The clinical significance of intraoperative adverse events in laparoscopic radical hysterectomies for early-stage cervical cancer

OBJECTIVE

Surgical quality plays a vital role in the treatment of malignant tumors. We investigated the classification of intraoperative adverse events (iAE) (ClassIntra) in relation to the surgical quality control of laparoscopic radical hysterectomies.

METHODS

A prospective cohort of 195 patients who had undergone laparoscopic radical hysterectomies for early stage cervical cancer between July 2019 and July 2021 was enrolled. Participants were classified into either an iAE or non-iAE groups in accordance with their intraoperative status. Surgical outcomes, patient satisfaction, and quality of life were compared between the two groups.

RESULTS

Overall, 48 (24.6%) patients experienced 71 iAE. The iAE group was associated with significantly longer operative times (mean: 270 vs. 245 min, P < 0.001), greater blood loss (mean: 215 vs. 120 mL, P < 0.001), and longer postoperative hospital stays (median: 16 vs. 11 days). Larger tumors and poor technical performance significantly increased the risk of iAE (P < 0.05). Multivariate analysis revealed that iAE were the only independent risk factors for postoperative complications (hazard ratio, 15.100; 95% confidence interval: 4.735-48.158, P < 0.001). Moreover, patients who experienced iAE had significantly lower satisfaction scores and poorer quality of life (P < 0.05).

CONCLUSIONS

ClassIntra may serve as an effective adjunctive tool for surgical quality control in laparoscopic radical hysterectomies.

Systematic Review and Meta-analysis of laparoscopic radical hysterectomy vs. Robotic assisted radical hysterectomy for early stage cervical cancer

OBJECTIVE

Following compelling evidence that open techniques may be related to better survival and disease free survival rates, many gynecologic oncologists in the US have turned away from performing laparoscopic radical hysterectomy (LRH) and robotic radical hysterectomy (RRH) for the treatment of early-stage cervical cancer. While this may be warranted as a safety concern, there is little high-quality data on the head-to-head comparison of LRH and RRH and therefore little evidence to answer the question of where this decrease in patient survival is originating from. In our systematic review, we aimed to compare the complications and outcomes of LRH against those of RRH.

DATA SOURCES

We searched PubMed, Cochrane CENTRAL, Medline, ClinicalTrials.Gov, SCOPUS, and Web of Science from database inception until February 1st, 2022.

METHODS OF STUDY SELECTION

A total of 676 studies were identified and screened through a manual three-step process. Ultimately 33 studies were included in our final analysis. We included all studies that compared LRH and RRH and included at least one of our selected outcomes. We included retrospective cohorts, prospective cohorts, case-control, and randomized clinical trials.

TABULATION, INTEGRATION, AND RESULTS

Data was independently extracted manually by multiple observers and the analysis was performed using Review Manager Software. PRISMA guidelines were followed. We analyzed homogenous data using a fixed-effects model, while a random-effects model was used for heterogeneous outcomes. We found that following RRH, women had a decreased hospital stay (MD = 0.80[0.38,1.21],(P < 0.002). We found no differences in estimated blood loss (MD = 35.24[-0.40,70.89],(P = 0.05), blood transfusion rate ((OR = 1.32[0.86,2.02],(P = 0.20), rate of post-operative complications (OR = 0.84[0.60,1.17],(P = 0.30), the operative time (MD = 6.01[-4.64,16.66],(P = 0.27), number of resected lymph node (MD = -1.22[-3.28,0.84],(P = 0.25) intraoperative complications (OR = 0.78[0.51,1.19],(P = 0.25), five-year overall survival (OR = 1.37[0.51,3.69],(P = 0.53), lifetime disease free survival (OR = 0.89[0.59,1.32],(P = 0.55), intraoperative and postoperative mortality (within 30 days) (OR = 1.30[0.66,2.54],(P = 0.44), and recurrence (OR = 1.14[0.79,1.64],(P = 0.50).

CONCLUSIONS

RRH seems to result in the patient leaving the hospital sooner after surgery. We were unable to find any differences in our ten other outcomes related to complications or efficacy. These findings suggest that the decreased survival seen in minimally invasive RH in previous studies could be due to factors inherent to both LRH and RRH.

PROSPERO PROSPECTIVE REGISTRATION NUMBER

CRD42022273727.

