Surgical treatment has been the preferred modality for the treatment of ECC. But the recent publication of LACC trial stated that conventional open surgery appeared the preferable survival outcomes compared with MIS.[1, 2]. In this study, we retrospectively compared the perioperative parameters and the results of follow-up after laparoscopic or open radical hysterectomy for ECC. Our data showed that LRH was superior to RAH in blood loss, the length of hospital stay and the risk of blood transfusion (Table 2). The results consisted with the published researches by other authors[6–9]. Jin Hee Kim et al. showed that laparoscopic radical hysterectomy was associated with fewer intraoperative complications (9.9% vs. 12.0%, P < 0.001) and shorter median length of stay (P < 0.001), compared with abdominal radical hysterectomy. Dong-Ho Kim’s team indicated that the mean estimated blood loss and length of hospital stay in laparoscopic radical hysterectomy group were significantly less than those in radical abdominal hysterectomy group (414.3 ml and 836.0 ml, respectively; P < 0.001; 10.7 days and 18.8 days, respectively; P < 0.01) . The study from Bogani G et al. stated that patients undergoing laparoscopic radical hysterectomy experienced less blood loss (200 vs 500 mL; P < 0.001) and shorter length of hospital stay (4 vs 8 days; P < 0.001), compared with the radical abdominal hysterectomy group. No between-group differences in intraoperative complications were recorded (P = 1.0). It’s seemingly suggested that laparoscopic radical hysterectomy was safe and feasible in management of ECC.
Over the median follow-up of 41 months in laparoscopic group and 49 months in abdominal surgery group, our data found that there were no differences in 5-years OS rate between two groups (92.8% vs 94.4%, long-rank p = 0.763, Fig. 2A). Though the rate of DFS at 3 years in laparoscopic surgery group was significantly lower than in laparotomic groups (91.8% vs 95.0 long-rank p = 0.030, Fig. 2B), the difference of DFS was attributed to the existence of subgroup with IB1-IIA1 staging cervical cancer combined with tumor ≥ 2 cm (Fig. 3C). For the patients with the diagnose of IA1-IA2 or IB1-IIA1 accompanying tumor < 2 cm, the rate of DFS was not statistically various between laparoscopic route and open approach (Fig. 3A, Fig. 3B). We believed that the standardized radical hysterectomy was an important fact associated with the surgical quality and clinical outcomes. In the present study, we had an insight to the precise anatomy of paracervical structure focusing on the dissection of cardinal ligament, sacral ligament and vesico-cervical ligament. The view of regional excision of parametrium was proposed by us in order to perform the standardized radical hysterectomy (Supplemental Fig. 1). According to the criterion of Class III or Type C radical hysterectomy, the cardinal ligament transection obeyed the principles of boundary near the pelvic floor vertically and at the pelvic side-wall laterally (Fig. 1A, Fig. 1B) The anterior, lateral and posterior parts of vesico-cervical ligament were transected near the bladder (Fig. 1D). Based on the elaborate anatomy of cardinal ligament and sacral ligament, hypogastric nerves as well as bladder and cervical branches of pelvic plexus were dissected and separated orderly from the ventral and caudal part of the paracervix, which facilized the nerve-sparing Type C1 radical hysterectomy. It was concluded that standardized radical hysterectomy based on regional excision of parametrium promised the surgical quality and clinical outcomes.
Of course, the adoption of LRH for ECC remains debatable. The reasons affecting therapeutic results were considered to associate with the use of uterine manipulation, virginal colpotomy and the circulating CO2. The tumor surface was exposed to circulating CO2 when intracorporeal colpotomy was performed. This may lead to the increasing risk of tumor spillage[16–19]. Uterine manipulators which were frequently used for visualization and retraction during minimally invasive hysterectomy may also disseminate tumor cells. In our study, for the patients with stage IB1-IIA1 combined with tumor ≥ 2 cm, the rate of 3-years DFS in LRH group was remarkably lower than in ARH group (75.0% vs 92.4%, p < 0.001). It was suggested that the worse survival outcomes of LRH was closely linked to the tumor size. The tumor ≥ 2 cm may have the increasing risk of cancer cells spillage if the uterine manipulation was used and the unenclosed colpotomy was carried out in LRH. Some scholars have tried to perform the enclosed colpotomy without the use of uterine manipulation to obtain a relatively tumor-free removal and improve the surgical quality of LRH for ECC.
In addition, the previous documents suggested laparoscopic hysterectomy for women with early-stage endometrial cancer was not associated with the inferior oncologic outcomes. In the clinical trial of NCT 00096408, the use of total abdominal hysterectomy compared with total laparoscopic hysterectomy resulted in the equivalent rate of DFS at 4.5 years (81.6% vs. 81.3%, P < 0.01) and OS (risk difference, P = 0.76). An update of a previous Cochrane Review published in 2012, Issue 9 concluded that laparoscopy for the management of early endometrial cancer was associated with the similar rates of OS and DFS compared with laparotomy approach. It was unreasonable to completely explain the differences in OS and DFS after laparoscopy or laparotomy treatment from the perspective of CO2 pneumoperitoneum and/or uterine manipulation. Now, we are trying to use Air-Seal pneumoperitoneum system to reduce the possible adverse effects of smoke dust. Our trial was not designed to attempt the new method to replace the conventional intracorporeal colpotomy. Further investigation is warranted for evaluating the survival outcomes with minimally invasive surgery.
There are some concerns that should be recognized when interpreting the results of the study. Firstly, LRH and ARH were performed by senior gynecologic oncologist who are both skillful at laparotomy and laparoscopy surgeries. This evaded the shortcomings of less experiences and techniques influencing the surgical quality of standardized radical hysterectomy. Secondly, the effects of regional excision of parametrium on the postoperative urination, defecation and the risk of perioperative infection and bleeding need be more checked in the following trial. Lastly, the cohort study was designed as a retrospective study with a small simple size. In the future, multicenter prospective randomized study especially taking into account methods for enclosed colpotomy not using a manipulator is necessary for further evaluating the values and feasibility of LRH for ECC.