tumors.

OBJECTIVE

Our objective was to discuss the literature behind the different procedures utilized in the management of cervical cancer, emphasizing the radical hysterectomy. In addition, we aimed to discuss ongoing trials looking at the utility of less radical surgeries as well as emerging technologies in the management of this disease.

EVIDENCE ACQUISITION

We performed a PubMed literature search for articles in the English language that pertained to the topic of surgical techniques and their outcomes in the treatment of cervical cancer.

RESULTS

The minimally invasive approaches to radical hysterectomy appear to reduce morbidity without affecting oncological outcomes, although further data are needed looking at long-term outcomes with the robotic platform. Trials are currently ongoing looking at the role of less radical surgery for patients with low-risk disease and the feasibility of sentinel lymph node mapping.

CONCLUSIONS AND RELEVANCE

Radical hysterectomy with pelvic lymphadenectomy has evolved into the standard therapy for nonbulky disease, and there is a clear advantage in the use of minimally invasive techniques to perform these procedures. However, pending ongoing trials, less radical surgery in patients with low-risk invasive disease as well as sentinel lymph node mapping may emerge as standards of care in selected patients with cervical carcinoma.

Early postoperative bladder training in patients submitted to radical hysterectomy: is it still necessary? A randomized trial

OBJECTIVES

To evaluate the role of bladder training during postoperative hospital stay in patients submitted to nerve-sparing radical hysterectomy, and to identify any clinical or surgical factor associated with postoperative bladder dysfunction.

DESIGN, SETTING, AND PARTICIPANTS

Parallel group randomized single institution trial, on gynaecologic malignancies patients conducted in Catholic University of Sacred Heart Rome, between April 2009 and November 2011. Randomization was on 1:1, using a block randomized computer-generated list.

INTERVENTIONS

Patients underwent Querleu-Morrow type B2 or C1 radical hysterectomy. After 2 days from surgery, patients were randomized to perform or not bladder training (scheduled clamping and unclamping of the trans-urethral catheter every three hours). Main outcome measures Necessity and duration of clean intermittent self catheterization.

RESULTS

Randomized participants were 111 women (bladder training arm n = 55; control arm n = 56). A total of 22 women (19.8%) required clean intermittent self catheterization, equally distributed in the two arms. At univariate analysis, only the type of radical hysterectomy was significantly associated with need of clean intermittent self catheterization (type C1 vs. type B2; p = 0.013). At univariate analysis, duration of clean intermittent self-catheterization was not associated with age, BMI, type of hysterectomy and of neo-adjuvant treatment.

CONCLUSIONS

Functional bladder disfunctions are the most common long-term complications following radical hysterectomy. Systematic postoperative bladder training following nerve-sparing radical hysterectomy does not influence the rate of urinary retention or re-admission for bladder catheterization.

Current and Future Status of Laparoscopy in Gynecologic Oncology

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

Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome

PURPOSE

The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls.

METHODS

One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs.

RESULTS

In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P < 0.001). Bladder function resumed sooner (P < 0.001), and patients were discharged earlier after VALRH (P < 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740).

CONCLUSION

VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach.

Laparoscopically assisted radical vaginal hysterectomy versus radical abdominal hysterectomy for the treatment of early cervical cancer

BACKGROUND

Cervical cancer is the second most common cancer among women and is the most frequent cause of death from gynaecological cancers worldwide. Standard surgical management for selected early-stage cervical cancer is radical hysterectomy. Traditionally, radical hysterectomy has been carried out via the abdominal route and this remains the gold standard surgical management of early cervical cancer. In recent years, advances in minimal access surgery have made it possible to perform radical hysterectomy with the use of laparoscopy with the aim of reducing the surgical morbidity and promoting a faster recovery.

OBJECTIVES

To compare the effectiveness and safety of laparoscopically assisted radical vaginal hysterectomy (LARVH) and radical abdominal hysterectomy (RAH) in women with early-stage (1 to 2A) cervical cancer.

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, and Cochrane Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE, and EMBASE up to July 2013. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) that compared laparoscopically assisted radical hysterectomy and radical abdominal hysterectomy, in adult women diagnosed with early (stage 1 to 2A) cervical cancer.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We found one RCT, which included 13 women, that met our inclusion criteria and this trial reported data on LARVH versus RAH.Women who underwent LARVH for treatment of early-stage cervical cancer appeared to have less blood loss compared with those who underwent RAH. The trial reported a borderline significant difference between the two types of surgery (median blood loss 400 mL (interquartile range (IQR): 325 to 1050) and 1000 mL (IQR: 800 to 1025) for LARVH and RAH, respectively, P value = 0.05). RAH was associated with significantly shorter operation time compared with LARVH (median: 180 minutes with LARVH versus 138 minutes with RAH, P value = 0.05).There was no statistically significant difference in the risk of perioperative complications in women who underwent LARVH and RAH. The trial reported two (29%) and four (57%) cases of intraoperative and postoperative complications, respectively, in the LARVH group and no (0%) reported cases of intraoperative complications and five (83%) cases of postoperative complications in the RAH group. There were no reported cases of severe perioperative complications.Bladder and bowel dysfunction of either a transient or chronic nature remain major morbidities after radical hysterectomy, and the one included study showed that there may be significantly less after LARVH.