A multicenter noninferior randomized controlled study comparing the efficacy of laparoscopic versus abdominal radical hysterectomy for cervical cancer (stage IB3 and IIA2): study protocol of the LAUNCH 3 trial

BACKGROUND

Cervical cancer is and will remain to be an important health problem in China, especially with an increasing proportion of younger patients who has more specific needs. In China, surgery to remove tumor burden followed by postoperative treatment with radiotherapy and chemotherapy based on clinicopathologic factors may be the best choice for stages IB3 and IIA2 patients. Radical hysterectomy in cervical cancer has been a classic landmark surgery in gynecology. The current trial is designed to evaluate whether there is a difference between laparoscopic RH and abdominal RH in cervical cancer (stages IB3 and IIA2) patient survival under stringent operation standards and consistent surgical oncologic principles. This paper reports the rationale, design, and implementation of the trial.

METHODS/DESIGN

This is an investigator-initiated, prospective, randomized, open, blinded endpoint (PROBE) controlled trial. A total of 1104 patients with stage IB3 and IIA2 cervical cancer will be enrolled over a period of 3 years. Patients are randomized (1:1) to either the laparoscopic RH or the abdominal RH group. Patients will then be followed up for at least 5 years. The primary end point will be 5-year overall survival, and secondary endpoints include 5-year progression-free survival, recurrence, and quality of life measurements.

DISCUSSION

The study results will provide more convincing evidence-based information for stages IB3 and IIA2 cervical cancer patients and their gynecologic cancer surgeons in their choice of surgical method.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT04939831 , retrospectively registered on 25 June 2021.

Laparoscopic radical hysterectomy and total vaginectomy for vaginal malignant melanoma with cervical metastasis

The presented case is a 63-years-old multiparous woman admitted with the complaint of postmenopausal bleeding. On gynecologic examination multifocal lesions were detected, including 1 cm on lateral vaginal wall, 4 cm on posterior vaginal wall and 0.5 cm on the left lateral part of the cervix. Histopathology examination gave a diagnosis of epithelioid malignant melanoma. Consequently, laparoscopic radical hysterectomy and total vaginectomy with bilateral pelvic and inguinofemoral lymph node dissection were planned. On both sides, pararectal and paravesical spaces were created and the ureter was identified. Then, the vesicouterine and vesicovaginal spaces were developed. Uterine artery and superior vesical artery were coagulated, cut and the lateral parametrium was prepared. The left ureter was dissected and the ureteral tunnel was unroofed up to the bladder entrance. Subsequently, the anterolateral parametrium was transected. Then, the infundibulopelvic and sacrouterine ligaments were sealed and transected. At this time, the rectovaginal space was developed. Bilateral paracolpos were transected. The endopelvic fascia with the levator muscles were sealed and cut circumferentially. Anteriorly, the pubovesicocervical fascia was transected and the bladder was mobilized up to the uretrovesical junction. Thereafter, through a vaginal approach, the cervix and vagina were inverted by grasping the cervix with a tenaculum. An incision on the posterior vaginal wall at the introitus was made and the urogenital diaphragm was dissected to connect with the pelvic cavity. The vaginal entrance was cut circumferentially and the surgical specimen was extracted. In conclusion, laparoscopy can be considered as a feasible approach for radical hysterectomy and total vaginectomy in selected patients.

Application of sevoflurane combined with remifentanil anesthesia in laparoscopic radical hysterectomy for cervical cancer

OBJECTIVE

To explore the effects of sevoflurane combined with remifentanil anesthesia on the physical stress and immunologic function of patients undergoing laparoscopic radical hysterectomy for cervical cancer.

METHODS

The clinical data of 74 patients undergoing laparoscopic radical hysterectomy for cervical cancer were retrospectively analyzed. Patients were divided into two groups according to the different anesthesia methods, among which 37 cases received propofol and remifentanil anesthesia were set as a control group (CG), and 37 cases received sevoflurane and remifentanil anesthesia were set as an observation group (OG).

RESULTS

The OG showed a lower heart rate, Ramsay score and bispectral index than the CG 30 min after the start of the surgery and at the end of the surgery. The levels of glucagon, angiotensin II and cortisol in the OG were lower than those in the CG upon skin incision, at the end of surgery, and at 1 h after surgery (P < 0.05). The levels of CD3⁺ and CD4⁺ of the OG were higher than those of the CG at 1 d and 3 d after surgery. In terms of Montreal Cognitive Assessment and Mini-Mental State Examination scores 1 d after surgery, the OG was higher than the CG.

CONCLUSION

Sevoflurane combined with remifentanil anesthesia for patients undergoing laparoscopic radical hysterectomy for cervical cancer is superior to propofol and remifentanil, and can ensure stable hemodynamics and mitigate physical stress, so it is worthy of clinical application.

