To the best of our knowledge, this is the first national survey investigating the gynecologic oncologists’ attitudes towards the MIS for the management of the gynecologic malignancies during the COVID-19 pandemic. Our study revealed that the use of MIS declined when compared to the pre-pandemic era. The majority of the participants adopted specific precautions for MIS. Significant number of participants expressed their concerns about the possibility of getting infected. Educational activities and scientific meetings were moved to online platforms. One participant (1%) was diagnosed with SARS-CoV-2infection. The rate of SARS-CoV-2 infection among patients with gynecologic malignancies was 2.7 %, with 0.5 % rate of mortality. The majority of the participants stated that in case of a SAM or confirmed ESOC, laparotomy was the preferred technique. Even in ASOC cases, laparotomy or nonsurgical diagnostic approaches such as paracentesis outweighed diagnostic L/S. For early-stage endometrial cancer cases with either low or high intermediate-risk patients, laparotomy was the preferred approach. Moreover, radical hysterectomy with laparotomy outweighed simple hysterectomy or conization for cervical cancer < 2 cm. SLN use either for endometrial or cervical cancer was not the preferred approach. The status of the hospital influenced gynecologic oncologist decision on the surgical approach, so that, participants in busy hospitals mainly used laparotomy, but not the SLN concept. Moreover, age and experience of the surgeon affected the route of surgery. Older and more experienced gynecologic oncologists preferred MIS both for SAM and staging purposes in patients with endometrial cancer.
After the emergence and dramatic increase of the COVID-19 cases worldwide, including Turkey, gynecologic cancer care had to change significantly(1). International and national societies recommended postponing elective surgeries and tailoring the treatment of gynecologic cancers in line with the severity of the pandemic (6). The most striking effect of these recommendations was the sharp decline in the number of gynecologic oncology surgeries, including MIS procedures. Moreover, several anecdotal reports regarding worse post-operative outcomes of asymptomatic COVID-19 patients and demonstration of high virus load in the peritoneal cavity and also in the smoke of energy devices further decreased the number of MIS for the surgical management of the gynecologic cancers (13-15). On the contrary, the use of L/S midst of the COVID-19 pandemic was reported to be safe in the majority of studies(16, 17). In fact, faster post-operative recovery and the advantage of the same day discharge make L/S an attractive option compared to laparotomy (11, 18). Despite these convincing data, the participants in our study refrained from practicing MIS in their daily routine. Interestingly, working in “hot” COVID-19 hospitals and lack of experience in MIS were the factors associated with decreased use of MIS during the pandemic. One explanation could be increased operation time for MIS in the hands of inexperienced laparoscopists, which could direct these participants to open surgery. These relatively “inexperienced” participants might feel more comfortable and might complete surgery faster with laparotomy. Evidently, the total number of surgeries declined significantly due to the postponing elective benign surgeries, but there is no data regarding the change in the rate of MIS either for benign or malignant cases during the pandemic.
Recently, outcomes of 126 gynecologic oncologic surgeries from Madrid, Spain, one of the most profoundly affected countries, was reported (17). Only four patients underwent laparotomy, and the rest of the abdominal surgeries (excluding vulva and breast) was carried out with L/S. Important to note that these surgeries were performed in a relatively COVID-19-free reference hospital. The authors expressed that MIS for gynecologic cancers was the preferred approach with the advantage of early discharge. On the other hand, a recent study from Turkey reported the outcomes of 200 patients undergoing gynecologic oncology surgery up to 25 May 2020 during the “hot” period of the pandemic(19). Nearly half of the patients had the diagnosis of endometrial carcinoma, where another quarter of the patients were operated for ovarian cancer. Laparotomy was performed in the majority of the cases (80 %). The surgeons reported that they had to modify the operation radicality for ten percent of the cases because of the pandemic. Two patients (1%) were diagnosed with respiratory distress post-operatively by thorax CT scan with similar findings to COVID-19. However, multiple nasopharyngeal PCR swabs for these two patients failed to confirm SARS-CoV-2 positive results. The findings in this study are in parallel with our results by also confirming the decreased use of L/S among gynecologic oncologists practicing in Turkey.
A global survey conducted via social media showed that one-third of the participants did not continue to perform L/S during the pandemic, whereas the rest of the respondents stated that they still performed MIS with or without modifications of their technique (20). Interestingly, majority of the participants considered SLN as a reliable tool for nodal evaluation. On the contrary, our study revealed that a significant number of surgeons, mainly working in hot COVID-19 hospitals did not perform SLN in their practice during the pandemic. SLN biopsy is the recommended approach, particularly for endometrial and cervical cancer patients decreasing total operation time and morbidity related to systemic lymphadenectomy (21, 22). However, because of the issues such as long learning curve, need for experience, and logistic problems (availability of tracer), the use of and preference for the SLN concept might decrease during the pandemic (23).As seen from different studies, the preferences of the route of the surgery (laparotomy or laparoscopy), the use of the SLN concept depended on geographic region, the status of the hospital, the experience of the surgeon (17, 19, 24).
In our study, the majority of the participants preferred to perform surgery for early-stage gynecologic cancers (including pelvic masses) with either laparotomy or L/S during the pandemic. Postponing surgery with alternative treatment modalities, such as expectant managementof pelvic masses or progestins for early-stage endometrial cancer, was not popular among Turkish gynecologic oncologists. Similarly, in other reports majority of the participants preferred surgery in case of endometrial cancer (17, 20). On the contrary, this was not the case for patients with ASOC, where after establishing tissue diagnosis, NACT was preferred. This might be related to limited number of intensive care unit (ICU) beds, avoidance from long hospitalization after extensive surgery, and reduced blood product reserves. Interestingly, some of these practices, such as surgery for SAM or early endometrial cancer, contradicted the current recommendations of international or national societies (17, 19). Nearly all of these society guidelines and recommendations are based on expert opinions without level I evidence, and real-world data is still limited. We believe that this might be one of the main reasons for nonadherence to the guideline recommendations.
The main strength of our study is the homogeneity of the participants. Members of MİJOD consists of gynecologic oncologists and gynecologists with a special interest in gynecologic oncology. They all have a formal education and experience in minimally invasive gynecologic oncology surgery. Hence, these factors enabled the study group homogenous and representative of the real world. Moreover, the questions of our survey covered a wide range of surgical procedures and different scenarios, which could give a broad insight into the daily routine practices during the pandemic. The anonymity also contributes to more liberal and honest responses without any bias. Our study also has several limitations. The first one is that the data were obtained from a single country. Thus, its generalizability needs to be investigated with further international studies. Moreover, this was a cross-sectional study without any follow-up. A second survey after specific time period could have been useful in order to demonstrate changes in practice patterns but in this time, anonymity could have been violated.
In conclusion, the use of MIS in gynecologic oncology decreased during the pandemic in Turkey. More experienced surgeons continued to perform MIS. Surgical treatment was the preferred approach for SAM, early-stage endometrial cancer, and ESOC. However, NACT was more popular compared to radical upfront surgery.