Urological Complications in Radical Surgery for Cervical Cancer: A Comparative Meta-Analysis before and after LACC Trial

BACKGROUND

After the LACC trial publication in 2018, the minimally invasive approach (MIS) has severely decreased in favor of open surgery: MIS radical hysterectomy was associated with worse oncological outcomes than open surgery, but urological complications were never extensively explored in pre- versus post-LACC eras, even if they had a great impact on post-operative QoL. The purpose of this meta-analysis is to compare functional and organic urological complication rates before and after LACC trial.

METHODS

An independent search of the literature was conducted 4 years before and after the LACC trial and 50 studies were included.

RESULTS

The overall rate of urologic complications was higher in pre-LACC studies while no differences were found for organic urological complications. Conversely, the overall risk of dysfunctional urological complications showed a higher rate in the pre-LACC era. This is probably related to a sudden shift to open surgery, with potential lower thermal damage to the urinary tract autonomic nervous fibers.

CONCLUSIONS

This meta-analysis showed that the incidence of urological complications in radical cervical cancer surgery was higher before the LACC trial, potentially due to the shift to open surgery. Nevertheless, further studies are needed to shed light on the connection between minimally invasive surgery and urological damage.

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.

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

OBJECTIVE

The aim of the study was to perform a systematic assessment of disease-free survival (DFS), overall survival, and morbidity rates after open radical hysterectomy (ORH) and minimally invasive surgery (MIS) for early-stage cervical cancer and discuss with experts the consequences of the LACC trial (published by Ramirez et al. in 2018) on clinical routine.

METHODS

A total of 5428 records were retrieved. After exclusion based on text screening, four records were identified for inclusion. Five experts from three independent large-volume medical centers in Europe were interviewed for their interpretation of the LACC trial.

RESULTS

The LACC trial showed a significantly higher risk of disease progression with MIS compared to ORH (HR 3.74, 95% CI 1.63 to 8.58). This was not seen in one epidemiological study and was contradicted by one prospective cohort study reported by Greggi et al. A systematic review by Zhang et al. mentioned a similar DFS for robot-assisted radical hysterectomy (RRH) and LRH. Recurrence rates were significantly higher with MIS compared to ORH in the LACC trial (HR 4.26, 95% CI 1.44 to 12.60). In contrast, four studies presented by Greggi reported no significant difference in recurrence rates between LRH/RRH and ORH, which concurred with the systematic reviews of Zhang and Zhao. The experts mentioned various limitations of the LACC trial and stated that clinicians were obliged to provide patients with detailed information and ensure a shared decision-making process.

CONCLUSIONS

The surgical treatment of early-stage cervical cancer remains a debated issue. More randomized controlled trials (RCT) will be needed to establish the most suitable treatment for this condition.

Decreasing utilization of minimally invasive hysterectomy for cervical cancer in the United States

OBJECTIVE

To examine the influence of the first level I evidence (Laparoscopic Approach to Cervical Cancer [LACC] trial) on minimally invasive hysterectomy use and perioperative complications for cervical cancer surgery.

METHODS

This was population-based retrospective observational study, querying National Inpatient Sample. Women with cervical cancer who underwent hysterectomy and lymphadenectomy from 10/2015-12/2018 were examined. A quasi-experimental analysis with interrupted-time series was performed to assess the influence of the LACC trial report on minimally invasive hysterectomy use and perioperative complication rates.

RESULTS

5120 women in the pre-LACC period and 1645 women in the post-LACC period were compared. Following the LACC trial report on 3/2018, the minimally invasive hysterectomy use dropped by 19.7 percent points in one month (55.2% in 3/2018 to 35.5% in 4/2018), followed by a continued decline of 8.0% (95% confidence interval 0.1-15.3) monthly. By 12/2018, minimally invasive hysterectomy was used in 17.9% of cases, which was 38.8 percent points lower than the expected rate per the pre-LACC period projection. In multivariable analysis, women in the post-LACC period were 63% less likely to undergo minimally invasive hysterectomy (adjusted-odds ratio 0.37, 95% confidence interval 0.33-0.42) but 23% more likely to have a perioperative complication (38.6% versus 29.1%, adjusted-odds ratio 1.23, 95% confidence interval 1.08-1.40) compared to those in the pre-LACC period. Women in the post-LACC group were more likely to have a longer hospital stay compared to those in the pre-LACC group (median, 3 versus 2 days, P < 0.001).