A multicenter non-inferior randomized controlled study comparing the efficacy of laparoscopic versus abdominal radical hysterectomy for cervical cancer (stages IB1, IB2, and IIA1): study protocol of the LAUNCH 2 trial

Background

A retrospective study and a randomized controlled trial published in late 2018 have shown that laparoscopic radical hysterectomy (RH) was associated with worse survival than abdominal RH among patients with early-stage cervical cancer. Radical hysterectomy in cervical cancer has been a classic landmark surgery in gynecology; therefore, this conclusion is pivotal. The current trial is designed to reconfirm whether there is a difference between laparoscopic RH and abdominal RH in cervical cancer (stages IB1, IB2, and IIA1) patient survival under stringent operation standards and consistent surgical oncologic principles.

Methods/design

This is an investigator-initiated, Prospective, Randomized, Open, Blinded End-point (PROBE)-controlled non-inferiority trial. A total of 780 patients with stage IB1, IB2, and IIA1 cervical cancer will be enrolled over a period of 3 years. Patients are randomized (1:1) to either the laparoscopic RH or the abdominal RH group. Patients will then be followed up for at least 5 years. The primary endpoint will be 5-year progression-free survival, and secondary endpoints include 5-year overall survival, recurrence, and quality of life measurements.

Discussion

The debate on laparoscopic versus abdominal RH is still ongoing, and high-quality evidences are needed to guide clinical practice. The study results will provide more convincing evidence-based information for early-stage cervical cancer patients and their gynecologic cancer surgeons in their choice of surgical method.

Trial registration

ClinicalTrials.govNCT04929769. Registered on 18 June 2021

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.

Step-wise Technical Description of Performing Ureteric Tunnel Dissection in Laparoscopic Radical Hysterectomy

Objectives:

Technical description of performing ureteric tunnel dissection in laparoscopic radical hysterectomy (LRH) surgery.

Materials and Methods:

This is a retrospective analysis. A total of 91 patients of the International Federation of Gynaecology and Obstetrics Stage IA2, IB1, and IB2 of cervical cancer were operated by the same surgeon between January 2015 and December 2019 were analyzed.

Results:

The median time for one side ureteric tunnel dissection was 3 min 15 s (range 2 min 35 s– 6 min 18 s). None of the cases were converted to laparotomy. The patients' median hospital stay was 2 days (range 1–4 days). There were no short-term or long-term complications related to ureteric tunnel dissection.

Conclusion:

This analysis explains the descriptive methodology of operative technique, especially for ureteric tunnel dissection in LRH. This technique is easily reproducible and replicable, with chances of marginal or negligible complication rates.

Laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator

OBJECTIVE

To demonstrate the experience of laparoscopic radical hysterectomy for cervical cancer without the use of a uterine manipulator and investigate the feasibility and treatment effectiveness of this surgical approach.

MATERIALS AND METHODS

The laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament without a uterine manipulator prevented the oppression of the uterine manipulator on the tumour. Vaginal ligation was performed below the lesion of cervical cancer, and the vagina was cut off below the ligation line. Consequently, the exposure of cancer tissues in the abdominal cavity was prevented, enabling a tumour-free operation. We reviewed the medical records of the 22 patients with stage IB1-IIA2 cervical squamous cell carcinoma who were treated at our hospital between May 2019 and February 2020. All the patients underwent the laparoscopic radical hysterectomy for cervical cancer by pulling the round ligament. All the patients were informed about the different therapeutic schemes and surgical approaches as well as their advantages and disadvantages. Information about operative time, intraoperative blood loss, hospitalisation duration, postoperative complications, postoperative adjuvant therapy, prognosis and other data were recorded.

RESULTS

All the surgical procedures were successfully completed without perioperative complications, such as vascular injury, pelvic injury and abdominal organ injury. The mean operative duration was 204 min, and the mean operative blood loss was 102 mL. The mean duration of postoperative hospital stay was 13 days. Nineteen patients received postoperative chemotherapy once before hospital discharge. Urinary retention was the major postoperative complication. All the patients were followed up for 14-23 months. The median follow-up time was 18 months. 21 of the 22 patients survived. No recurrence was detected in the patients during follow-up. One patient who had a pelvic lymph node metastasis but refused complete chemoradiotherapy died before the last follow-up.

CONCLUSIONS

This surgical approach appears to be safe and feasible for patients with cervical cancer. A larger sample size and longer follow-up period are required to confirm whether this surgical approach can actually and effectively improve the prognosis.

