Can laparoscopic radical hysterectomy be a standard surgical modality in stage IA2–IIA cervical cancer?

doi:10.1016/j.ygyno.2012.06.003

Gynecologic Oncology

Volume 127, Issue 1, October 2012, Pages 102-106

https://doi.org/10.1016/j.ygyno.2012.06.003 Get rights and content

Abstract

Objectives

To determine if laparoscopic radical hysterectomy (LRH) can be substituted for radical abdominal hysterectomy for women with International Federation of Gynecology and Obstetrics (FIGO) stage IA2–IIA cervical cancer.

Methods

We retrospectively reviewed the medical records of cervical cancer patients who underwent LRH with laparoscopic pelvic lymphadenectomy (LPL) and/or laparoscopic para-aortic lymphadenectomy (LPAL) from March 2003 to December 2011.

Results

Of 118 enrolled patients, six were in FIGO stage IA2, 66 were in IB1, 41 were in IB2, one was in IIA1, and four were in IIA2. The median operating time, perioperative hemoglobin change, the number of harvested pelvic and para-aortic lymph nodes were 270 min (range, 120–495), 1.7 g/dL (range, 0.1–5), 26 (range, 9–55), and 7 (range, 1–39), respectively. There was no unplanned conversion to laparotomy. Intra- and postoperative complications occurred in 16 (13.5%) and 8 (6.7%) patients, respectively. In a median follow-up of 31 months (range, 1–89), 5-year recurrence-free and overall survival rates were 90% and 89%, respectively. Univariate analysis showed that cervical stromal invasion (P = 0.023) and lymph node metastasis (P = 0.018) affected survival rate. Cox-proportional hazards regression analysis showed that lymph node metastasis was the only independent factor for poor prognosis (hazard ratio = 7.0, P = 0.022).

Conclusions

LRH with LPL and/or LPAL in women with stage IA2–IIA cervical cancer is safe and feasible in terms of survival and morbidity. Our data suggest the need for larger prospective trials which could support this approach as a new standard of care for stage IA2–IIA cervical cancer.

Highlights

► LRH with LPL and/or LPAL for stage IA2–IIA cervical cancer is safe and feasible, including tumors > 4 cm in size. ► LPAL can be performed when indicated without increasing morbidity. ► LRH can be a standard treatment, sharing same surgical indication for radical abdominal hysterectomy.

Introduction

Laparoscopic radical hysterectomy with lymphadenectomy for the treatment of early stage cervical cancer was initially introduced by Nezhat et al. and Querleu et al. in the early 1990s [1], [2]. Since then, several groups have reported the feasibility and the safety of this procedure [3], [4]. Laparoscopic radical hysterectomy resulted in lower morbidity rates, including less postoperative pain, less blood loss, and shorter hospital stays with oncological outcomes comparable to open procedures, as noted by many studies [5], [6], [7]. Although these optimistic results have not been evaluated by randomized trials, laparoscopic radical hysterectomy is progressively recognized as a new standard treatment strategy for early stage cervical cancer. Although primary surgical treatment is one of several therapeutic options for cervical cancer with a tumor size > 4 cm, the majority of previous studies on laparoscopic radical hysterectomy in early stage cervical cancer showed surgical and survival data for patients with tumor size < 2 cm or < 4 cm [5], [6], [7], [8], [9]. Consequently, the safety and feasibility of laparoscopic radical hysterectomy for International Federation of Gynecology and Obstetrics (FIGO) stage IA2–IIA cancers, including IB2 and IIA2 cancers, and laparoscopic para-aortic lymphadenectomy (LPAL) have rarely been highlighted. This might be why laparoscopic radical hysterectomy is not substituted for radical abdominal hysterectomy for patients with stage IA2–IIA cervical cancers. The aim of this study was to determine if laparoscopic radical hysterectomy (LRH) can substitute for conventional radical abdominal hysterectomy — that is, if LRH can be applied to all operable cervical cancer patients. Hence, we evaluated the operative feasibility and the surgical/oncological outcomes of LRH with laparoscopic pelvic lymphadenectomy (LPL) and/or LPAL in patients with stage IA2–IIA cervical cancers in a single institution.

