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

Laparoscopic radical hysterectomy and pelvic lymph node dissection for early cervical cancer effectively improves surgical efficacy

OBJECTIVE

To evaluate the efficacy and safety of laparoscopic radical hysterectomy (LRH) combined with pelvic lymph node dissection (PLND) in patients with early-stage cervical cancer.

METHODS

This retrospective study analyzed 58 cases of early cervical cancer who underwent surgical treatment at Western Theater Command General Hospital between January 2019 and September 2020. Patients were divided into two groups based on surgical approach: the observation group (n=26) received LRH and PLND without uterine manipulator, while the control group (n=32) underwent LRH with uterine manipulator and PLND. Clinical data including operative time, intraoperative blood loss, time to first flatus, postoperative hospital stay, number of lymph nodes dissected, and postoperative pain (VAS score at 7 days) were compared between groups. Serum tumor markers (CA125, CA199, CEA, and SCC) were measured and analyzed. Postoperative complications and quality of life were assessed during a 6-month follow-up period. Patients were further categorized into good prognosis (n=40, no recurrence) and poor prognosis (n=18, recurrence) groups based on 1-year follow-up outcomes to identify independent prognostic factors.

RESULTS

The observation group demonstrated significantly better outcomes compared to the control group, including shorter operative time, reduced intraoperative blood loss, earlier return of bowel function, shorter hospital stay, lower postoperative pain scores, and decreased serum tumor marker levels (all P<0.05). The observation group also had a higher number of lymph nodes dissected (P<0.05). Furthermore, this group showed a significantly lower incidence of postoperative complications and better quality of life at 6 months postoperatively (P<0.05). Multivariate analysis identified the number of lymph nodes dissected and surgical approach as independent prognostic factors.

CONCLUSION

LRH without uterine manipulator combined with PLND demonstrates superior surgical outcomes, reduced complication rates, and improved recovery for patients with early-stage cervical cancer, representing a valuable advancement in clinical practice.

Oncologic Outcomes of Laparoscopic Radical Hysterectomy Incorporating Modified Tumor-Free Techniques

OBJECTIVE

It remains unclear whether modifying laparoscopic radical hysterectomy to adopt tumor-free principles can improve oncologic outcomes in patients with early-stage cervical cancer.

METHODS

We performed a single-center retrospective cohort study of 276 patients with early-stage cervical cancer who were treated between January 2017 and January 2023, including 151 patients who underwent laparoscopic radical hysterectomy that incorporated modified tumor-free techniques (MTF group) and 125 patients who underwent conventional laparoscopic radical hysterectomy with a uterine manipulator and unprotected intracorporeal colpotomy (non-MTF group). Oncologic outcomes and perioperative results were analyzed using inverse probability treatment weighting (IPTW).

RESULTS

Patients in the MTF group had shorter length of hospital stay than those in the non-MTF group. However, there were no significant differences in operative time, decrease in hemoglobin, or complications. After a median follow-up of 36.0 months (range 15.3-62.0 months) for the MTF group and 66.8 months (range 3.0-82.5 months) for the non-MTF group, recurrence was observed in two (1.3%) and 16 (12.8%) of the patients, respectively. The 2-year disease-free survival (DFS) rates in the MTF group and non-MTF group were 99.3% and 91.9%, respectively. In the primary analysis limited to 2-year survival, the adjusted multivariate analysis showed that use of modified tumor-free techniques was an independent predictor of longer DFS (hazard ratio 0.10 95% CI, 0.01-0.77, P =.027). After IPTW, patients in the MTF group had a more favorable DFS than those in the non-MTF group (log-rank P =.031).

CONCLUSION

Laparoscopic radical hysterectomy that incorporates modified tumor-free techniques is a feasible treatment for patients with early-stage cervical cancer. Oncologic outcomes of individuals who underwent this procedure were more favorable than those of conventional laparoscopic radical hysterectomy.

Effect of ligamentum teres uteri preservation in laparoscopic high hernia sac ligation in children with indirect inguinal hernia

BACKGROUND

Routinely separating the ligamentum teres uteri (LTU) intraoperatively remains an unresolved issue for female children undergoing surgery for indirect inguinal hernia (IIH).

AIM

To identify the effect of LTU preservation in laparoscopic high hernia sac ligation (LHSL) in children with IIH.