The long-term urinary dysfunction after type C2 radical hysterectomy in patients with cervical cancer

Radical hysterectomy (RH) may cause lower urinary tract symptoms (LUTS) for patients with cervical cancer. Few data are available on the long-term LUTS of these patients and whether the symptoms relate to the route of surgery remain unclear. Here, we assessed the long-term urinary dysfunction in cervical cancer patients after RH based on a self-reported questionnaire. A total of 168 patients after type C2 RH, either by laparoscopy (LRH) or laparotomy (ARH), were analysed. The median length of follow-up was 54 ± 8.35 months. The total incidence of urinary dysfunction was around 40%. Patients with LRH had more intermittent stream and feeling of incomplete emptying than those in ARH group. Our data indicate the irreversible damage of RH to urinary function of cervical cancer patients, who should be informed of the long-term and high incidence of urinary dysfunction after RH when they choose surgical treatment.Impact StatementWhat is already known on this subject? Radical hysterectomy (RH) with pelvic lymphadenectomy is standard surgical care for patients with cervical cancer. RH could induce urinary dysfunction, including bladder sensation loss, hypertonic and hypotonic bladder, urinary incontinence, etc. Studies mainly focus on short- or mid-term urinary dysfunction and stated that spontaneous recovery of urinary function is to be expected within 6-12 months after surgery.What the results of this study add? The lower urinary tract symptoms last for years after type C2 RH, indicating the irreversible damage of RH to urinary function of cervical cancer patients. The incidence of bladder dysfunction is increased in patients submitted to laparoscopic RH compared to abdominal RH.What the implications are of these findings for clinical practice and/or further research? Cervical cancer patients should be informed of the long-term and high incidence of urinary dysfunction after RH when they choose surgical treatment.

Standardization and experience may influence the survival of laparoscopic radical hysterectomy for cervical cancer

OBJECTIVE

Minimally invasive radical hysterectomy has been shown to be associated with poorer outcome in an influential prospective, randomized trial. However, many centers worldwide performing minimally invasive radical hysterectomy have data and experience that prove otherwise. We aim to review surgical and oncologic outcomes of patients operated by Laparoscopic Radical Hysterectomy in a tertiary hospital, by experienced surgeons and standardization in radicality, for cervical carcinoma Stage 1A1-1B1 from January 2009 to May 2014.

MATERIALS & METHODS

Standardised surgical technique with Parametrium & Paracolpium resection approach was adopted by qualified and experienced Gynecologic/Gyne-Oncologic Endoscopic & Minimally Invasive Surgeons in performing Laparoscopic Radical Hysterectomy for Cervical Cancer stage 1A1-1B1 from January 2009-May 2014, involving 53 patients. Electronic Medical Record system (EMR) Of Chang Gung Memorial Hospital(Tertiary Referral Centre), Department of Obstetrics & Gynecology was accessed for surgical and oncologic outcomes.

RESULTS

Fifty-Three patients operated from January 2009 to May 2014 were followed up for an average of 96.7 months with longest follow-up at 127 months. There were no cases of recurrence or death reported. 5 Year - Survival Rate and 5 Year Disease-Free Survival Rate were 100%. Two patients received post-operative pelvic radiation concurrent with chemotherapy using Cisplatin due to greater than 1/3 cervical stromal invasion.

CONCLUSION

It is vital to standardize minimally invasive surgical techniques for early stage cervical cancer, with focus on adequate radicality and resection which may contribute to excellent survival outcomes. Further international multi-center randomized trial (Minimally Invasive Therapy Versus Open Radical Hysterectomy In Cervical Cancer) will provide justification for continued practice of MIS in early stage cervical cancer.

Comparison of oncological outcomes and major complications between laparoscopic radical hysterectomy and abdominal radical hysterectomy for stage IB1 cervical cancer with a tumour size less than 2 cm

OBJECTIVE

To compare the oncological outcomes and major complications of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) for stage IB1 cervical cancer (FIGO 2009) with a tumour size less than 2 cm.

METHODS

We retrospectively compared the oncological outcomes and major complications of 1207 stage IB1 cervical cancer patients with a tumour size less than 2 cm who received LRH (n = 546) or ARH (n = 661) in 37 hospitals.

RESULTS

(1) There was no significant difference in 3-year overall survival (OS; 97.3% vs. 98.5%, P = 0.288) or 3-year disease-free survival (DFS; 95.1% vs. 95.4%, P = 0.792) between LRH (n = 546) and ARH (n = 661).(2) The rate of any 1 complication refers to the incidence of one or more complications in a patient, which was higher with LRH than ARH (OR = 4.047, 95% CI = 2.035-8.048, P < 0.001). Additionally, intraoperative complications occurred with LRH (OR = 12.313, 95% confidence intervals [CI] = 1.571-96.493, P = 0.017), and postoperative complications (OR = 3.652, 95% CI = 1.763-7.562, P < 0.001) were higher with LRH than ARH. The ureteral injury rate was higher with LRH than with ARH (1.50% vs. 0.20%, OR = 9.814, 95% CI = 1.224-78.712, P = 0.032). The ureterovaginal fistula rate was higher with LRH than ARH. The rates of obturator nerve injury, bladder injury, vesicovaginal fistula, rectovaginal fistula, venous thromboembolism, bowel obstruction, chylous leakage, pelvic haematoma, and haemorrhage were similar between the groups.

