Management Of Early Cervical Cancer Research Articles

Useful MRI Findings for Minimally Invasive Surgery for Early Cervical Cancer.

Simple SummaryRadical hysterectomy and lymph node dissection are extensive procedures with severe post-operative morbidities and should be avoided on patients with low risk of recurrence. Still, due to lack of good prognostic tools, radical surgery is performed on most patients with early stage cervical cancer, leading to overtreatment and unnecessary morbidities. The recent International Federation of Gynecology and Obstetrics (FIGO) staging system accepts the use of magnetic resonance imaging (MRI) in addition to physical examination. Currently, 3 Tesla (3T) MRI is available widely and, due to its high soft tissue contrast, can provide more useful information on precise estimation of tumor size and metastasis than can physical examination in patients with cervical cancer. Therefore, this imaging modality can help gynecologic oncologists to determine whether minimally invasive surgery is necessary and can be used for early detection of small recurrent cancers.According to the recent International Federation of Gynecology and Obstetrics (FIGO) staging system, Stage III cervical cancer indicates pelvic or paraaortic lymph node metastasis. Accordingly, the new FIGO stage accepts imaging modalities, such as MRI, as part of the FIGO 2018 updated staging. Magnetic resonance imaging (MRI) is the best imaging modality to estimate the size or volume of uterine cancer because of its excellent soft tissue contrast. As a result, MRI is being used increasingly to determine treatment options and follow-up for cervical cancer patients. Increasing availability of cancer screening and vaccination have improved early detection of cervical cancer. However, the incidence of early cervical cancers has increased compared to that of advanced cervical cancer. A few studies have investigated if MRI findings are useful in management of early cervical cancer. MRI can precisely predict tumor burden, allowing conization, trachelectomy, and simple hysterectomy to be considered as minimally invasive treatment options for early cervical cancer. This imaging modality also can be used to determine whether there is recurrent cancer following minimally invasive treatments. The purpose of this review is to highlight useful MRI features for managing women with early cervical cancer.

Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

Minimally invasive surgery (MIS) has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay. It is imperative, however, when new techniques are adopted, in the context of treating oncology patients, that the oncological efficacy and safety are established rigorously rather than assumed based on first principles. Here we have attempted to provide a comprehensive review of all the contentious and topical themes surrounding the use of MIS in the treatment of endometrial and cervix cancer following a thorough review of the literature. On the topic of endometrial cancer, we cover the role of laparoscopy in both early and advanced disease, together with the role and unique benefits of robotic surgery. The surgical challenge of patients with a raised body mass index and the frail and elderly are discussed and finally the role of sentinel lymph node assessment. For cervical cancer, the role of MIS for staging and primary treatment is covered, together with the interesting and highly specialist topics of fertility-sparing treatment, ovarian transposition and the live birth rate associated with this. We end with a discussion on the evidence surrounding the role of adjuvant hysterectomy following radical chemoradiation and pelvic exenteration for recurrent cervical cancer. MIS is the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations, based on the available evidence, are that the open approach should be considered the gold standard for the surgical management of early cervical cancer and that MIS should only be adopted in the context of research. Careful counselling of patients on the current evidence, discussing in detail the risks and benefits to enable them to make an informed choice, remains paramount.

Effect of Quality Control Program in Surgical Management of Early Cervical Cancer.

BackgroundRegular assessments of clinical performance in gynecologic cancer surgery is important for the safety of patients. We evaluated the effects of quality control (QC) program on the treatment pattern and clinical outcomes of early cervical cancer.MethodsMedical records of cervical cancer patients who received operation in our institution from January 2007 to December 2018 were retrospectively reviewed. Cases were divided into 2 groups, before and after the initiation of QC program, group 1 (2007–2013) and group 2 (2014–2018), based on the operation date. Two groups were compared in clinicopathologic variables, surgical methods, operative details, adjuvant treatments, recurrence and survival.ResultsA total of 305 cervical cancer patients were included in the analysis, 210 in group 1 and 95 in group 2. In group 2, minimally invasive surgery (MIS) was more frequently performed (60.0% vs. 76.8%, P = 0.004), especially in earlier stages (stage IA, 72.6% vs. 100.0%; stage IB, 52.2% vs. 69.5%). However, the median tumor size treated by MIS was decreased in stage IB (20 mm vs. 17 mm, P = 0.015). Frequency of adjuvant treatment was also reduced in stage IB (56.5% vs. 37.3%, P = 0.016). Recurrence within 3 years, 3-year disease free survival and overall survival did not show significant difference; however, 3-year recurrence after MIS was significantly reduced in stage IB.ConclusionQC program enforced stricter patient selection criteria for MIS and positively affected clinical outcomes in cervical cancer patients who underwent surgery. Systemic monitoring should be considered for patient safety.

