Risk Factors for Recurrence after Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer: A Multicenter Retrospective Study

Robotic radical hysterectomy after conization for patients with small volume early-stage cervical cancer

Laparoscopy and robotics are recommended for managing gynecological cancer, as they are associated with lower morbidity and comparable outcomes to open surgery. However, in the case of early cervical cancer, new evidence suggests worse oncological outcomes with these approaches compared to open surgery, though the limited number of robotic cases makes it challenging to draw definitive conclusions for this particular approach. The prior conization has been proposed as a strategy to reduce the risk of tumor spillage and contamination during minimally invasive (MIS) radical hysterectomy (RH). Retrospective studies have indicated that undergoing conization before RH is linked to a reduced risk of recurrences, especially in cervical tumors measuring less than 2 cm. Nevertheless, these studies lack the statistical power needed to definitively establish conization as a recommended step before RH. Furthermore, these studies do not have enough cases utilizing the robotic approach and specific conclusions cannot be drawn from this technique. The question of whether a subset of cases would benefit from preoperative conization and whether conization should be performed to recommend MIS over open surgery remains unanswered. Prospective clinical trials involving women diagnosed with early-stage cervical cancer <2 cm, randomized between undergoing conization before robotic RH or without prior conization are mandatory to assess the role of conization before robotic RH in cervical cancer.

Effect of internal jugular vein catheterization on intracranial pressure and postoperative cognitive function in patients undergoing robot-assisted laparoscopic surgery

Background

We aimed to evaluate the effects of internal jugular vein (IJV) catheterization on intracranial pressure (ICP) and postoperative delirium (POD) during robot-assisted laparoscopic surgery by measuring the optic nerve sheath diameter (ONSD).

Methods

Data from a prospective single-center cohort study, conducted from October 2021 to February 2022, were used. Forty out of 80 patients scheduled for laparoscopic radical hysterectomy or prostatectomy were assigned to the group receiving IJV catheterization (Group I), and the other 40 only received peripheral venous cannulation (Group C) according to clinical need of patients. Ultrasonography of ONSDs, the proportion of regurgitation time in a cardiac cycle, and hemodynamic parameters were measured at four time points: immediately after induction of anesthesia in the supine position (T0), 30 min (T1), 60 min (T2) after orienting to the Trendelenburg position, and before returning to the supine position at the end of surgery (T3). Time to eye opening and emergence stay, POD, and QoR-15 were compared.

Results

The ONSDs increase gradually as the surgery progressed. Group I showed a higher value of ONSD at T1 (4.72 ± 0.29 mm vs. 4.5 ± 0.33 mm, p = 0.0057) and T3 (5.65 ± 0.33 mm vs. 5.26 ± 0.31 mm, p < 0.0001). The proportions of the regurgitation time of IJVV were greater in Group I than those in Group C at T1 (14.95, 8.5%-18.9% vs. 9.6%, 0%-17.2%, p < 0.0001) and T3 (14.3, 10.6%-18.5% vs. 10.4%, 0%-16.5%, p = 0.0003). Group I had a delayed time to eye opening (10.7 ± 1.72 min vs. 13.3 ± 2.35 min, p < 0.0001) and emergence stay (32.2 ± 5.62 min vs. 39.9 ± 6.7 min, p < 0.0001). There were no significant differences in POD and QoR-15 between the two groups on day three.

Conclusion

IJV cannulation may not be the preferred approach in robot-assisted laparoscopic surgery as it was risk factor for IJVV regurgitation, ICP elevation, emergence delayed.

Therapies in Cervical Cancer-Editorial

George Papanikolaou is famously quoted as saying "the first observation of cancer cells in the smear of the uterine cervix gave me one of the greatest thrills I ever experienced during my scientific career" [...].