METHODS

The participants were 100 female children with unilateral IIH admitted from April 2022 to January 2024 to the Pediatric Surgery Department of Zhangzhou Municipal Hospital of Fujian Province. They were categorized based on LTU retention into the control group (n = 45 cases), which underwent LTU ligation intraoperatively, and the experimental group (55 cases), which had the LTU preserved intraoperatively. All children underwent LHSL.

RESULTS

This study comparatively analyzed the operation time, hospitalization time, blood loss, postoperative recurrence rate, and complications (repeated pain in the inguinal region, foreign body sensation in the inguinal region, bloody exudation at the inguinal incision, and incision infection), which were all comparable between the two groups.

CONCLUSION

The above results indicate that LTU preservation during LHSL exerts certain therapeutic benefits for children with IIH. LTU preservation does not increase hospitalization time, blood loss, postoperative recurrence rate, and complications, which is safe and feasible, compared with conventional LTU ligation. LHSL with LTU preservation should be performed if conditions permit, which is worth popularizing.

Comparison of survival outcomes between robotic and laparoscopic radical hysterectomies for early-stage cervical cancer: a systemic review and meta-analysis

OBJECTIVE

Survival outcomes of robotic radical hysterectomy (RRH) remain controversial. Therefore, we performed a meta-analysis to evaluate survival outcomes between RRH) and laparoscopic radical hysterectomy (LRH) in patients with early-stage cervical cancer.

METHODS

Studies comparing between RRH and LRH published up to November 2022 were systemically searched in the PubMed, Cochrane Library, Web of Science, ScienceDirect, and Google Scholar databases. Manual searches of related articles and relevant bibliographies of the published studies were also performed. Two researchers independently extracted data. Studies with information on recurrence and death after minimally invasive radical hysterectomy were also included. The extracted data were analyzed using the Stata MP software package version 17.0.

RESULTS

Twenty eligible clinical trials were included in the meta-analysis. When all studies were pooled, the odds ratios of RRH for recurrence and death were 1.19 (95% confidence interval [CI]=0.91-1.55; p=0.613; I²=0.0%) and 0.96 (95% CI=0.65-1.42; p=0.558; I²=0.0%), respectively. In a subgroup analysis, the quality of study methodology, study size, country where the study was conducted, and publication year were not associated with survival outcomes between RRH and LRH.

CONCLUSION

This meta-analysis demonstrates that the survival outcomes are comparable between RRH and LRH.

TRIAL REGISTRATION

International Prospective Register of Systematic Reviews Identifier: CRD42023387916.

Comparison of the efficacy and safety of total laparoscopic hysterectomy without and with uterine manipulator combined with pelvic lymphadenectomy for early cervical cancer

OBJECTIVE

Some studies have reported that the prognosis of total laparoscopic hysterectomy (TLH) for early-stage cervical cancer (CC) is worse than that of open surgery. And this was associated with the use of uterine manipulator or not. Therefore, this study retrospectively analyzes the efficacy and safety of TLH without uterine manipulator combined with pelvic lymphadenectomy for early-stage CC.

METHODS

Fifty-eight patients with CC (stage IB1-IIA1) who received radical hysterectomy from September 2019 to January 2020 were divided into no uterine manipulator (n = 26) and uterine manipulator group (n = 32). Then, clinical characteristics were collected and intraoperative/postoperative related indicators were compared.

RESULTS

Patients in the no uterine manipulator group had significantly higher operation time and blood loss than in the uterine manipulator group. Notably, there was no significant difference in hemoglobin change, blood transfusion rate, number of pelvic nodules, anal exhaust time, complications and recurrence rate between the two groups. Additionally, patients in the uterine manipulator group were prone to urinary retention (15.6%) and lymphocyst (12.5%), while the no uterine manipulator group exhibited high probability of bladder dysfunction (23.1%) and urinary retention (15.4%). Furthermore, the 1-year disease-free survival rate and the 1-year overall survival rate were not significantly different between the two groups.

CONCLUSION

There was no significant difference in the efficacy and safety of TLH with or without uterine manipulator combined with pelvic lymphadenectomy in the treatment of patients with early-stage CC. However, the latter requires consideration of the negative effects of high operation time and blood loss.

An optimized robotic surgical technique for cervical cancer: investigating whether the use of the pulling robotic arm has better surgical outcomes

Objective

The evidence for adopting the 3^rd robotic arm (RA) called the pulling RA rather than a uterine manipulator to manipulate the uterus in the robotic radical hysterectomy (RRH) for cervical cancer is still limited. We present a single-center retrospective experience comparing using the pulling RA to replace a uterine manipulator vs. using a uterine manipulator to manipulate the uterus in RRH.

