The incidence of perioperative lymphatic complications after radical hysterectomy and pelvic lymphadenectomy between robotic and laparoscopic approach : a systemic review and meta-analysis

BACKGROUND

Although many studies have reported perioperative complications after radical hysterectomy and pelvic lymph node dissection using robotic and laparoscopic approaches, the risk of perioperative lymphatic complications has not been well identified. The aim of this meta-analysis is to compare the risks of perioperative lymphatic complications after robotic radical hysterectomy and lymph node dissection (RRHND) with laparoscopic radical hysterectomy and lymph node dissection (LRHND) for early uterine cervical cancer.

MATERIALS AND METHODS

The authors searched the PubMed, Cochrane Library, Web of Science, ScienceDirect, and Google Scholar databases for studies published up to July 2022 comparing perioperative lymphatic complications after RRHND and LRHND while treating early uterine cervical cancer. Related articles and bibliographies of relevant studies were also checked. Two reviewers independently performed the data extraction.

RESULTS

A total of 19 eligible clinical trials (15 retrospective studies and 4 prospective studies) comprising 3079 patients were included in this analysis. Only 107 patients (3.48%) had perioperative lymphatic complications, of which the most common was lymphedema ( n =57, 1.85%), followed by symptomatic lymphocele ( n =30, 0.97%), and lymphorrhea ( n =15, 0.49%). When all studies were pooled, the odds ratio for the risk of any lymphatic complication after RRHND compared with LRHND was 1.27 (95% CI: 0.86-1.89; P =0.230). In the subgroup analysis, study quality, country of research, and publication year were not associated with perioperative lymphatic complications.

CONCLUSIONS

A meta-analysis of the available current literature suggests that RRHND is not superior to LRHND in terms of perioperative lymphatic complications.

Learning Laparoscopic Radical Hysterectomy: Are We Facing an Emerging Situation?

Despite wide screening campaigns and early detection, cervical cancer remains the fourth most common cancer among women. Radical hysterectomy, whether by open, laparoscopic or by robotic-assisted techniques, is the mainstay treatment. However, for adequate surgical results and good oncological prognosis, a gynecological surgeon should be trained to perform those procedures. The learning curve of radical hysterectomy, especially by laparoscopy, is influenced by several factors. The LACC trial, the decrease in cervical cancer incidence and radical hysterectomy procedures have widely reduced the learning curve for surgeons. This article mainly discusses the learning curve of laparoscopic radical hysterectomy for cervical cancers, and how several factors are influencing it negatively, with the need to have medical authorities reset specific surgical training programs and allocate them to special oncological centers.

Increased Institutional Surgical Experience in Robot-Assisted Radical Hysterectomy for Early Stage Cervical Cancer Reduces Recurrence Rate: Results from a Nationwide Study

The aim of this study was to evaluate the impact of institutional surgical experience on recurrence following robotic radical hysterectomy (RRH) for early stage cervical cancer. All women in Sweden who underwent an RRH for stage IA2-IB1 cervical cancer at tertiary referral centers from its implementation in December 2005 until June 2017 were identified using a Swedish nationwide register and local hospital registers. Registry data were controlled by a chart review of all women. Recurrence rates and patterns of recurrence were compared between early and late (≤50 vs. >50 procedures) institutional series. Six hundred and thirty-five women were included. Regression analysis identified a lower risk of recurrence with increased experience but without a clear cut off level. Among the 489 women who did not receive adjuvant radio chemotherapy (RC-T), the rate of recurrence was 3.6% in the experienced cohort (>50 procedures) compared to 9.3% in the introductory cohort (p < 0.05). This was also seen in tumors < 2 cm regardless of RC-T (p < 0.05), whereas no difference in recurrence was seen when analyzing all women receiving RC-T. In conclusion, the rate of recurrence following RRH for early stage cervical cancer decreased with increased institutional surgical experience, in tumors < 2 cm and in women who did not receive adjuvant RC-T.

Radical Hysterectomy After Neoadjuvant Chemotherapy for Locally Bulky-Size Cervical Cancer: A Retrospective Comparative Analysis between the Robotic and Abdominal Approaches

