Laparoscopic-vaginal radical hysterectomy in surgical treatment of cervical cancer

Radical vaginal hysterectomy has been performed in surgical treatment of cervical cancer for over one hundred years. After the term of decrease of popularity of this operation, nowadays we can observe gradual come back to the idea of radical vaginal hysterectomy. Possibility of association of advanced laparoscopic techniques/lymphadenectomy/with vaginal operation have changed the approach to the surgical treatment of cervical cancer. The aim of the study is to present the method of laparoscopic-vaginal radical hysterectomy based on Schauta-Amreich technique. The 51 year old women was admitted to the hospital and cervical cancer FIGO stage IIA was diagnosed according to clinical and histopathological examination. We performed laparoscopic-vaginal radical hysterectomy in general anaesthesia. First after cutting of ligamentum teres uteri and infundibulo-pelvicum, laparoscopic pelvic lymphadenectomy was done. Subsequently vaginal stage of operation was performed. Then we did laparoscopy and controlled operation field again. Combining Schauta operation with laparoscopy allows us to estimate lymph nodes as well as make vaginal phase of operation easier because of mobilization of uterus. We consider that laparoscopic-vaginal radical hysterectomy could be a valuable element in broadening the spectrum of many kinds of operations used in treatment of cervical cancer.     

Modified radical hysterectomy for early Ib cervical cancer.

A total of 39 patients with selected early Ib cervical cancer were treated with modified radical hysterectomy (MRH) and compared with 102 patients with nonbulky Ib cervical cancer treated with radical hysterectomy (RH). Postoperative voiding difficulty (15.4 vs 46%) and constipation (43.6 vs 74.5%) were significantly less after MRH than after RH. All patients with MRH were followed uneventfully and the 3-year survival rate is 100%. No recurrence or persistence of disease was noted. It is suggested that patients with exophytic squamous cell carcinoma of the cervix less than 2 cm in diameter and invading less than 10 mm, as diagnosed by conization, may be effectively treated with MRH, resulting in less morbidity.     

Early stage cervical cancer: aborted versus completed radical hysterectomy.

In a retrospective study, the treatment results of patients with stage IB and IIA cervical cancer were evaluated. In 26 patients radical hysterectomy was discontinued after intra-operative finding of positive lymph nodes. These patients received radiotherapy. In 57 patients lymph nodes were negative, and radical hysterectomy was completed. Of these, 13 patients received adjuvant radiotherapy because of positive surgical margins or parametrial involvement, and 44 patients received no adjuvant therapy. Five-year survival was 61% in patients with positive pelvic lymph nodes and 88% in patients with negative pelvic lymph nodes, comparable with the results mentioned in the literature. The complication rate did not differ from similar other reports. This management shows treatment results comparable with other reports with minimal morbidity.     

A comparison of laparascopic-assisted radical vaginal hysterectomy and radical abdominal hysterectomy in the treatment of cervical cancer

