Challenges and Controversies in the Surgical Treatment of Cervical Cancer: Open Radical Hysterectomy versus Minimally Invasive Radical Hysterectomy

Prospective Study on the Use of Endo-Stapler for Enclosed Colpotomy to Prevent Tumor Spillage in Gynecologic Oncology Minimally Invasive Surgeries

Background and Objectives

This is a prospective trial of the endo-stapler application for vaginal closure before colpotomy in cases of carcinoma endometrium and carcinoma cervix, managed by minimally invasive surgery with due consideration of its surgical technique and short-term oncologic follow-up outcomes.

Methods

This was a prospective, single center study completed between March 1, 2020 and December 31, 2022. A total of 62 patients (43 cases of carcinoma endometrium and 19 cases of carcinoma cervix) were recruited for the study. Oncologic survival outcomes at the end of 1 and 2 years were documented.

Results

There were no major intraoperative bowel, urinary, or vascular injuries. None of the cases required conversion to laparotomy peroperatively. Our study had 8 patients with carcinoma endometrium (8/43) and 7 patients of carcinoma cervix (7/19) who have completed 24 months of follow-up without any recurrence to date.

Conclusion

Endo-stapler application for enclosed colpotomy to prevent tumor spillage is a futuristic step in gynecologic oncology cases managed by laparoscopy.

Robotic Single-Site Radical Hysterectomy for Early Cervical Cancer: A Single Center Experience of 5 Years

BACKGROUND

The mainstay of treatment for early-stage cervical cancer is surgery; we present a 5-year experience of robotic single-site radical hysterectomy (RSRH) focused on surgical and oncologic outcomes.

METHODS

This retrospective study included 44 cases of RSRH performed in patients with early-stage cervical cancer.

RESULTS

The median follow-up period for the 44 patients was 34 months. The mean total operation time was 156.07 ± 31.77 min, while mean console time was 95.81 ± 24.95 min. Two cases had complications, which required surgical management, while four cases (9.1%) exhibited recurrence. The disease-free survival rate at 5 years was 90.9%. The sub-division analysis showed that Stage Ia2 and stage Ib1 patient sub-group showed better DFS than that of the stage Ib2 patient sub-group. The learning curve analysis showed that the CUSUM-T initially peaks at the sixth case then gradually decreases before rising and peaking at the 24th case. After 24th case, the CUSUM-T gradually decreases and reaches zero.

CONCLUSION

The surgical outcomes of RSRH for early-stage cervical cancer treatment were safe and acceptable. However, RSRH could be considered carefully only in well-selected patient groups. Large-scale prospective studies are necessary in the future to validate the results.

Evaluation of Surgical Outcomes of Abdominal Radical Hysterectomy and Total Laparoscopic Radical Hysterectomy for Cervical Cancer: A Retrospective Analysis of Data Collected before the LACC Trial

Although a surgical approach is one of the key treatments for stages IA1-IIA2, results of the Laparoscopic Approach to Cervical Cancer (LACC) published in 2018 radically changed the field, since minimally invasive surgery was associated with a four-fold higher rate of recurrence and a six-fold higher rate of all-cause death compared to an open approach. We aimed to evaluate surgical outcomes of abdominal radical hysterectomy (ARH) and total laparoscopic radical hysterectomy (TLRH) for cervical cancer, including data collected before the LACC trial. In our retrospective analysis, operative time was significantly longer in TLRH compared to ARH (p < 0.0001), although this disadvantage could be considered balanced by lower intra-operative estimated blood loss in TLRH compared with ARH (p < 0.0001). In addition, we did not find significant differences for intra-operative (p = 0.0874) and post-operative complication rates (p = 0.0727) between ARH and TLRH. This was not likely to be influenced by age and Body Mass Index, since they were comparable in the two groups (p = 0.0798 and p = 0.4825, respectively). Finally, mean number of pelvic lymph nodes retrieved (p = 0.153) and nodal metastases (p = 0.774), as well as death rate (p = 0.5514) and recurrence rate (p = 0.1582) were comparable between the two groups. Future studies should be aimed at assessing whether different histology/grades of cervical cancer, as well as particular subpopulations, may have significantly different outcomes using minimally invasive surgery or laparotomy, with or without neoadjuvant chemotherapy.