CONCLUSION

Following the LACC trial results, U.S. surgeons rapidly shifted from minimally invasive to open hysterectomy for cervical cancer. Decreasing utilization of minimally invasive surgery was associated with an increase in perioperative complications and longer hospital admissions.

Survival rates of patients who undergo minimally invasive surgery for endometrial cancer with cervical involvement

Objective: Compare the oncologic outcomes of patients with intermediate-risk endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 206 patients with intermediate-risk endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 206 patients included in this study, 76 underwent open surgery (36.9%) and 130 underwent MIS (63.1%). In patients with stage IB endometrial cancer, the recurrence rate, disease-free survival, and overall survival were not significantly different between those who underwent minimally invasive surgery and those who underwent open surgery. However, in patients with stage II endometrial cancer, the recurrence rate was significantly higher among those who underwent minimally invasive surgery (37.5% vs. 5.3%, p = 0.013). Patients with stage II endometrial cancer who underwent minimally invasive surgery had a significantly lower disease-free survival (p = 0.012) than those who underwent open surgery, however, the overall survival (p = 0.252) was similar between the two groups. Conclusion: Minimally invasive surgery results in less favorable survival outcomes than open surgery in patients with stage II endometrial cancer.

Comparison of abdominal and minimally invasive radical hysterectomy in patients with early stage cervical cancer

PURPOSE

The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer.

METHODS

A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach.

RESULTS

In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252).

CONCLUSION

In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Minimally invasive surgery for early-stage cervical cancer: Rediscovering the Schautheim robot-assisted procedure

INTRODUCTION

The Laparoscopic Approach to Cervical Cancer (LACC) trial recently showed a significant inferiority of the minimally invasive surgery when we considered them both equivalent in the treatment of cervical cancer. The objective of this article is to describe and discuss the interest of the Schautheim procedure.

SURGICAL TECHNIQUE

The Schautheim is the association of a radical hysterectomy by laparoscopy/robot assisted or not as described by Wertheim after a primary vaginal closure, like the first step of Schauta's hysterectomy. This technique is described in ten steps, with a video material.

DISCUSSION

The return to open surgery could lead to a loss of benefits associated with the laparoscopic approach in terms of per and post-operative morbidity. One way to achieve similar results would be to prohibit the use of uterine manipulators and create a vaginal cuff.

CONCLUSION

Several authors suggest that early-stage cervical cancer patients could still be operated by laparoscopy without reducing overall survival or increasing risk of recurrence if certain measures are followed.

Long-term oncological outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer: A retrospective, single-institutional study in the wake of the LACC trial

AIM

The objective of this study was to investigate the long-term oncological outcomes of minimally invasive radical hysterectomy (MIRH) for the treatment of early-stage cervical cancer retrospectively in the wake of the laparoscopic approach to cervical cancer (LACC) trial.

METHODS

A total of 109 patients with stage IA1 with lymphovascular space involvement, IA2, and IB1 cervical cancers were included in this study. The surgical and oncological outcomes were retrospectively evaluated. All patients underwent type C MIRH with a no-touch isolation technique for cervical tumor.

RESULTS

The median number of resected pelvic lymph nodes was 36 (range, 14-94), and 10 patients (9.2%) had positive nodes. One patient (0.9%) had positive surgical margins. Forty-six patients (42%) underwent adjuvant therapy. The median follow-up time was 73 months (range, 30-146 months). Five patients (4.6%) developed recurrent disease, and 3 patients (2.8%) died of cervical cancer. The 5-year disease-free survival and overall survival rates were 96.3% and 97.2%, respectively. A comparison between patients with tumor diameter ≤ 2 cm (n = 59) and those with tumor diameter > 2 cm (n = 50) did not identify any significant differences, with 5-year disease-free survival 96.6% versus 94.0% and 5-year overall survival 98.3% versus 96.0%, respectively.

CONCLUSION

In this retrospective study, MIRH with a no-touch isolation technique for stage IA to IB1 cervical cancer was a safe approach in terms of oncological outcomes. However, every surgeon who treats early-stage cervical cancer should inform each patient of the results of the LACC trial because it has an exceedingly high impact.