AUTHORS' CONCLUSIONS

The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. Therefore, the absence of reliable evidence, regarding the effectiveness and safety of the two surgical techniques for the management of early-stage cervical cancer, precludes any definitive guidance or recommendations for clinical practice. The trial did not report data on long-term outcomes, but was at moderate risk of bias due to very low numbers of included women.

[Postoperative pain management after minimally invasive hysterectomy: thoracic epidural analgesia versus intravenous patient-controlled analgesia]

BACKGROUND

In view of the development of innovative and non-traumatic surgical techniques, postoperative pain management should be carried out depending on the invasiveness of the intervention. In the present study two analgesic strategies were compared in patients undergoing minimally invasive hysterectomy: epidural analgesia (EDA) and intravenous patient-controlled analgesia (iv-PCA).

MATERIAL AND METHODS

For this prospective case controlled study 60 women with benign uterine diseases undergoing vaginal hysterectomy (VH) or laparoscopically assisted vaginal hysterectomy (LAVH) were enrolled. Patients were divided for analysis into two groups (n=30 each) according to the postoperative analgesic strategy (EDA group versus iv-PCA group). A matched-pair analysis was applied (matching criteria: risk assessment, surgeon and age of patient) to minimize the differences between both groups. Patients were evaluated with respect to the extent of pain determined by a numeric rating scale (NRS 0-10 scale), analgesic consumption, rate of postoperative nausea and vomiting (PONV), mobilization from bed, oral intake of nutrition, complications, duration of stay in the recovery room as well as hospital stay and health-related quality of life (SF-36 Health Survey; collected before and 6 weeks after surgery).

RESULTS

Laparoscopically assisted removal of the uterus was carried out in 22 women and by vaginal hysterectomy in 38 women. No significant differences between the study groups were seen in the duration of surgery (iv-PCA 58 ± 25 min versus EDA 60 ± 26 min). Demographic data of both groups as well as intraoperative hemodynamic and respiratory parameters were comparable to a great extent. Compared to the iv-PCA group, women in the EDA group showed lower NRS values (p<0.01): recovery room admission 4.7 ± 2.5 iv-PCA vs. 0.9 ± 1.3 EDA, recovery room discharge 3.8 ± 1.8 iv-PCA vs. 1.0 ± 1.2 EDA, day of surgery at 8 p.m. 5.0 ± 2.1 iv-PCA vs. 1.8 ± 2.3 EDA and first postoperative day at 8 a.m. 3.5 ± 1.7 iv-PCA vs. 1.9 ± 2.2 EDA. In addition, less PONV (iv-PCA 9/30 vs. EDA 1/30, p<0.01), less shivering (iv-PCA 8/30 vs. EDA 2/30, p<0.05), reduced fatigue (iv-PCA 26/30 vs. EDA 9/30, p<0.05) and a lower consumption of analgesics were found. Average postoperative requirement for piritramide in the iv-PCA group was 7 mg (range 0-24 mg) on the day of surgery and 5 mg (0-39 mg) on the first postoperative day. In the EDA group no opiate medication was given postoperatively (p<0.01). Duration of stay in the recovery room was shorter in the EDA group (71 ± 32 min vs. 50 ± 13 min, p<0.05). Hospital stay was 5 days on average in both groups. There were no surgical complications or epidural catheter-related complications. Because of urinary retention catheterization of the bladder had to be made in 3 patients of the iv-PCA group and 13 patients of the EDA group (p<0.05). Furthermore, the possibility to take a shower postoperatively was restricted in the EDA group because the epidural catheter was in place and thereby hygiene concerns. Regarding the early oral nutritional intake as well as postoperative mobilization, no significant differences between groups were found. In comparison with the preoperative status, the results regarding health-related quality of life were significantly better for both groups after a follow-up of 6 weeks (p<0.01); however, this effect was especially pronounced in the EDA group (p<0.05).

CONCLUSIONS

To reduce the number of patients suffering from postoperative pain a procedure-specific pain management should be developed. The results of this study have shown that even in minimally invasive surgery, such as vaginal hysterectomy and laparoscopically assisted vaginal hysterectomy there are some advantages for epidural analgesia compared to intravenous patient-controlled analgesia. In particular reduced pain intensity, lower need for analgesics and reduced occurrence of PONV can lead to excellent patient comfort, fast recovery as well as positive effects on health-related quality of life. However, there are also some disadvantages such as an increased rate of urinary retention and restriction of mobility.

