2 Expert lectures
Dr. Samar Nahas, Chair of the Department of OB&GYN/Division Director of Gynecologic Oncology and Minimally Invasive Surgery at the University of California Riverside, was invited to present the “Current status and future prospect of minimally invasive surgery for cervical cancer in the United State-in the light of LACC trial”.
Dr. Nahas first reviewed the history of abdominal radical hysterectomy, radical trachelectomy, and vaginal radical hysterectomy. A meta-analysis confirmed no oncologic safety differences between vaginal radical trachelectomy and vaginal radical hysterectomy. Given that studies have found that the rate of parametrial invasion in patients with tumors less than 2 cm occurs in less than 1% of patients, simple trachelectomy has been shown to promote comparable survival rates to radical trachelectomy in many studies.3,4 When laparoscopic radical hysterectomy was developed, researchers began to compare three techniques of radical hysterectomy (abdominal, laparoscopic, and robotic) and found that minimally invasive surgery may be a more effective and safer option for the surgical treatment of early-stage cervical cancer. Then, Dr. Nahas reviewed the results of the LACC trial which caused a significant debate amongst the crowd and provoked a significant switch to favor open surgery in the academic world. Even though the results were inconsistent with surgeons' own experiences and literature, it was hard to defend personal experience in the face of the randomized trial, particularly in the face of conflicts concerning medical insurance and lawsuit. The debates on the LACC trial were mainly focused on the quality of the study such as the surgeon's qualification and the quality control of surgery. The current consensus amongst the audience concerning the LACC trial was that the issue cannot be definitively settled until another prospective randomized trial that includes single pathologist review, preoperative MRI, parametrical measurements, and quality indicators of radical hysterectomy is performed on a sufficient number of patients. Additionally, well-trained, certified gynecologic oncologists will have to be selected to conduct such a trial. Furthermore, if MIS is performed, in-depth counseling and consultation with the patients before the surgery is necessary.
Dr. Zhiqing Liang of Southwest Hospital of Army Medical University (AMU) presented the Chinese colleagues' opinion of MIS for cervical cancer based on data analysis of Chinese multi-center and technology improvement. His team's study showed promising results in OS rates in local advanced-stage patients when using laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer.5,6 He believes that the key point of laparoscopic surgery, in such a case, is the transection of the vagina with a cold knife and the removal of the specimen through the vagina. These results have been supported by studies in other countries. In 2015, a systematic review7 found that though laparoscopic surgeries required a longer time to perform, there is less blood loss and a more rapid recovery. In 2020, Chinese experts retrospectively compared the long-term oncological outcomes between laparoscopic and abdominal surgery in stage IA1 (lymph-vascular space invasion-positive, LVSI positive) to IB1 cervical cancer patients with different tumor sizes in 4891 patients from 2009 to 2016.8 They found that the modified laparoscopic-vaginal radical hysterectomy demonstrates a significantly better OS rate at 5 years (96.1%) compared to 92% for the total laparoscopic surgery. Furthermore, the disease-free survival (DFS) rate at 5 years of stage IB1 was 98.6% in the modified laparoscopic-vaginal radical hysterectomy group, which is significantly higher than that of the laparoscopic radical hysterectomy. Dr. Liang then pointed out that the DFS and OS differences found in LACC trials are secondary endpoints and should be considered tentative. An additional randomized trial should be required to determine the efficacy of minimally invasive radical hysterectomy in cervical cancer patients. Lastly, he pointed out the principle of tumor-free surgery should be adapted up to the end of the operation. He suggested some technological improvements focusing on tumor-free surgery as follows.
1. The operation procedure in LACC was to transect the vagina completely during the laparoscopy, which will inevitably lead to tumor cell spreading and also spilling into the pelvic cavity, which might be the primary reason for pelvic recurrence. It is suggested that lymphadenectomy and para-uterine tissue dissection should be completed by laparoscopy and that the hysterectomy and vaginal opening should be performed transvaginally to avoid tumor cell spread.
2. Using a uterine manipulator will damage the epithelial cell layer of the vagina and make it easier for the detached tumor cells to implant in the vaginal mucosa. Also, tumor cells may be stimulated by the force applied on the manipulator and thus be squeezed into the interstitial vessels of the cervix, causing the tumor to spread. Vaginal closure or vaginal cerclage may be an improved technique.
3. The enlarged lymph nodes should be removed completely to assure the integrity of the tumoral tissue.
4. If necessary, one should be advised to wash the abdominal cavity and trocar sites with chemotherapy drugs and to clean the vagina with distilled water or cisplatin after suturing the vagina.
Dr. Sichen Liang from Peking University People's Hospital showed data derived from their retrospective study9 comparing laparoscopy and open surgery in 237 patients with locally advanced cervical cancer from 2009 to 2018. With similar baseline and clinical-pathological features in the two different surgical approaches, there were no significant differences in the complications which commonly consisted of urinary retention, urinary system injury, hydronephrosis, intestinal injury, intestinal obstruction, hernia, lymphocyst, lymphedema of lower limbs, thrombotic diseases, and infections. The 5-year OS rates of the laparoscopy group and the laparotomy group were 86.8% and 87.8%, respectively, and the 5-year tumor-free survival rates were 81.7% and 84.6%, respectively, with no significant differences. During the follow-up period, the recurrence rate in the laparoscopy and the laparotomy group were 15.7% and 12.3%, without significant differences. Dr. Liang's team concluded that the prognosis between laparoscopic surgery and open surgery in locally advanced cervical cancer patients with stage IB2 to IIA2 did not appear to be significantly different.
Dr. Sha Wang from Peking University People's Hospital presented another study10 on comparing pelvic floor dysfunction and quality of life (QoL) between laparoscopic and abdominal radical hysterectomy in cervical cancer patients at Peking University People's Hospital. 150 patients who underwent radical hysterectomy with either laparoscopic hysterectomy (LRH) or abdominal approach (ARH) were included. The validated versions of the pelvic floor distress inventory-short form 20 (PFDI-20), the overactive bladder symptom score (OABss), and the Euro quality of life five dimensions questionnaire (EQ-5D) system were used in detailed evaluation of postoperative lower urinary tract symptom (LUTS), anal distress, and QoL. The results showed that there were significant differences in the total score of PFDI-20 and OABss between the LRH group and the ARH group (P < 0.05). Patients who underwent LRH suffered from more severe symptoms of LUTS and anal distress. There were no significant differences in the EQ-5D scores between the two groups (P < 0.05). Multiple analyses confirmed that LRH was a risk factor for LUTS and OAB after controlling for other factors. LRH was also a risk factor for anal distress based on colorectal-anal distress inventory (CRADI) scores. They concluded that compared to abdominal surgery, the laparoscopic approach seems to increase postoperative distress concerning the lower urinary tract and defecation. Therefore, the overall conclusion is that laparoscopic surgery should be carefully selected in clinical practice.