OBJECTIVES: The aim of this study was to compare peri-operative morbidity and recurrence-free survival of early-stage cervical cancer patients treated by laparoscopic-assisted radical vaginal hysterectomy (LARVH) with time-matched radical abdominal hysterectomy (RAH) controls at our center. METHODS: Since July 1984, all patients with FIGO stage IA/IB cervical cancer undergoing radical surgery by members of our division have been entered into a prospective database. Since November 1996, one surgeon at our center has performed LARVH on all surgically appropriate patients. Non-parametric tests were used. Differences between medians were compared using Wilcoxon Rank Sum test. Statistical analysis used the Kaplan-Meier method to calculate disease-free survival. Differences between survival curves were compared with the log rank test. Statistical significance was defined as P < 0.05. RESULTS: Between November 1996 and December 2003, 71 and 205 patients have undergone LARVH and RAH, respectively, for FIGO stage IA/IB carcinoma of the cervix. Both groups were similar with respect to age and Quetelet index. There were no differences in tumor size, histology, grade, depth of invasion, lymph node metastases, or surgical margins. All laparoscopic procedures were completed successfully with no conversions to laparotomy. Intra-operative morbidity characteristics analyzed (LARVH vs. RAH) were blood loss 300 ml vs. 500 ml (P < 0.001), operative time 3.5 h vs. 2.5 h (P < 0.001), and intra-operative complications 13% vs. 4% (P < 0.03). Intra-operative complications in the LARVH group included: cystotomy (7), ureteric injury (1), and bowel injury (1). There was no difference in transfusion rates. There was no difference between post-operative infectious and non-infectious complications (LARVH vs. RAH), 9% vs. 5% and 5% vs. 2%, respectively. The median time to normal urine residual was 10 days vs. 5 days (P < 0.001), and the median length of hospital stay was 1 day vs. 5 days (P < 0.001). Twenty-two percent of patients received post-operative radiotherapy for high-risk features in both groups. After a median follow-up of 17 and 21 months, there have been 4 recurrences in the LARVH group and 13 in the RAH (P = NS). The overall 2-year recurrence-free survival was 94% and 94% in the LARVH and RAH groups, respectively (P = NS). CONCLUSION: Our data demonstrate that early cervical cancer can be treated successfully with LARVH with similar efficacy and recurrence rates to RAH. The major benefits are less intra-operative blood loss and shorter hospital stay. It is a safe procedure with low overall morbidity and complication rates. However, at present, LARVH is associated with an increase in intra-operative complications, and patients may have an increased time to return to normal bladder function.     

Invasive cervical cancer treated initially by standard hysterectomy

Ninety-two patients with invasive cervical cancer initially treated by standard hysterectomy were evaluated for features related to survival. The cell type included squamous cell (64) and adenocarcinoma (28). Posthysterectomy therapy included radiation therapy (78), pelvic lymphadenectomy (3), and radical parametrectomy (1). Hysterectomy was initially performed for the following indications: invasive lesion missed on cone biopsy, 17; hemorrhage at cone biopsy, 2; bleeding, 16; abnormal cytology, 13; presumed endometrial cancer, 9; known cancer, 7; pelvic relaxation, 5; planned therapy, 3; fibroids, 3; adnexal mass, 2; chronic discharge, 1; pyometra, 1; postpartum endometritis, 1. The cumulative 5-year survival for all patients was 68%, for squamous cell 80%, and for adenocarcinoma 41% (P = 0.0001). On postoperative evaluation 84 patients had presumed Stage I and 7 had parametrial involvement (Stage II). Patients with Stage I disease were then examined separately by cell type. Fifty-seven patients with squamous cell disease had cumulative 5-year survival of 85%. Radiation therapy in the immediate postoperative period produced a survival of 88%, compared to observation only with a 69% survival (P = .10). Patients with squamous cell disease and more than 50% cervical invasion had a 75% survival compared to a 96% survival for those with less than 50% (P = .02). The presence of disease at the surgical margins, grade, age, and increase in radiation therapy did not influence survival. Twenty-seven patients with presumed Stage I adenocarcinoma had a cumulative 5-year survival rate of 42%. Survival was significantly influenced by tumor grade (P = .018) and the amount of postoperative radiation therapy (P = .03), while age, amount of residual tumor, and presence of tumor at surgical margins did not influence survival. Patients with invasive squamous cell carcinoma treated by standard hysterectomy and postoperative radiation therapy have a prognosis similar to those treated initially by either radical surgery or radiation therapy. Patients with adenocarcinoma appear to have a significantly decreased survival when compared to patients with squamous cell disease and their prognosis is related to tumor grade and the amount of postoperative pelvic radiation.     

Laparoscopically assisted radical vaginal hysterectomy vs. radical abdominal hysterectomy for cervical cancer: a match controlled study