Radical hysterectomy (RH) is the standard treatment for early stage cervical cancer, but the surgical approach for locally bulky-size cervical cancer (LBS-CC) is still unclear. We retrospectively compared the outcomes of women with LBS-CC treated with neoadjuvant chemotherapy (NACT) and subsequent RH between the robotic (R-RH) and abdominal approaches (A-RH). Between 2012 and 2014, 39 women with LBS-CC FIGO (International Federation of Gynecology and Obstetrics) stage IB2–IIB were treated with NACT-R-RH (n = 18) or NACT-A-RH (n = 21). Surgical parameters and prognosis were compared. Patient characteristics were not significantly different between the groups, but the NACT-R-RH group had significantly more patients with FIGO stage IIB disease, received multi-agent-based NACT, and had a lower percentage of deep stromal invasion than the NACT-A-RH group. After NACT-R-RH, surgical parameters were better, but survival outcomes, such as disease-free survival (DFS) and overall survival (OS), were significantly worse. On multivariate analysis, FIGO stage IIB contributed to worse DFS (p = 0.003) and worse OS (p = 0.012) in the NACT-A-RH group. Women with LBS-CC treated with NACT-R-RH have better perioperative outcomes but poorer survival outcomes compared with those treated with NACT-A-RH. Thus, patients with FIGO stage IIB LBS-CC disease might not be suitable for surgery after multi-agent-based NACT.

Role of robotic surgery in cervical malignancy

Surgical treatment is the mainstay of the management of early-stage cervical cancer. Abdominal radical hysterectomy and trachelectomy have long been the standard surgical approach to early-stage cervical cancer, achieving excellent survival outcomes. Recently, laparoscopic radical hysterectomy and trachelectomy have become the preferred alternative to abdominal surgery because laparoscopic approaches lead to better surgical outcomes without compromising survival outcomes. Since the robotic surgery platform was approved for the use of gynaecologic surgery in 2005, robotic radical hysterectomy and trachelectomy have been increasingly used in the surgical management of early-stage cervical cancer. However, the role of robotic surgery is poorly defined. This review examines the role of robotic surgery in the surgical management of cervical cancer by comparing the published data on its use with those of abdominal and laparoscopic surgeries.

Introduction of robot-assisted radical hysterectomy for early stage cervical cancer: impact on complications, costs and oncologic outcome

INTRODUCTION

The objective was to assess the impact of robot-assisted radical hysterectomy (RRH) on surgical and oncologic outcome and costs compared with open radical hysterectomy (ORH) at a tertiary referral center in Sweden.

MATERIAL AND METHODS

In this retrospective analysis all patients treated with radical hysterectomy and pelvic lymphadenectomy for early stage uterine cervical cancer during 2006-2015 were included (n = 304). The patients were divided into two groups, ORH (n = 155) and RRH (n = 149). Patient characteristics, FIGO stage, histology, adjuvant therapy, operation time, length of stay (LOS), lymph node yield, recurrence rate and survival were retrieved from medical records. Complications were graded according to the Clavien-Dindo classification. In addition, costs related to the surgical treatments were calculated.

RESULTS

Blood loss, LOS and intraoperative complications were significantly lower as well as lymph node yield after RRH. No differences in postoperative complications or costs were observed between the two groups. Recurrence of disease was detected in 13.4 and 10.3% after RRH and ORH, respectively. Regression analysis demonstrated that histology, tumor size, positive lymph nodes and type of operation (RRH) were significantly associated with recurrence.

CONCLUSION

The introduction of RRH was accompanied by similar postoperative complication rates and costs but lower LOS compared with ORH. An initial learning curve may account for the higher recurrence rate observed after RRH. These data reinforce the need for structured training and monitoring of outcomes when novel treatment modalities are introduced.

Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer

BACKGROUND AND OBJECTIVES

To compare intraoperative, pathologic and postoperative outcomes of robotic radical hysterectomy (RRH) to total laparoscopic radical hysterectomy (TLRH) in patients with early stage cervical carcinoma.

METHODS

We prospectively analyzed cases of TLRH or RRH with pelvic lymphadenectomy performed for treatment of early cervical cancer between 2000 and 2008.

RESULTS

Thirty patients underwent TLRH and pelvic lymphadenectomy for cervical cancer from August 2000 to June 2006. Thirteen patients underwent RRH and pelvic lymphadenectomy for cervical cancer from April 2006 to January 2008. There were no differences between groups for age, tumor histology, stage, lymphovascular space involvement or nodal status. No statistical differences were observed regarding operative time (323 vs 318 min), estimated blood loss (157 vs 200 mL), or hospital stay (2.7 vs 3.8 days). Mean pelvic lymph node count was similar in the two groups (25 vs 31). None of the robotic or laparoscopic procedures required conversion to laparotomy. The differences in major operative and postoperative complications between the two groups were not significant. All patients in both groups are alive and free of disease at the time of last follow up.

CONCLUSION

Based on our experience, robotic radical hysterectomy appears to be equivalent to total laparoscopic radical hysterectomy with respect to operative time, blood loss, hospital stay, and oncological outcome. We feel the intuitive nature of the robotic approach, magnification, dexterity, and flexibility combined with significant reduction in surgeon's fatigue offered by the robotic system will allow more surgeons to use a minimally invasive approach to radical hysterectomy.