ObjectiveLaparoscopic/robotic radical hysterectomy has been historically considered oncologically equivalent to open radical hysterectomy for patients with early cervical cancer. However, a recent prospective randomized trial (Laparoscopic Approach to Cervical Cancer, LACC) has demonstrated significant inferiority of the minimally invasive approach. The aim of this study is to evaluate the oncologic outcomes of combined laparoscopic-vaginal radical hysterectomy.MethodsBetween August 1994 and December 2018, patients with invasive cervical cancer were treated using minimally-invasive surgery at the Universities of Jena, Charité Berlin (Campus CCM and CBF) and Cologne and Asklepios Clinic Hamburg. 389 patients with inclusion criteria identical to the LACC trial were identified. In contrast to the laparoscopic/robotic technique used in the LACC trial, all patients in our cohort underwent a combined transvaginal-laparoscopic approach without the use of any uterine manipulator.ResultsA total of 1952 consecutive patients with cervical cancer were included in the analysis. Initial International Federation of Gynecology and Obstetrics (FIGO) stage was IA1 lymphovascular space invasion (LVSI+), IA2 and IB1/IIA1 in 32 (8%), 43 (11%), and 314 (81%) patients, respectively, and histology was squamous cell in 263 (68%), adenocarcinoma in 117 (30%), and adenosquamous in 9 (2%) patients. Lymphovascular invasion was confirmed in 106 (27%) patients. The median number of lymph nodes was 24 (range 2–86). Lymph nodes were tumor-free in 379 (97%) patients. Following radical hysterectomy, 71 (18%) patients underwent adjuvant chemoradiation or radiation. After a median follow-up of 99 (range 1–288) months, the 3-, 4.5-, and 10-year disease-free survival rates were 96.8%, 95.8%, and 93.1 %, and the 3-, 4.5-, and 10-year overall survival rates were 98.5%, 97.8%, and 95.8%, respectively. Recurrence location was loco-regional in 50% of cases with recurrence (n=10). Interestingly, 9/20 recurrences occurred more than 39 months after surgery.ConclusionThe combined laparoscopic-vaginal technique for radical hysterectomy with avoidance of spillage and manipulation of tumor cells provides excellent oncologic outcome for patients with early cervical cancer. Our retrospective data suggest that laparoscopic-vaginal surgery may be oncologically safe and should be validated in further randomized trials.

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with LN assessment. All pathologic specimens were centrally reviewed by an expert gynecologic pathologist. Results Median age at surgery was 38 years (range; 23-67). Stage at diagnosis was IA2 (33%) and IB1 (67%). Histologic type included squamous cell carcinoma (48%) and adenocarcinoma (52%). Surgery included conization and LN assessment in 44/100 (44%) women and simple hysterectomy with LN assessment in 56/100 (56%) women. Minimally invasive surgery (MIS) was performed in 96/100 (96%) patients: laparoscopic in 83; robotic in 13. Positive LNs were noted in 5/100 women (5%). Residual disease in the hysterectomy specimen was diagnosed in 1/56 patients (1.8%). Median follow-up was 25 months (range 0-71). To date, recurrent disease has been diagnosed in 3 patients (3%). Conclusions Conservative surgery is oncologically safe in women with early stage, low-risk cervical carcinoma.

Patients with early cervical cancer can be treated either by surgery or by chemoradiation [1]. International guidelines recommend treatment by one oncologic modality rather than combined therapy to avoid treatment-related toxicity (European Society of Gynaecological Oncology, National Comprehensive Cancer Network) [2,3]. Consequently, pretreatment decision for one of these treatment options has to be made by an interdisciplinary tumor board council. Indeed, this recommendation reflects not only tumor-stage and histology-related factors but also "unspoken" arguments like surgical skills, national traditions, availability of radiation oncology and others. Moreover, best treatment for patients with tumor stages IB (±lymphovascular invasion) ≥4 cm, IIA and IIB is not defined yet, that opens the door for a wide spectrum of different strategies. Patients with these potentially operable stages are often undergo adjuvant chemoradiation (up to 85%) according to Peters et al. [4] or Sedlis et al.'s criteria [5], whereas primary chemoradiation could be a single treatment alternative [6]. Highrisk features for adjuvant chemoradiation are known as lymph-node positivity, parametrial involvement and R1/R2-resection. Lymph node metastases can be confirmed or excluded with high accuracy by intraoperative frozen section and consequently radical hysterectomy can be continued or abandoned. Transvaginal creation of a tumor-adapted vaginal cuff in iodine-positive area is an ideal tool to avoid vaginal tumor involvement. The most problematic parameter preoperatively is parametrial spread. In accordance to a previously published study by Kong et al. [7] and Woo et al. [8] could demonstrate a pooled sensitivity and specificity of 0.73 and 0.93 for the detection of parametrial invasion. Radical hysterectomy is the state-of-the-art surgery for patients with early cervical cancer. A standardized surgical approach with curative intent was defined in the last century in Vienna. Whereas Schauta [9] used a transvaginal approach, his disciple, Wertheim [10] propagated a transabdominal route. Both techniques underwent several modifications over the next decades and with the advent of laparoscopic surgery the advantages of an abdominal and transvaginal access could be combined [11,12]. Thereafter a historical change and oncosurgical tragedy occurred: gynecologic surgeons renounced the transvaginal part of radical hysterectomy completely, the main reason being lack of training in vaginal surgery [13-15].

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