OBJECTIVES: The technical feasibility of laparoscopically assisted radical vaginal hysterectomy has been well described, but its advantages over the open technique remain largely unproven. We reviewed and compared our experiences with both approaches. METHODS: All patients undergoing laparoscopically assisted radical vaginal hysterectomy (LARVH) between 1996 and 2003 were identified and matched for age, FIGO stage, histological subtype and nodal metastases using a control group of women who underwent radical abdominal hysterectomy (RAH) during the same time period. RESULTS: Fifty-seven women were listed for LARVH, resulting in five conversions. Fifty cases were matched successfully using the criteria above. The majority of cases were FIGO stage 1B1. Statistically significant differences (P < 0.05) were present when the following were compared for LARVH vs. RAH: duration of surgery (median 180 vs. 120 min), blood loss (median 350 vs. 875 ml), hospital stay (median 5 days vs. 8 days) and duration of continuous bladder catheterisation (median 3 days vs. 7 days). There were no statistically significant differences with regard to nodal yield, completeness of surgical margins or perioperative complication rate. Four major complications (8%, three cystotomies and one enterotomy) occurred in the LARVH group and three in the RAH group (6%, one pulmonary embolism, one ureteric injury and one major haemorrhage). Three women in LARVH group had seen a specialist regarding postoperative bladder dysfunction, versus 12 in the RAH group (P = 0.04). No patients in the LARVH group reported constipation requiring regular laxatives, versus six in the RAH group (P = 0.03). Median follow-up was 52 months for LARVH and 49 months for RAH. There was no significant difference between recurrence rates or overall survival (94% for LARVH vs. 96% for RAH). CONCLUSIONS: Despite the inherent limitations of LARVH and its associated learning curve, the procedure conveys many advantages over the open technique in terms of blood loss, transfusion requirement and hospital stay. In addition, the incidence of postoperative bladder and bowel dysfunction appears low-suggesting improved quality of life-without compromising survival.     

Modified radical hysterectomy in the treatment of early squamous cervical cancer

OBJECTIVE: The aim of this study was to evaluate the results of modified radical hysterectomy in the treatment of early cervical cancer. MATERIAL AND METHODS: A retrospective chart review of 56 patients with stage I (IA in 35, IB in 21) squamous cervical carcinoma treated with modified radical hysterectomy and followed for a minimum of 5 years (mean, 12 years; range, 5.1-29) was conducted. All pathology slides were reviewed for tumor size, grade, depth of invasion, and lymph-vascular permeation. RESULTS: The mean depth of invasion was 0.5 cm (range, 0.1-2.5 cm), and the mean tumor size was 1.1 cm (range, 0.1-7 cm). Only 3 patients (5.4%) had positive nodes. None of the patients with tumors 2 cm or less in size had positive nodes, whereas 33.3% of the patients with tumors more than 2 cm in size had positive nodes. A recurrence developed in 2 patients (5-year recurrence rate of 3.6%). There were 10 deaths during the entire follow-up period, but only 2 were related to cervical cancer. The disease-specific and overall 5-year survival rates were 96.4 and 94.6%, respectively. The disease-specific 5-year survival rate was 100% among the 47 patients with tumors 2 cm or less and 75% for the 9 patients with tumors larger than 2 cm. Univariate analysis identified stage, lymph node status, and tumor size as statistically significant prognostic factors for overall survival. Tumor grade, lymph-vascular permeation, and depth of invasion (1-3 mm vs >3 mm) were not statistically significant for overall survival. CONCLUSIONS: Modified radical hysterectomy appears to be effective surgical therapy for patients with squamous cervical carcinoma 2 cm or less in size.     

Self-assessment of morbidity following radical hysterectomy for cervical cancer.

The aim of this study was to assess the magnitude of the morbidity following radical surgery for early stage cervical cancer. We performed a retrospective survey of all women who had undergone a radical hysterectomy and lymphadenectomy between the months of July 1995 and December 1996 inclusive at either the Royal Marsden or St George's Hospital (n =38), using a detailed questionnaire on bladder, ano-rectal and sexual function, both before and after treatment. Sixteen women (44.4%) received adjuvant radiotherapy. The mean interval between surgery and inquiry was 16.4% months (range 8-25 months). The mean age at the time of surgery was 40.5 years. Thirty-six out of 38 women contacted responded (94.7%). Overall 33 women (91.7%) reported new bladder, ano-rectal or sexual symptoms. Complaints of urinary incontinence, particularly of urge incontinence, and of voiding difficulties increased significantly after surgery (P <0.05). However, only 5.3% of women had sought treatment. Tenesmus increased significantly (P <0.05), while increases in diarrhoea and faecal incontinence were not statistically significant (P =0.051). Although 12.9% of women stated an improvement in their sex lives, 54.8% thought that their sex life was worse after treatment, and 12.9% of women had ceased sexual activity altogether. Of women of childbearing age 53.8% felt adversely affected by their loss of fertility. Bladder, ano-rectal and sexual symptoms are very common following radical hysterectomy for cervical cancer, with adverse effect on quality of life, and persist into the second year after treatment.     