CONCLUSIONS

The oncological outcomes of LRH and ARH for stage IB1 cervical cancer patients with a tumour size less than 2 cm do not differ significantly. However, incidences of any 1 complication, intraoperative complications, and postoperative complications were higher with LRH than ARH, with complications manifesting mainly as ureteral injury and uterovaginal fistula.

Laparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB: description of the technique, our experience and results after the era of LACC trial

PURPOSE

The aim of this study is to evaluate surgical data and oncological outcome of laparoscopic nerve-sparing radical hysterectomy without uterine manipulator for cervical cancer stage IB, over the last 8 years.

METHODS

This retrospective study includes 32 patients with cervical cancer Figo stage (2009) IB who underwent laparoscopic nerve-sparing radical hysterectomy without using any kind of uterine manipulator. Patients were eligible if they had squamous cell carcinoma, adenocarcinoma, or adeno-squamous carcinoma, and no para-aortic lymph node involvement by imaging or after frozen section. The median value and range were assessed for operative outcomes and relapse rate and disease-free survival rate were evaluated using the Kaplan-Meier method.

RESULTS

In the study, 32 patients were included and among them 27 women were stage IB1 (18 cases with tumor size 2-4 cm) and 5 women stage IB2 (Figo stage 2009). The median age of patients was 50.5 years (range 31-68) and median body mass index (B.M.I) was 25.3 kg/m² (range 19-33.5 kg/m²). The average operating time was 228 min (range 147-310 min) and median hospital stay was 2.7 days (range 2-7 days). Approximate blood loss was 188 ml (range 120-300 ml). After a median follow-up of 37 months, we had 2 recurrences out of 32 cases and no death. Especially for patients with Figo stage (2009) IB1, the recurrence rate was 3.7% (1/27). The 3-year PFS was 93.7% and the number at risk 23 (71.8%) and especially for the IB1 stage (2009) women, the 3-year PFS was 96.1% and the number at risk 21 (77.7%). The 3-year OS was 100% with no. at risk 71.8%.

CONCLUSIONS

Laparoscopic nerve-sparing radical hysterectomy without uterine manipulator is feasible and safe surgical procedure for cervical cancer with acceptable surgical and oncological outcomes in the hands of well-trained and experienced laparoscopic surgeons. Our retrospective study reveals better oncological outcome compared to other studies on the minimally invasive approach, where uterine manipulator was routinely used and no vaginal sealing of the tumor was made.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Survival outcomes of single-port access laparoscopic radical hysterectomy for early-stage cervical cancer

BACKGROUND

Emerging data from the Laparoscopic Approach to Cervical Cancer trial (NCT00614211) suggested that minimally invasive surgery (MIS) for cervical cancer is correlated with worse survival outcomes than open surgery. This finding could be attributed to the different learning curves for laparoscopic surgery among surgeons. This study aimed to assess the feasibility, safety, and survival outcomes of single-port access (SPA) laparoscopic radical hysterectomy (LRH) for treating early cervical cancer.

METHODS

This was a retrospective cohort study of consecutive patients with early-stage cervical cancer who underwent SPA LRH between 2009 and 2018 performed by a single surgeon with expertise in SPA laparoscopy using conventional instrumentation and a homemade glove port system.

RESULTS

Type C (93.2%) and B (6.8%) radical hysterectomy were performed in 59 women with cervical cancer classified as IA (3.4%), IB (94.9%), and IIA (1.7%). Forty-one patients (69.5%) had squamous cell carcinoma and 32 patients (52.5%) had tumors < 2 cm. The median operative time was 235 (125-382) minutes. There were no perioperative complications or cases of conversion to open surgery. Postoperative complications, including chylous ascites, low hemoglobin, lymphedema, and vault dehiscence, were observed in 5 patients (8.5%). Median follow-up time was 3.1 (0.6-8.6) years and 3 patients experienced recurrence (1 local and 2 distant failures). Five-year disease-free survival was 94.9% (56/59) and the 5-year overall survival rate was 98.3% (58/59).

CONCLUSIONS

SPA LRH is feasible and safe for patients with early-stage cervical cancer when performed by experienced surgeons without compromising the radicality and oncologic outcomes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Robotic Radical Hysterectomy Is Not Superior to Laparoscopic Radical Hysterectomy in Perioperative Urologic Complications: A Meta-Analysis of 23 Studies

OBJECTIVE

This study aimed to compare the risks of intraoperative and postoperative urologic complications after robotic radical hysterectomy (RRH) compared with laparoscopic radical hysterectomy (LRH).