Assessment of ESGO Quality Indicators in Cervical Cancer Surgery: A Real-World Study in a High-Volume Chinese Hospital

The ESGO developed a list of fifteen quality indicators for cervical cancer surgery in order to audit and improve clinical practice in 2020. However, data from the developing countries with high incidence rates of cervical cancer is still lacking. Therefore, we conducted a retrospective study of 7081 cases diagnosed as cervical cancer between 2014 and 2019 in a Chinese single center according to the quality indicators proposed by ESGO. A total of 5952 patients underwent radical procedures, with an average of 992.0 per year. All surgeries were performed or supervised by a certified gynecologic oncologist as surgical qualification grading system has been established. Compared with the low-volume group, patients in the high-volume group (≥15 cases/year) had a shorter hospital stay (P<0.001), more free surgical margins (P=0.031), and less complications (P<0.001), but the 5-year recurrence-free survival and overall survival rates were similar (P>0.05). Treatment was not planned at a multidisciplinary team meeting but with the consultation system. The required preoperative workup was incomplete in 19.7% of patients with pelvic MRI and 45.7% of patients with PET-CT. A total of 1459 (20.6%) patients experienced at least one complication after surgery. The CDC grade IIIb or higher complications occurred in 80 patients, accounting for 5.5% complications. The urological fistula rate within 30 postoperative days were 0.3%. After primary surgical treatment, 97.4% patients had clear vaginal and parametrial margins. After restaging FIGO 2009 to FIGO 2018 system, 14.7% patients with a stage T1b disease were T-upstaged. After a median follow-up of 42 months, recurrence occurred in 448 patients, and 82.1% patients recurred within 2 years. The 2-year RFS rate of patients with pT1b1N0 was 97.3% in 2009 FIGO staging system. Lymph node staging was performed in 99.0% patients with a stage T1 disease. After a primary surgical treatment for a stage pT1b1N0 disease, 28.3% patients received adjuvant chemoradiotherapy. Above all, most of quality indicators reached the targets, except four quality indicators. The quality indicators of ESGO should be popularized and applied in China to guarantee quality of surgery.

The Impact of Surgical Practice on Oncological Outcomes in Robot-Assisted Radical Hysterectomy for Early-Stage Cervical Cancer, Spanish National Registry

Simple Summary

Minimal invasive surgery (MIS) has been associated with lower disease-free survival than open surgery among women who underwent radical hysterectomy for early-stage cervical cancer. However, the mechanisms by which MIS increases mortality in cervical cancer remain uncertain. We aimed to determine if surgical practice among centers using robotic surgery has an impact on oncological outcomes. We evaluated 215 women with early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009) who underwent robot-assisted radical hysterectomy in five Spanish tertiary centers between 2009 and 2018. A higher surgical volume, higher participation in clinical trials, higher rate of MRI use for diagnosis, greater use of sentinel lymph node biopsies, and a favorable learning curve with low rates of early recurrences were observed for the centers with better oncological outcomes. These factors might have a significant impact on oncological outcomes in all surgical approaches.

Abstract

This study aimed to assess whether surgical practice had a significant impact on oncological outcomes among women who underwent robot-assisted radical hysterectomy for early-stage cervical cancer (≤IB1 or IIA1, FIGO 2009). The secondary objective was to audit the pre-surgical quality indicators (QI) proposed by the European Society of Gynaecological Oncology (ESGO). The top 5 of 10 centers in Spain and Portugal were included in the analysis. The hospitals were divided into group A (n = 118) and group B (n = 97), with recurrence rates of <10% and >10%, respectively. After balancing both groups using the propensity score, the ORs for all events were higher and statistically significant for group B (recurrences OR = 1.23, 95% CI = 1.13–1.15, p-value = 0.001; death OR = 1.10, 95% CI = 1.02–1.18, p-value = 0.012; disease-specific mortality OR_r = 1.11, 95% CI = 1.04–1.19, p-value = 0.002). A higher surgical volume, higher participation in clinical trials, higher rate of MRI use for diagnosis, greater use of sentinel lymph node biopsies, and a favorable learning curve with low rates of early recurrences were observed among the centers with better oncological outcomes. These factors might have a significant impact on oncological outcomes not only after robot-assisted surgery, but also after laparoscopies and open surgeries in the treatment of cervical cancer.