Enhanced Recovery after Surgery (ERAS) Protocol for Early Discharge within 12 Hours after Robotic Radical Hysterectomy

To evaluate safety of quick discharge after robotic radical hysterectomy (RRH) in a tertiary hospital which has the enhanced recovery after surgery (ERAS) protocol. Among 94 consecutive cervical cancer patients who had undergone RRH, operative outcomes and the rate of unexpected visit after surgery were analyzed retrospectively. Patients were categorized as a surgery-to-discharge time of ≤12 h (early discharge [ED]) or >12 h (late discharge [LD]). About 77% (n = 72) of analyzed 94 patients discharged within 12 h after RRH. The ED group had significant correlation with shorter duration for urinary catheter required, less operative blood loss, and less voiding difficulty after long-term follow up compared to the LD group. There was no difference of perioperative complications and unexpected visit between the two groups. Performing nerve sparing (NS) RRH was only independent predictor for ED (p = 0.043, hazard ratio for LD = 0.22, confidence interval = 0.05–0.95). In conclusion, the ED within 12 h after RRH was safe in the setting of ERAS protocol. The NS-RRH could avoid the delay of genitourinary function recovery after surgery which caused LD. It can become the reasonable clinical pathway to discharge early patients who undergo NS-RRH with ERAS protocol.

Neoadjuvant Chemotherapy Prior Fertility-Sparing Surgery in Women with FIGO 2018 Stage IB2 Cervical Cancer: A Systematic Review

Simple Summary

In order to provide our contribution to the knowledge of women affected by IB2 cervical cancer, who wish to preserve fertility, we revised and updated the available literature in the debated issue of neoadjuvant chemotherapy prior to fertility-sparing treatment. The effectiveness of preoperative chemotherapy in tumors larger than 2 cm virtually proposes a conservative opportunity to a broader group of women, while keeping low, and hopefully absent, the risk of local and distant relapse. Available studies of neoadjuvant chemotherapy to the fertility-sparing approach have shown that a suboptimal response at surgery seems to be an independent prognostic factor in poorer survival, and, therefore, the careful selection of patients and the surgical approach after neoadjuvant chemotherapy remains crucial. Finally, we proposed an algorithm to be helpful in the decision-making process of that subgroup of patients.

Abstract

Nowadays, the optimal management of patients with cervical cancers measuring 2–4 cm desiring to maintain fertility is still uncertain. In this systematic review, we assessed the reliability of neoadjuvant chemotherapy (NACT) prior to fertility-sparing (FS) surgery in International Federation of Gynecology and Obstetrics (FIGO) 2018 stage IB2 cervical cancer, in terms of pathologic response, oncological and obstetric outcomes. The review of the literature was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Data, using MEDLINE and PubMed, were searched for from 1 January 2005 up to 1 December 2020. We identified 20 articles and 114 women with IB2 disease, possible candidates for NACT prior to FS surgery. However, uterine conservation was achieved only in 76.7% of them. Patients reached optimal pathological response to NACT in 60.9% of cases and a TIP (cisplatin, ifosfamide and paclitaxel) regime was related to the best response. Suboptimal response to NACT appeared to be an independent negative prognostic factor. Up to 9.2% of patients recurred with a median 7.4-months DFS, and 4.6% of patients died of disease. Fifty percent of women tried to conceive after treatment and NACT prior to conization appeared to be the most promising alternative to upfront radical trachelectomy in terms of obstetric outcomes. In conclusion, NACT prior to FS surgery is an option, but the literature about this issue is still weak and FS should be carefully discussed with patients.