Rubbing salt on the wound.

Abstract

The quotation ‘People who peek through key-holes have to expect an occasional poke in the eye’ comes to mind in view of the recently published LACC Trial in the New England Journal of Medicine showing significantly worse survival following ‘keyhole’ surgery (laparoscopic or robotic) in early stage cervical cancer (Ramirez et al. N Engl J Med 2018;379:1895–904). A second study in the same edition reinforced the results by also showing a worse survival with ‘keyhole’ surgery (Melamed et al. N Engl J Med 2018;379:1905–14). This must be considered to be as unfortunate as having ‘both eyes poked at the same time via the same keyhole’. Before gynaecological oncologists have regained full sight, comes this third publication focusing on fertility-sparing surgery in early stage cervical cancer which ‘rubs salt on the wound’ by also showing excellent survival with an abdominal approach. The study by Li et al. (BJOG 2019; 126:1169–74) the largest published series on abdominal radical trachelectomy (ART) demonstrating a 98.6% 5-year survival, agrees well with the abdominal arm in the LACC trial of 99% 3-year survival and contrasts significantly with the laparoscopic arm of 93.8% 3-year survival. In addition, the results are comparable to previous publications on ART and add substantially to the literature (previously, 866 cases with a cumulative mortality rate of 1.4%). Of interest are the results on tumours larger than 2 cm with a recurrence rate of 5.3% compared with 2.0% in tumours <2 cm (nonsignificant P value). Analysis of the New England Journal of Medicine publications identified that it was in this sub-group specifically there were the greatest differences in recurrences. It is also in this sub-group that survival differences are the greatest compared with vaginal radical trachelectomy (cumulative recurrence rate of 23.9%), which also utilises a laparoscopic approach (BJOG 2019;126:1169–74). Data following total laparoscopic radical trachelectomy are limited. Consistent with this, is the FIGO 2018 re-classification of cervix cancer reducing the cut-off between IB1 and IB2 tumours from 4 to 2 cm (Bhatla et al. Int J Gynaecol Obstet 2018;143 (Suppl 2):22–36). Where does all this leave us? Is the problem the surgeon or the tools or the procedure? Many are questioning the surgical techniques in order to retain a minimally invasive approach including the use of manipulators, the CO2 pneumoperitoneum, tumour exposure to the peritoneum and the surgical radicality. It's also time to reflect. Fertility-sparing or not, why have different surgeons/centres been advocating different surgical procedures/approaches? One explanation is the Collingridge dilemma stating that technological advances contain two components; (1) information: where the effects of technological advances cannot be predicted until they are extensively developed and widely used in clinical practice, and (2) power: where control (by the use of robust clinical evaluations) is difficult when the technology has become entrenched (Collingridge. The Social Control of Technology. London, UK: Palgrave Macmillan, 1981). This is highlighted by the Pacing problem, where innovations develop exponentially while control mechanisms develop incrementally. The solution would be the Precautionary principle, where innovations should not be embraced until developers can prove they will not cause harm. Critics argue this will not eliminate innovations developing in the wrong direction but result in no innovations developing at all. Although it is painful to have to revert back to an abdominal route, the solace is that ‘rubbing salt on the wound’, regardless of the additional pain, will help the wound recover faster. And so, for women with a stage IB2 cervical tumour (FIGO 2018) who wish to preserve fertility, the recommended operation should be an ‘abdominal’ radical trachelectomy. None declared. A completed disclosure of interests form is available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.