DATA SOURCES

We searched Pubmed, EMBASE, and the Cochrane Library for studies published up to March 2019. Related articles and relevant bibliographies of published studies were also checked.

METHODS OF STUDY SELECTION

Two researchers independently performed data extraction. We selected comparative studies that reported perioperative urologic complications.

TABULATION, INTEGRATION, AND RESULTS

Twenty-three eligible clinical trials were included in this analysis. When all studies were pooled, the odds ratio for the risk of any urologic complication after RRH compared with LRH was .91 (95% confidence interval [CI], .64-1.28; p = .585). The odds ratios for intraoperative and postoperative complications after RRH versus LRH were .86 (95% CI, .48-1.55; p = .637) and .94 (95% CI, .64-1.38; p = .767), respectively. In a secondary analysis study quality, study location, and the publication year were not associated with intraoperative or postoperative urologic complications.

CONCLUSION

Current evidence suggests that RRH is not superior to LRH in terms of perioperative urologic complications.

Laparoscopic Radical Hysterectomy with Enclosed Colpotomy and without the Use of Uterine Manipulator for Early-Stage Cervical Cancer

It was reported recently that minimally invasive radical hysterectomy was associated with worse prognosis than the open abdominal counterpart for the management of early-stage cervical cancer. Uterine manipulator and intracorporeal open colpotomy may be the 2 main suspects responsible for the inferiority. We hypothesize that minimally invasive radical hysterectomy with enclosed colpotomy and without the use of a uterine manipulator will improve survival. Thus, laparoscopic radical hysterectomy with abdominal uterine manipulation and enclosed colpotomy was performed in women with early-stage cervical cancer. The round ligament, the ovary ligament, and the fallopian tube were sutured together for the abdominal manipulation of the uterus. Meanwhile, the upper vagina was ligated before colpotomy to avoid tumor spillage. There were no intraoperative and postoperative complications. The abdominal uterine manipulation and enclosed colpotomy technique, which are both safe and feasible in this study, provide a relatively tumor-free approach for minimally invasive radical hysterectomy. Further investigation of oncologic outcomes in larger prospective studies are needed to confirm our hypothesis.

Laparoscopic Nerve-Sparing Radical Hysterectomy vs Laparoscopic Radical Hysterectomy in Cervical Cancer: A Systematic Review and Meta-Analysis of Clinical Efficacy and Bladder Dysfunction

It is widely accepted that nerve-sparing radical hysterectomy is associated with less postoperative morbidity compared with radical hysterectomy, whereas clinical safety is similar in the 2 procedures. However, there is insufficient evidence to compare these procedures performed via a laparoscopic approach. We performed a systematic review and meta-analysis of studies to compare the clinical efficacy and the rate of bladder dysfunction, including urodynamic assessment, in laparoscopic nerve-sparing radical hysterectomy (LNSRH) and laparoscopic radical hysterectomy (LRH). Thirty articles including a total of 2743 participants were analyzed. Operating times were shorter (MD, 29.88 minutes; 95% confidence interval [CI], 11.92-47.83 minutes) and hospital stays were longer (MD, -1.56 days; 95% CI, -2.27 to -0.84 days) in the LRH group compared with the LNSRH group. In addition, blood loss and the number of resected lymph nodes were not significantly different between the 2 groups. However, resected parametrium length (MD, -0.02 cm; 95% CI, -0.05 to -0.00 cm) and vaginal cuff width (MD, -0.06 cm; 95% CI, -0.09 to -0.04) were smaller in the LNSRH group. Furthermore, LNSRH tended to result in more satisfactory micturition (odds ratio, 2.90; 95% CI, 2.01-4.19), shorter catheterization time (MD, -7.20 days; 95% CI, -8.10 to -6.29 days), and shorter recovery to normal postvoid residual urine time (MD, -7.71 days; 95% CI, -8.92 to -6.50 days). Other bladder dysfunction symptoms, including urinary retention, nocturia, dysuria, urinary incontinence, and frequency/urgency were more frequent in the LRH group. Furthermore, LNSRH achieved better results in urodynamic assessments (all p < .05). In conclusion, LNSRH was associated with lower rates of impaired bladder function and a shorter extent of resection compared with LRH. Clinical applications involving LNSRH should be explored with caution.