Methods

106 patients diagnosed with IA, IB1-IB2 and IIA1 cervical cancer were retrospectively included for intraoperative and postoperative parameters analysis. 50 patients received RRH by adopting the pulling RA instead of a uterine manipulator to pull the uterus (3-RA RRH group), and another 56 patients were performed RRH with a uterine manipulator (2-RA RRH group). RRH with the pulling RA consisted of a camera arm, 3 RAs including a pulling RA, and 2 conventional assistant arms (3-RA RRH group). In comparison, RRH with a uterine manipulator included 2 RAs and 2 conventional assistant arms (2-RA RRH group). Besides, 3-RA' RRH group was selected from the 25^th-50^th cases in the 3-RA RRH group based on the learning curve and was compared with the 2-RA RRH group in terms of intraoperative and postoperative parameters.

Results

The patients' early post-operative complication (≤7 days) (p=0.022) and post-operative anemia (p < 0.001) of the 3-RA RRH were significantly lower than that in the 2-RA RRH group. The results of comparing the 2-RA RRH group with the 3-RA' RRH group were consistent with the aforementioned results, except for the operative time (220.4 vs. 197.4 minutes, p=0.022) and hospital stay (7.8 vs. 8.7 days, p=0.034). The median follow-up in the 3-RA RRH and 2-RA RRH groups was 29 and 50 months till March 2023. The 3-RA RRH and 2-RA RRH groups' recurrence rates were 2% (1/50) and 5.4% (3/56), respectively. The mortality in the 3-RA RRH and 2-RA RRH groups was 2% (1/50) and 3.5% (2/56), respectively.

Conclusion

Our study suggested that replacing the uterine manipulator via the 3^rd RA is viable; the results showed comparable surgical outcomes between the two methods. Thus, 3-RA RRH could be considered a well-executed surgical option in well-selected patients.

Urinary retention between nerve-sparing radical hysterectomy and radical hysterectomy for cervical cancer: A meta-analysis

This study intended to assess the urinary retention between nerve-sparing radical hysterectomy and radical hysterectomy in cervical cancer. Relevant studies were selected from databases of PubMed, Embase, Wanfang, and China National Knowledge Internet with the last report up to January 15, 2022. Hazard ratio (HR) and 95% confidence interval (CI) were chosen as the evaluation index. Heterogeneity was assessed using Cochran Q test and I2 test. Subgroup analysis was conducted based on areas and cancer types (primary and metastatic cancer). A total of 8 articles (retrospective cohort studies) were selected in the meta-analysis. There were significant correlations between nerve-sparing radical hysterectomy and radical hysterectomy in related with urinary retention (HR [95% CI] = 1.78 [1.37, 2.31], P < .001) and (HR [95% CI] = 2.49 [1.43, 4.33], P = .001) of cervical cancer patients. Egger test revealed a significant publication bias (P = .014). Sensitivity analysis via omitting 1 study at each time showed that omission of any study made significant difference (P < .05), indicating reliability and good stability for the analysis. Additionally, there were significant heterogeneities in most subgroups.

Does the Use of a Uterine Manipulator or Intracorporeal Colpotomy Confer an Inferior Prognosis in Minimally Invasive Surgery-Treated Early-stage Cervical Cancer?

STUDY OBJECTIVE

To identify whether the use of a uterine manipulator (UM) or intracorporeal colpotomy conferred inferior short-term survival among patients treated for early-stage cervical cancer.

DESIGN

Retrospective cohort study.

SETTING

Tertiary university-based hospital.

PATIENTS

1169 patients with stage IB1 to IB2 cervical cancer.

INTERVENTIONS

All patients underwent minimally invasive radical hysterectomy and pelvic lymphadenectomy.

MEASUREMENTS AND MAIN RESULTS

A total of 1169 patients diagnosed with preoperative stage IB1 to IB2 cervical cancer were primarily treated with surgery from 2018 to 2019. The eligible patients had a median age of 48 years (range, 23-76 years), and the median follow-up time was 34 months (range, 3.57-50.87 months). The 2-year overall survival rate of the patients with pathologic stage IB1 and IB2 was 99.8% and 98.8%, respectively, according to the 2018 International Federation of Gynecology and Obstetrics staging system. Univariable analysis revealed that the UM group had a 7.6-times higher risk of death than that of the manipulator-free group (p = .006), but multivariable analysis clarified that only tumor size (p = .016; hazard ratio, 2.285; 95% confidence interval, 1.166-4.479) and parametrial involvement (p = .003; hazard ratio, 3.556; 95% confidence interval, 1.549-8.166) were independent risk factors for overall survival. There was no statistically significant difference in survival between patients who underwent intracorporeal and protective colpotomy.