Postoperative pain and perioperative outcomes after laparoscopic radical hysterectomy and abdominal radical hysterectomy in patients with early cervical cancer: a randomised controlled trial

BACKGROUND

Non-randomised studies have suggested that the postoperative complications of (Campos LS, Limberger LF, Stein AT, Kalil AN) laparoscopic radical hysterectomy are similar to those in abdominal radical hysterectomy. However, no study evaluating postoperative pain comparing both techniques has been published thus far. Our objective was to compare pain intensity and other perioperative outcomes between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in early cervical cancer.

METHODS

This single centre, randomised, controlled trial enrolled 30 cervical cancer patients who were clinically staged IA2 with lymph vascular invasion and IB according to the FIGO (International Federation of Gynaecology and Obstetrics) classification, and underwent LRH or ARH between late 1999 and early 2004. Postoperative pain, as measured by a 10-point numerical rate scale, was considered the primary endpoint. Postoperative pain was assessed every six hours during a patient's usual postoperative care. Perioperative outcomes were also registered. Both surgical techniques were executed by the same surgical team. Secondary outcomes included intraoperative and other postoperative surgicopathological factors and 5-year survival rates.

RESULTS

IA2 patients with lymphatic vascular space invasion and IB cervical cancer patients were randomised to either the LRH group (16 patients) or the ARH group (14 patients). Four patients (25%) in the LRH group and 5 patients (36%) in the ARH group presented with transoperative or serious postoperative complications. All of the transoperative complications occurred in the LRH group. The relative risk of presenting with complications was 0.70; CI 95% (0.23-2.11); P = 0.694. LRH group mean pain score was significantly lower than ARH after 36 h of observation (P = 0.044; mean difference score: 1.42; 95% CI: 0.04-2.80). The survival results will be published elsewhere.

CONCLUSIONS

LRH provided lower pain scores after 36 h of observation in this series. The perioperative and serious postoperative complications ratios were comparable between the groups.

TRIAL REGISTRATION

NCT01258413.

Differences in Epidural and Analgesic Use in Patients with Apparent Stage I Endometrial Cancer Treated by Open versus Laparoscopic Surgery: Results from the Randomised LACE Trial

Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH). Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH (n = 353) or TLH (n = 407) (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery. Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%, P < 0.001) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%, P = 0.09), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%, P < 0.0001), 6–14 days (35% versus 15%, P < 0.0001), and 15–60 days (15% versus 9%, P = 0.02) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62, P < 0.0001) and four weeks (0.89 versus 0.63, P = 0.01) following surgery. Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH.

Total microlaparoscopic radical hysterectomy in early cervical cancer

This report suggests that microlaparoscopy has a role in the management of early cervical cancer with results comparable with standard laparoscopy.

Background and Objective:

In less than 2 decades, laparoscopy has contributed to modification in the management of early cervical cancer patients, and all comparisons between open and laparoscopic-based radical operations showed an identical oncological outcome. The aim of this study is to describe surgical instrumentations and technique to perform total microlaparoscopy radical hysterectomy in early cervical cancer patients and report our preliminary results in terms of operative time and perioperative outcomes.

Methods:

Between January 1, 2012, and March 25, 2012, 4 consecutive early cervical cancer patients were enrolled in this study.

Results:

We performed 3 type B2 and 1 type C1-B2 total microlaparoscopy radical hysterectomy, and in all cases concomitant bilateral salpingo-oophorectomy and pelvic lymphadenectomy were carried out. Median operative time was 165 minutes (range: 155 to 215) (mean: 186), and median estimated blood loss was 30 mL (range: 20 to 50). Median number of pelvic lymph nodes removed was 12 (range: 11 to 15). All procedures were completed without 5-mm port insertion and without conversion. No intraoperative or early postoperative complications were reported.

Conclusions:

This report suggests a role of microlaparoscopy in the surgical management of early cervical cancer with adequate oncological results, superimposable operative time, and perioperative outcomes with respect to standard laparoscopy.

Laparoscopic, robotic and open method of radical hysterectomy for cervical cancer: A systematic review

BACKGROUND

Over the last two decades, numerous studies have indicated the feasibility of minimally invasive surgery for early cervical cancer without compromising the oncological outcome.

OBJECTIVE

Systematic literature review and meta analysis aimed at evaluating the outcome of laparoscopic and robotic radical hysterectomy (LRH and RRH) and comparing the results with abdominal radical hysterectomy (ARH).