Section snippets

Materials and methods

We collected data on 130 consecutive patients who underwent laparoscopic surgery for cervical cancer at Kangbuk Samsung Hospital from March 2003 to December 2011. Initial staging was defined according to FIGO criteria and evaluated by clinical pelvic examination and magnetic resonance imaging scan. We excluded 12 patients from the study: two with FIGO stage IB1 who underwent laparoscopic radical trachelectomy with LPL for future pregnancy, one with FIGO stage IA1 with LVSI who underwent

Patient characteristics

Clinical and histopathological characteristics of the patients are summarized in Table 1. On pathological examination, 46 (39.0%) patients had tumors > 4 cm and 18 (15.3%) had tumors > 6 cm in longest diameters. A majority of patients had squamous cell carcinoma. Lymph node metastases were noted in 28 (23.8%) patients. Pelvic lymph node metastases were noted in 19 (16.1%), para-aortic lymph node metastasis in 1 (0.8%), and both in 8 (6.4%) patients.

Surgical data

Table 2 presents surgery-related measurements.

Discussion

Laparoscopic radical hysterectomy has been increasingly performed over the last two decades, and has now been established as the standard surgical modality for treating early cervical cancer at some specialized centers [5], [7], [14], [20]. The shift in surgical paradigm from open to minimally invasive procedures for cervical cancer is based on evidence revealing comparable surgical and oncological outcomes between the two modalities [8], [9], [22], [23].

In this study, we also found favorable

Conflict of interest statement

The authors declare no conflicts of interest regarding this study.