Efficacy and safety outcomes of robotic radical hysterectomy in Chinese older women with cervical cancer compared with laparoscopic radical hysterectomy

Background

Recently, as a complex integrating a number of modern high-tech means, robotic surgery system is a well-deserved revolutionary tool in globally minimally invasive surgical field. For the first time in China, the objective of this study was to evaluate the efficacy and safety outcomes of robotic radical hysterectomy (RRH) in Chinese older women with cervical cancer compared with laparoscopic radical hysterectomy (LRH).

Methods

In this prospective, randomized and double-blinded study, 60 Chinese older women with cervical cancer were evenly divided to accept the RRH or LRH. Follow-up period lasted for 24 months.

Results

Median age for the entire cohort was 65 (range: 61-69) years. There was no difference in International Federation of Gynecology and Obstetrics (FIGO) stages and cell types between two groups (p > 0.05 for all). Uterine size, tumor size, vaginal length and numbers of left and right pelvic lymph nodes did not differ between two groups (p > 0.05 for all). No difference was observed in numbers of left and right lymph node metastasis (p > 0.05 for all). All patients had negative margins without conversion to laparotomy. There were significantly less postoperative complications in the RRH group than in the LRH group (p < 0.05). Shorter indwelling time of bladder and drain catheters was observed in the RRH group than in the LRH group (p < 0.05 for all). Length of postoperative hospital stay in the RRH group was significantly shorter compared with that in the LRH group (p < 0.05). Patients in two groups similarly experienced the recurrence and death (p > 0.05 for all).

Conclusions

This study demonstrated that RRH provided additional benefits for Chinese older women with cervical cancer because of less complications and faster recovery compared with LRH. Meanwhile, this study supported an equivalence of surgical qualities and survival outcomes of RRH to LRH. Robotics-assisted surgical method is effective, safe and feasible for Chinese older women with cervical cancer.

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.

Vaginal extension improves sexual function in patients receiving laparoscopic radical hysterectomy

OBJECTIVE

To investigate as to whether vaginal extension (VX) following laparoscopic radical hysterectomy (LRH) improves sexual function in patients with early-stage cervical cancer patients.

METHODS

A total of 216 patients with stage Ia1-IIa2 cervical cancer were recruited, 115 of them received LRH concurrently with VX (group VX) and the other 101, LRH only (group C). Demographic, clinicopathological, and peri-operative data were collected. The Female Sexual Function Index (FSFI) questionnaire was administrated before and one year after surgery. Serum estrogen and follicle-stimulating hormone levels were also measured one year after surgery. The total and domain-wise FSFI scores before and after surgery were compared.

RESULTS

Irrespective VX or not, all 6 domains of the FSFI scores in women with early-stage cervical cancer were significantly reduced one year after LRH. VX, however, significantly attenuated this reduction and improved all 6 FSFI domain scores, at the only cost of <20min longer operating time. In addition, more ovarian reserve and better pre-operational sexual function also contributed to the attenuation. The ovarian reserve was improved if ovarian preservation procedure was performed during LRH.

CONCLUSIONS

While the sexual function in patients receiving VX procedure does not fully achieve the pre-operational level, the improvement is nonetheless global and significant. Ovarian preservation procedure during LRH may also help improve the sexual function. Therefore, VX and ovarian preservation may be desirable for patients with early-stage cervical cancer who undergo RH.

Learning curve analysis of laparoscopic radical hysterectomy for gynecologic oncologists without open counterpart experience

Objective

To evaluate the learning curve of laparoscopic radical hysterectomy (LRH) for gynecologic oncologists who underwent residency- and fellowship-training on laparoscopic surgery without previous experience in performing abdominal radical hysterectomy (ARH).

Methods

We retrospectively reviewed 84 patients with FIGO (International Federation of Gynecology and Obstetrics) stage IB cervical cancer who underwent LRH (Piver type III) between April 2006 and March 2014. The patients were divided into two groups (surgeon A group, 42 patients; surgeon B group, 42 patients) according to the surgeon with or without ARH experience. Clinico-pathologic data were analyzed between the 2 groups. Operating times were analyzed using the cumulative sum technique.

Results

The operating time in surgeon A started at 5 to 10 standard deviations of mean operating time and afterward steeply decreased with operative experience (Pearson correlation coefficient=-0.508, P=0.001). Surgeon B, however, showed a gentle slope of learning curve within 2 standard deviations of mean operating time (Pearson correlation coefficient=-0.225, P=0.152). Approximately 18 cases for both surgeons were required to achieve surgical proficiency for LRH. Multivariate analysis showed that tumor size (>4 cm) was significantly associated with increased operating time (P=0.027; odds ratio, 4.667; 95% confidence interval, 1.187 to 18.352).