Comparative study of laparoscopico-vaginal radical hysterectomy and abdominal radical hysterectomy in patients with early cervical cancer

OBJECTIVE: The objective of this study was to compare the outcomes of patients treated by laparoscopico-vaginal (modified) radical hysterectomy (LVMRH) to those of patients treated by abdominal radical hysterectomy (RH). METHODS: From 1997 to 2002, we performed 37 cases of LVMRH + pelvic lymph node dissection (PLND) and 47 cases of laparoscopico-vaginal radical hysterectomy (LVRH) with paraaortic lymph node sampling + PLND. Inclusion criteria for the laparoscopic surgery were patients with FIGO stage IA1 to IB1, for exocervical mass of grossly less than 2 cm. As a control, we selected 46 cases for MRH group and 96 cases for RH group. RESULTS: Operating time, the number of lymph nodes obtained and the rate of complications were similar in both groups. The hospital stay was significantly shorter in laparoscopic group. Four (8.5%) of 47 LVRH patients and 2 (2.1%) of 96 RH patients had recurrences. Recurrence-free survival in RH group was significantly higher than LVRH group (P = 0.0194). In LVRH group, patients with large tumor volume (>or=4.2 cm(3)) had significantly higher recurrence rate of 42.9% (3/7) than those with small volume (1/40) (P = 0.0021). The 3-year progression-free survivals were 97.1% in LVRH group (<4.2 cm(3)) and 98.9% in RH group. CONCLUSION: Laparoscopic surgery for the treatment of early cervical cancer is a safe and effective alternative to conventional RH. Considering the higher recurrence rate in patients with large tumor volume, it would be better if laparoscopic surgery is limited to patients with small volume disease (tumor diameter <2 cm or volume <4.2 cm(3)).     

子宫颈癌C1型术式的规范化

广泛子宫切除术联合盆腔淋巴结切除术是早期子宫颈浸润癌的常用术式,术后尿潴留是其最常见的并发症.子宫颈癌C1型手术,是Q-M子宫颈癌分型手术中的重要组成部分.实施C1型手术,可以明显减少广泛子宫切除术后的泌尿系统功能障碍.文章对子宫颈癌C1型手术存在的争议、与C1型手术相关的解剖、以及实施C1型手术的关键步骤进行讨论.     

Urodynamics following radical abdominal hysterectomy for cervical cancer

Summary We performed urologic evaluations and urodynamic studies on 40 patients before and 2 weeks, 6 months and 1 year after radical abdominal hysterectomy for cervical cancer. Preoperative findings were mostly within normal limits. Fourteen days after surgery, all patients had small, spastic bladders and 68% had residual urine. Bladder sensation was impaired in all patients at 2 weeks and in 63% after 1 year. The average bladder capacity was 400 ml before surgery, 180 ml at 2 weeks, 350 ml at 6 months, and 460 ml at 1 year. One year postoperatively, no patient had residual urine, but 17.5% had asymptomatic bacteriuria, 17.5% had bladder trabeculation, 62.5% had abnormal compliance, and 85% used abdominal straining to void. Three patients developed overflow incontinence and 8 women developed urodynamic stress incontinence. Most patients were tolerant of the observed dysfunction.     

A comparative study of laparoscopic radical hysterectomy with radical abdominal hysterectomy for early-stage cervical cancer: a long-term follow-up study

Objective

To determine whether laparoscopic radical hysterectomy (LRH) is a feasible alternative to radical abdominal hysterectomy (RAH) for early-stage cervical cancer.

