The LLAC study is the leading study on laparoscopic treatment of cervical cancer. The unexpected results of this study, however, have raised many questions. On the one hand, laparoscopic treatment has a better postoperative outcome and a better quality of life for women than open surgery in a short-term period; on the other hand, according to this study, it could determine a higher risk of cancer recurrence or death. In agreement with the LLAC study, the systematic review and meta-analysis of observational studies by Nitecki et al. confirmed that women who underwent radical laparoscopic hysterectomy for early-stage cervical cancer have an increased risk of recurrence and death in comparison to open surgery13.
As mentioned above, many editorials evaluated the different features of laparoscopic radical hysterectomy, which could determine so high recurrence rates, among these: the learning curve, the length of the vaginal border, the radicality of the parametric section, the ethnic differences, the extension of the lymphadenectomy, and the standardization of surgical technique.
In our study, we have considered the possible role of the uterine manipulator, considering if it could increase the recurrence rates. The uterine manipulator is an instrument widely used in laparoscopic hysterectomy that helps expose the anatomy during surgical procedures. It allows, in fact, a perpendicular dissection of the uterine arteries, through the lateralization of the uterus, increases the distance between the uterine cervix and the ureters, reducing the risk of ureter lesion, allows to elevate the uterus, and allows to delineate the vaginal fornices to facilitate the colpotomy, maintaining the pneumoperitoneum after the vaginal incision14. The role of the uterine manipulator in gynecological malignancies may be controversial.
Nica et al. compared 115 women with early-stage cervical cancer that had surgery with the use of an intrauterine manipulator and 109 women without it. They concluded that patients with low-risk features had good long-term oncology outcomes and that a significant predictor of disease recurrence is tumor size, through the dissemination of malignant cells during minimally invasive colpotomy15.
Yinxia Liu et al. investigated the relationship between LVSI and surgical approach in early-stage cervical cancer. As mentioned above, in fact, the LLAC trial had a worldwide implication. Many hypotheses were advanced, one of this the possibility that uterine manipulators may spread malignant cells through the LVSI. In particular, 735 patients with early-stage cervical cancer were enrolled in this study. Among these, 375 underwent radical laparoscopic hysterectomy and pelvic lymphadenectomy, and 378 underwent open surgery. They concluded that uterine manipulators are not associated with LVSI in surgery for early-stage of cervical cancer. Conversely, these could be related to lymph node metastasis and deep stromal invasion16.
The SUCCOR study, a retrospective study, in line with data described in the literature, showed a worse disease-free survival in women who underwent a minimally invasive treatment than open surgery. Avoiding the use of a uterine manipulator or closing the vagina over the tumor could improve these results17.
Our study showed that the five-year rates of recurrence in patients treated with minimally invasive surgery are not low, about 10%, similar to the data in the literature13 and LLAC study12. However, these recurrence rates do not seem to be related to the use of the intrauterine manipulator, confirming the results of the SUCCOR study17. However, we need to underline that our study has numerous limitations: it is a retrospective study, has a small number of cases, and the follow-up of the patients is only five years.