The basic principles of oncologic surgery during minimally invasive radical hysterectomy

Abstract

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].

Retrospective Analysis of Cervical Cancer Treatment Outcomes: Ten Years of Experience with the Vaginal Assisted Radical Laparoscopic Hysterectomy VARLH

“…Treatment method should be selected individually, but oncological carefulness has to address the vast majority [ 39 , 40 ]. Promising results of our study prove that laparoscopic surgery should not be excluded in the treatment for early-stage cervical cancer.…”

Clinical effects of cervical conization with positive margins in cervical cancer

“…Patients who underwent minimally invasive radical hysterectomy could have shorter survival than those who underwent conventional abdominal radical hysterectomy. A possible explanation is the use of an intrauterine manipulator in minimally invasive surgery, which might increase the intrauterine pressure and spread the cancer cells into the lymphovascular space 16 – 19 . However, other reports showed that the use of manipulators is not associated with worse prognosis, and its clinical significance remains controversial 20 , 21 .…”

Minimally Invasive Surgery for Cervical Cancer in Light of the LACC Trial: What Have We Learned?

“…Fundamental rules of oncologic surgery include the avoidance of tumor spillage and tumor manipulation and resection in tumor-free margins [ 49 ]. Techniques of MIS radical hysterectomy commonly include the use of a uterine manipulator even in patients with a visible cervical tumor, which, consequently, likely violates the above principles.…”