Study design

A retrospective, matched case-control study of 24 consecutive cases with International Federation of Gynecology and Obstetrics stage I-II cervical cancer who underwent LRH by a single surgeon between January 1994 and December 2001. Cases were matched with controls (ratio 1:2) who underwent RAH by surgeon, age, stage and histology. Patient characteristics, clinical course, intra-operative complications and disease-free survival were compared between the two groups. Median counts were analyzed using the Mann-Whitney U-test. Differences between means were compared using Student's t-test. Dichotomous groupings were analyzed using Chi-squared test and Fisher's exact test as appropriate. Survival data were estimated using Kaplan-Meier estimates and compared with the log-rank test.

Results

The mean estimated blood loss in the RAH group was significantly greater than that in the LRH group (836.0 ml and 414.3 ml, respectively; p < 0.001). Five patients (20.8%) from the LRH group and 23 patients (47.9%) from the RAH group received blood transfusion (p < 0.03). The mean length of hospital stay was significantly shorter in the LRH group compared with the RAH group (10.7 days and 18.8 days, respectively; p < 0.01). No statistically significant difference existed between the two groups with respect to operative time, pelvic lymph node count, frequency of lymph node involvement, extent of parametrial or vaginal resection margins, adjuvant treatment and intra-operative complications. Median follow-up was 78 months for the LRH group and 75 months for the RAH group. There was no significant difference in the 5-year disease-free survival rate between the groups (90.5% and 93.3% for LRH and RAH, respectively; p = 0.918).

Conclusions

LRH is a useful alternative to RAH for the management of early-stage cervical cancer. The benefits of LRH include reduced blood loss, fewer transfusions and shorter hospital stay, with comparable oncologic outcome.     

腹腔镜保留神经宫颈癌根治术的临床研究

目的:研究腹腔镜保留盆腔自主神经的宫颈癌根治术(SNSRH)治疗宫颈癌的可行性,评估术后膀胱功能恢复的效果。方法:选择ⅠA2～ⅡA期宫颈癌患者35例。研究组17例应用SNSRH术,术中保留盆腔内脏神经、腹下神经、下腹下神经丛及其膀胱分支;对照组18例患者用传统腹腔镜子宫广泛切除术。比较两组的手术时间、出血量、术后膀胱功能恢复及术后并发症情况。结果:研究组手术时间336±17min,长于对照组的218±8min(P0.05);研究组术中出血量301±12.5ml,与对照组255±33.3ml的差异无统计学意义(P0.05);术后第7天,研究组及对照组残余尿少于100ml患者的比例分别为64%及11%,两组差异有显著的统计学意义(P0.05);研究组留置尿管时间10±3.0天,明显短于对照组23±5.4天(P0.05)。两组患者均无手术并发症及肿瘤切缘不净情况发生。结论:腹腔镜NSRH治疗早期宫颈癌安全、可行,能明显改善术后的膀胱功能。     

Ovarian function after radical hysterectomy with ovarian preservation for cervical cancer

OBJECTIVE: To investigate the function of preserved ovaries following radical hysterectomy in premenopausal women with cervical carcinoma and to attempt to identify clinical factors influencing ovarian function. STUDY DESIGN: Between 1991 and 1998, 33 premenopausal patients with International Federation of Gynecology and Obstetrics stage IB and II cervical cancer underwent radical hysterectomy with ovarian preservation, including lateral ovarian transposition in 20 patients. In 12 cases of squamous cell carcinoma with deep stromal invasion or a suspicious, positive node, neoadjuvant chemotherapy was performed. Postoperative whole pelvic radiotherapy was administered to 11 patients. Ovarian function was evaluated by serum FSH level during the follow-up period, 12 months to 9 years. RESULTS: Fifteen of 33 patients became climacteric after treatment. Ten of 12 patients over 40 years old became climacteric, as did 5 of 21 under 39 (P = .0013). Using multiple regression analysis, a significant correlation between ovarian dysfunction and age (under 40) was observed (P = .0286). No ovarian recurrence or symptomatic ovarian cyst was observed in preserved ovaries during the study period. CONCLUSION: Ovarian preservation is safe in patients under 40 years old undergoing radical hysterectomy even if they received additional treatment, such as neoadjuvant chemotherapy or postoperative radiotherapy with ovarian transposition.