SEARCH STRATEGY

Medline, PubMed, Embase, Cochrane library and Reference lists were searched for articles published until January 31(st) 2011, using the terms radical hysterectomy, laparoscopic radical hysterectomy, robotic radical hysterectomy, surgical treatment of cervical cancer and complications of radical hysterectomy.

SELECTION CRITERIA

Studies that reported outcome measures of radical hysterectomy by open method, laparoscopic and robotic methods were selected.

DATA COLLECTION AND ANALYSIS

Two independent reviewers selected studies, abstracted and tabulated the data and pooled estimates were obtained on the surgical and oncological outcomes.

RESULTS

Mean sample size, age and body mass index across the three types of RH studies were similar. Mean operation time across the three types of RH studies was comparable. Mean blood loss and transfusion rate are significantly higher in ARH compared to both LRH and RRH. Duration of stay in hospital for RRH was significantly less than the other two methods. The mean number of lymph nodes obtained, nodal metastasis and positive margins across the three types of RH studies were similar. Post operative infectious morbidity was significantly higher among patients who underwent ARH compared to the other two methods and a higher rate of cystotomy in LRH.

CONCLUSIONS

Minimally invasive surgery especially robotic radical hysterectomy may be a better and safe option for surgical treatment of cervical cancer. The laparoscopic method is not free from complications. However, experience of surgeon may reduce the complications rate.

Vaginal-assisted laparoscopic radical hysterectomy: rationale, technique, results

The authors conclude that vaginal-assisted laparoscopic radical hysterectomy is an oncologic viable alternative to abdominal radical hysterectomy, laparoscopic-assisted radical vaginal hysterectomy, totally laparoscopic radical hysterectomy, and robotic radical hysterectomy.

Objective:

Total laparoscopic radical hysterectomy (TLRH) makes it difficult to resect adequate vaginal cuff according to tumor size and to avoid tumor spread after opening the vagina. Laparoscopic-assisted radical vaginal hysterectomy (LARVH) is associated with higher risk for urologic complications.

Methods:

The vaginal-assisted laparoscopic radical hysterectomy (VALRH) technique comprises 3 steps: (1) comprehensive laparoscopic staging, (2) creation of a tumor-adapted vaginal cuff, and (3) laparoscopic transsection of parametria. We retrospectively analyzed data of 122 patients who underwent VALRH for early stage cervical cancer (n=110) or stage II endometrial cancer (n=12) between January 2007 and December 2009 at Charité University Berlin.

Results:

All patients underwent VALRH without conversion. Mean operating time was 300 minutes, and mean blood loss was 123cc. On average, 36 lymph nodes were harvested. Intra- and postoperative complication rates were 0% and 13.1%, respectively. Resection was in sound margins in all patients. After median follow-up of 19 months, disease-free survival and overall survival for all 110 cervical cancer patients was 94% and 98%, and for the subgroup of patients (n=90) with tumors ≤pT1b1 N0 V0 L0/1 R0, 97% and 98%, respectively.

Conclusion:

VALRH is a valid alternative to abdominal radical hysterectomy and LARVH in patients with early-stage cervical cancer and endometrial cancer stage II with minimal intraoperative complications and identical oncologic outcomes.

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.

Surgical treatment of lymph node metastases in stage IB cervical cancer. The laterally extended parametrectomy (LEP) procedure: experience with a 5 year follow-up

INTRODUCTION

In 2003, we published our preliminary experience with the use of an operative technique (laterally extended parametrectomy, the LEP procedure) without adjuvant therapy, in the treatment of 29 stage IB, cervical cancer patients with pelvic lymph node metastases. In our present paper, by an extended recruiting period, with a completed 5 year follow up, we studied the outcome of LEP operations, used with the same indications.

METHODS

In 70 out of 106 LEP-Wertheim operated patients, no adjuvant treatment was used. In 36 patients, where histology suggested tumor spread beyond the threshold of our surgery, adjuvant chemo-radiotherapy was advised. 5 year follow up was completed (without any patient lost for follow up) for the whole cohort of patients.

RESULTS

In 70 patients treated by LEP procedure alone, the overall 5-year survival was 91.4%. For those 36 patients, who were excluded due to disease spread above study criteria, 5 year survival was 44%. Complications in 10% of the cases necessitated a second operation. Apart from transient hyper continence and one case of permanent incontinence, no severe quality of life consequence of the operation was observed.

CONCLUSIONS

Our results suggest that in two-thirds of pelvic lymph node positive, stage IB cervical cancer cases surgery alone could provide equal or better survival (without the toxicity of chemo-radiotherapy), than any kind of multimodality treatment alternatives. LEP procedure should be considered a treatment option for stage IB cervical cancer patients with pelvic lymph node metastases.