CONCLUSION

Short-term survival outcomes in women undergoing minimally invasive radical hysterectomy for treatment of early-stage cervical cancer did not differ when a UM was avoided or when a protective colpotomy was performed.

C-X-C Chemokine Receptor Type 4 (CXCR-4) Functionally-Selective Allosteric Agonist ATI2341 Promotes the Recovery of Uterosacral Ligament

This study intends to assess whether CXCR4 functionally-selective allosteric agonist ATI2341 recovers uterosacral ligament. The 50 female rats were assigned into five groups including A group (normal healthy rats), B group (rats with uterine ligament injury), C group (injury rats treated with UC-MSCs cells), D group (treated with ATI2341); E group (treated with UC-MSCs cells and ATI2341) followed by analysis of uterus pathological changes by H&E staining and the expression of CD44, CD90, CXCR4, and SDF-1 by Western Blot or PT-PCR. There was regular and pyknotic fibrillar connective tissue and few small vessels in A group without infiltration of inflammatory cells. However, B group showed infiltration of inflammatory cells with few fibroblasts of fibrous tissue. The quantity of infiltration of inflammatory cells in C group and D group was less than that in B group with few visible new-born vessels. The improvement of pathological condition in uterus tissue in E group was the most among treatment groups. The number of wavy fiber was increased gradually and fibrillar connective tissue was changed into dense with elevated new-born vessels in ligament. The expression CD44, CD90, CXCR4 and SDF-1 was upregulated effectively by ATI2341. In conclusion, ATI2341 can upregulate the expression of CD44, CD90, CXCR4 and SDF-1 and promote the recovery of uterine ligament in rats, indicating that it might be a new approach for the treatment of uterine ligament.

Construction of Nursing Practice Model in Case Management of Concurrent Chemotherapy and Radiochemotherapy Treatment in Cervical Cancer

Objective

To construct a case management model of synchronous radiotherapy and concurrent chemotherapy and radiochemotherapy (CRR) for cervical cancer led by nurses and carry out preliminary implementation and evaluation, so as to explore a new model of nursing practice.

Methods

Totally 80 cervical cancer patients were included in this study, 43 patients were in the experimental group, and 37 patients were in the control group. The clinical data, side effects, psychological reactions, and nutritional indexes were collected before and after the intervention.

Results

The results of Hospital Anxiety and Depression Scale (HADs) showed that anxiety and depression scores decreased after intervention in the experimental group, and the difference between two groups had significant after intervention (P < 0.05). Serum fatty acids, albumin, and cholesterol in the experimental group were decreased after the intervention. Moreover, the incidence of radiation vaginitis and radiation dermatitis had significant differences between the two groups (P < 0.05).

Conclusion

The case management nursing practice mode of concurrent radiotherapy and chemotherapy for cervical cancer can effectively promote the self-management of risk factors, reduce the occurrence of complications, and improve the ability of self-care.

A Research Study to Measure the Efficacy of Terminating Cervical Cancer via Customized Optimum Pathway

Background

To develop a precise prognostic model of overall survival in patients with terminating cervical cancer based on surveillance, epidemiology, and end results (SEER) program.

Methods

The patients were retrieved from SEER data who are diagnosed with terminating cervical cancer from 2004 to 2016. The data were performed using univariate and multivariate analyses and constructed nomograms for predicting survival. Use C-index to validate the model accuracy.

Results

Totally 15839 patients diagnosed with cervical cancer were independently allocated into the training set (n = 11088) and validation set (n = 4751). The multivariate analysis results indicated that age, race, stage_T, stage_M, and stage_N were confirmed as independent risk predictors, and those factors are applied to construct this clinical model. The C-index of overall survival in the training set was 0.6816 (95% confidence intervene (CI), 0.694-0.763) and that in the validation set was 0.6931(95% CI, 0.613-0.779). All calibration curves of various factors were consistent with predicted and actual survival.

Conclusion

The nomogram provides a novel method for predicting the survival of patients with terminating cervical cancer, assisting in accurate therapeutic methods for patients with primary terminating cervical cancer.