Conclusion

After completing the residency- and fellowship-training course on gynecologic laparoscopy, gynecologic oncologists, even without ARH experience, might reach an acceptable level of surgical proficiency in LRH after approximately 20 cases and showed a gentle slope of learning curve, taking less effort to initially perform LRH.

Urinary and anal dysfunction after laparoscopic versus laparotomic radical hysterectomy

OBJECTIVE

The aim of this study was to compare urinary and anal dysfunction after laparoscopic (LRH) and abdominal (ARH) radical hysterectomy for cervical cancer.

STUDY DESIGN

Consecutive patients who underwent radical hysterectomy for treatment of cervical cancer were enrolled in this study and divided into two groups, according to the surgical approach. Urinary and anal symptoms were evaluated before and 6 months after surgery.

RESULTS

Fifty-four women were considered: 27 LRH and 27 ARH. Urinary incontinence was significantly more frequent both after LRH (37% vs 86.9%, p=0.0004) and after ARH (33.3% vs 100%, p<0.0001); urge incontinence (3.7% vs 29.6%, p=0.02) and increased bladder sensation (0 vs 22.2%, p=0.02) were significantly more common postoperatively in patients undergone ARH. In both groups more patients complain about increase of straining during voiding (LRH: 0 vs 34.7%, p=0.009; ARH: 3.7% vs 29.6% p=0.02) after surgery. Postoperative constipation by obstructed defecation was more frequent after ARH (Wexner score: 0 vs 2, p=0.03) but not after LRH.

CONCLUSION

From our results, laparoscopic approach for radical hysterectomy seems to reduce the postoperative occurrence of urge incontinence, increased bladder sensation and constipation by obstructed defecation, in comparison with abdominal radical surgery.

Laparoscopic radical hysterectomy and pelvic lymphadenectomy can be routinely used for treatment of early-stage cervical cancer: a single-institute experience with 404 patients

STUDY OBJECTIVE

The aim of our study was to determine if laparoscopic radical hysterectomy (LRH) can be routinely used for the treatment of early-stage cervical cancer.

DESIGN

From May 2008, LRH was planned for all primarily operable cervical cancer patients after receiving informed consent in our department. The surgical and oncologic outcomes were retrospectively evaluated (Canadian Task Force classification III).

SETTING

University teaching hospital.

PATIENTS AND INTERVENTIONS

By August 2013, 404 patients with invasive cervical cancer were deemed operable, and all of them were subjected to upfront LRH, except 1 patient who insisted on open surgery.

MEASUREMENTS AND MAIN RESULTS

The planned LRH was abandoned in 3 patients because of inoperability. The median operative time was 240 minutes (range, 100-410 minutes). The median blood loss was 300 mL (range, 50-800 mL). The median number of harvested pelvic lymph nodes was 23.5 (range, 11-54). Two patients had positive surgical margins. Intraoperative complications occurred in 7 of the patients, and a conversion to open surgery was mandatory for 2 patients (conversion rate = 0.5%). Postoperative urinary tract fistula developed in 3 patients. Sixty-nine patients underwent adjuvant therapy. The median duration of follow-up was 31 months (range, 7-69 months). Thirty patients developed recurrent disease with a median disease-free interval of 12 months (range, 6-23 months), and 24 died of disease. The estimated 3-year overall survival rate was 94.9% in the women with a tumor ≤ IB1 and 81.3% in those with a tumor >IB1, and the 3-year progression-free survival rates were 94.1% and 79.6%, respectively.

CONCLUSION

LRH is adequate, safe, and feasible for women with cervical cancer, and it can be routinely used for the treatment of early-stage tumors as a primary modality.

Laparoscopic radical hysterectomy and lymph node dissection learning experience at campus Virchow - Charite

AIM

The purpose of this study was to establish and analyze the laparoscopic technique of radical hysterectomy and para-aortic and pelvic lymphadenectomy and to retrospectively evaluate its feasibility and morbidity.

PATIENTS AND METHODS

During a one-year period 12 patients underwent laparoscopic radical surgical procedures for cervical or endometrial cancer. All our patients underwent radical pelvic lymphadenectomy, whereas we performed radical para-aortic lymphadenectomy-alone in five patients and radical type-C hysterectomy in eight patients.

RESULTS

The mean operating time for para-aortic and pelvic lymphadenectomy was 120 and 152 minutes respectively, and 153.75 minutes for type C hysterectomy. A mean of 41.6 pelvic lymph nodes and 21.2 para-aortic lymph nodes were removed. The mean extensions of parametrium in laparoscopic radical hysterectomy type C were 45×30 mm.

CONCLUSION

Following a short learning curve, laparoscopic para-aortic and pelvic lymphadenectomy is a safe and effective technique for staging cervical, and endometrial cancer.