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The use of a vaginal uterine manipulator may compromise the oncological outcomes of patients with cervical cancer undergoing minimally invasive radical hysterectomy (MIS-RH). We aimed to describe the safety and efficacy of a novel uterine manipulation device during MIS-RH.
Retrospective study.
A university hospital and a tertiary care hospital.
Patients with early-stage cervical cancer who were treated with MIS-RH.
We developed the U-traction, a new device that consists of a 65-mm half-curved cutting needle with a 2.5-mm polyester tape (45-cm long), and investigated its utility to manipulate the uterus during MIS-RH.
This study describes the utility and safety of the U-traction for uterine manipulation during laparoscopic or robotic RH in 8 patients with cervical cancer. Uterine manipulation was successfully and safely performed using the U-traction during laparoscopic or robotic RH in patients with cervical cancer without any complications. The application time was less than 5 minutes. In all cases, the use of a vaginal manipulator, an additional incision for an extra port, or the need for assistant surgeons for uterine manipulation was avoided.
The novel U-traction device allows for easy and reproducible uterine manipulation during MIS-RH. With this device, the use of a vaginal uterine manipulator can be avoided, and MIS-RH can be safely performed without the need for an assistant surgeon for uterine manipulation.
Robotic Total Mesometrial Resection versus Laparoscopic Total Mesometrial Resection in Early Cervical Cancer: A Case-Control Study
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Citation Excerpt :
Both patients (nos. 21 and 33 in Table 4) relapsed locoregionally and were submitted to a robotic pelvic exenteration. The role of minimally invasive surgery in the management of gynecologic cancers is well established and continues to evolve [19–26], also in the field of compartmental surgery of cervical cancer [16,17]. To the best of our knowledge this is the first case-control study comparing surgical outcomes and complication rates of R-TMMR and L-TMMR in patients with early-stage cervical cancer.
To report our experience with robotic total mesometrial resection (R-TMMR) comparing perioperative results with a series of laparoscopic total mesometrial resections (L-TMMRs).
Multicenter retrospective case-control study (Canadian Task Force classification II-2).
Catholic University of the Sacred Heart of Rome (Italy) and Campobasso (Italy).
From July 2013 to August 2015 all cervical cancer patients with preoperative FIGO stage IA2 to IB1 were assessed at preoperative magnetic resonance imaging scan and clinically confirmed by investigation under anesthesia, complying strictly with the FIGO criteria. Surgical and postsurgical data of the TMMR procedures were collected.
R-TMMR and L-TMMR for early cervical cancer were performed.
Twenty-one women underwent R-TMMR (cases) and 42 patients were submitted to L-TMMR (control subjects) for early cervical cancer. The median estimated blood loss was 150 mL in the cases and 200 mL in the control subjects (p = .992). The median operative time, calculated from the beginning of intraperitoneal procedures to skin closure, was 246 minutes in the cases and 260 minutes in the control subjects (p = .913). The median time to discharge from the hospital was postoperative days 4 (range, 2–5) and 6 (range, 4–15) for R-TMMR and L-TMMR, respectively (p = .001).
The few differences we registered do not seem to be clinically relevant, thus making the 2 procedures comparable. Further prospective trials are needed to confirm our results.
Survival rate comparisons amongst cervical cancer patients treated with an open, robotic-assisted or laparoscopic radical hysterectomy: A five year experience
2016, Surgical Oncology
Citation Excerpt :
We further recognize that the overall study population was very limited in size and the individual groups were disproportionate. Also, one could argue that a radical hysterectomy is not standard treatment for stage IIB cervical cancer patients [27] and theoretically, these subjects should have been precluded from the analysis. Since the study design incorporated a retrospective evaluation, the impact of selection bias on patient outcomes is of significant concern.
The purpose of this retrospective study was to assess the 5-year survival outcomes of cervical cancer patients who underwent an, open radical hysterectomy (ORH), robotic-assisted radical hysterectomy (RRH) or laparoscopic radical hysterectomy (LRH) for the treatment of their disease.
We conducted a review of all cervical cancer patients who were managed with an ORH, RRH or LRH.
Forty-nine patients were treated with LRH, 58 were managed via RRH and 39 patients underwent an ORH. The LRH (1.78 h) patients had a significantly shorter operative duration than the RRH (2.88 h) and ORH (2.39 h) subjects (p < 0.001). Blood loss was the highest in the ORH (475 cc) group (RRH = 207 cc and LRH = 312 cc) (P < 0.001). Moreover, the ORH (5.04 days) patients had a significantly longer hospital stay than the LRH (2.95 days) and RRH (2.50 day) subjects (P < 0.001). Kaplan–Meier survival analysis revealed a progression free survival (PFS) rate of 84.6% for the ORH group, 89.8% for the LRH group and 89.7% for the RRH patients (P = 0.271) at 60 months; overall survival was 92.3% for the ORH group, 95.9% for the LRH group and 96.6% for the RRH patients (P = 0.80).
The results from this study suggest that, irrespective of operative approach, patients who underwent a radical hysterectomy for early stage cervical cancer attained similar 5-year disease free and overall survival outcomes.
Laparoscopic Radical Hysterectomy and Pelvic Lymphadenectomy Can Be Routinely Used for Treatment of Early-stage Cervical Cancer: A Single-institute Experience With 404 Patients
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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.
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).
University teaching hospital.
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.
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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.
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Can laparoscopic radical hysterectomy be a standard surgical modality in stage IA2–IIA cervical cancer?

Abstract

Objectives

Methods

Results

Conclusions

Highlights

Introduction

Section snippets

Materials and methods

Patient characteristics

Surgical data

Discussion

Conflict of interest statement

Am J Obstet Gynecol

Baillieres Clin Obstet Gynaecol

Am J Obstet Gynecol

Gynecol Oncol

J Minim Invasive Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Lancet Oncol

J Minim Invasive Gynecol

Gynecol Oncol

J Minim Invasive Gynecol

J Minim Invasive Gynecol

J Minim Invasive Gynecol

Eur J Surg Oncol