Frozen section examination of sentinel lymph nodes can be used as a decisional tool in the surgical management of early cervical cancer

IntroductionSentinel lymph node (SLN) detection has been shown to be accurate in detecting lymph node involvement in early-stage cervical cancer. The objective of this study was to evaluate the accuracy...

Surgical Management of Early Cervical Cancer: When Is Laparoscopic Appropriate?

This paper reviews the recent literature data on minimally invasive surgical approach to early cervical cancer compared to abdominal approach, with the aim of evaluate the oncological outcomes and the appropriateness of current indications. A recent multicenter randomized controlled trial and a concurrent large epidemiological study, contrary to the previous retrospective data, showed that minimally invasive surgery is associated with significantly poorer survival than the open approach. Open surgery is to be considered the standard of care for early cervical cancer as implemented in the current guidelines, and the patients must be carefully counseled if minimally invasive surgery is offered. Minimally invasive surgery can be considered safe only for sentinel lymph node mapping in a fertility-sparing setting and could be considered after preoperative conization and for small tumors, adopting preventive surgical maneuvers and in reference centers. However, prospective evidences about the suggested indications are not yet available.

Surgical and Oncological Outcome of Total Laparoscopic Radical Hysterectomy versus Radical Abdominal Hysterectomy in Early Cervical Cancer in Singapore.

Introduction:The Wertheim's radical abdominal hysterectomy (RAH) has been the traditional surgical approach for operable Stage IB cervical cancer in Singapore whereas total laparoscopic radical hysterectomy (TLRH) was introduced only in 2009. In this study, we aimed to compare the long-term surgical outcome between the two routes of surgery in our center.Methods:This is a prospective study performed in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases.Results:From November 2009 to December 2014, 51 TLRHs and 85 RAHs were performed. Median blood loss in the TLRH group was significantly lower than in the RAH group (300 vs. 500 mL; P = 0.002) as was median hospital stay (5 vs. 6 days; P = 0.001). Operative time was significantly higher in the TLRH group (262 vs. 228 min; P < 0.001). There was no significant difference in bladder recovery. Intraoperative complications were encountered in 2 (3.9%) TLRH patients and 1 (1.2%) RAH patient. Postoperative complications occurred in 3 (5.9%) TLRH patients and 8 (9.4%) RAH patients. With a median follow-up of 117 (range 1.6–314.6) weeks in the TLRH group and 143.3 (range 0.4–304.7) weeks in the RAH group, 9 (17.6%) TLRH patients and 7 (8.2%) RAH patients had recurrence. There was no significant difference in the overall 3-year survival between the TLRH group and the RAH group for tumor size ≤2 cm (100.0% vs. 97.0%; P = 0.37). However, there was a trend toward lower survival for the TLRH group for tumor size >2 cm (61.9% vs. 85.4%; P = 0.06).Conclusion:The results of our study suggest that with appropriate patient selection, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore, especially in women with small tumors ≤2 cm but should be used with caution in women with larger tumors.

Early Cervical Cancer: Current Dilemmas of Staging and Surgery.

Advances in cervical cancer screening and treatment have resulted in high cure rates in developed countries for early-stage disease. Current research focuses on minimizing morbidity and maximizing quality of life. Imaging has been disappointing in identifying small volume metastases. Sentinel lymph node biopsy represents a significant advantage with high sensitivity, low false negative rates, reduced morbidity, and equivalent survival in recent studies compared to pelvic lymphadenectomy. Non-radical surgical options are currently being investigated for early cervical cancer in a number of large prospective studies in patients at low risk for metastases. Evidence suggests that sentinel lymph node biopsy and non-radical surgery are safe approaches for the staging and management of early cervical cancer in appropriately selected patients with the potential to significantly reduce treatment-related morbidity.

Robotic surgery for early stage cervical cancer: Evolution and current trends.

The management of early stage cervical cancer often includes surgery in the form of radical hysterectomy, radical trachelectomy, or radical parametrectomy. Surgical techniques have evolved to include minimal invasive approaches, and more recently, to include robotic assisted techniques. This review highlights the evolution of surgical management of early cervical cancer and specifically explores robotic assisted radical hysterectomy, radical trachelectomy, radical parametrectomy, and the role of neoadjuvant chemotherapy.

Effect of sentinel lymph-node biopsy alone on the morbidity of the surgical treatment of early cervical cancer: Results from the prospective randomized study Senticol2.

5521 Background: Sentinel lymph node (SLN) biopsy is now part of the management of early cervical cancer. Feasibility and low false negative rate in case of bilateral detection have been demonstrat...

Fertility Conserving Management of Early Cervical Cancer: Our Experience of LLETZ and Pelvic Lymph Node Dissection

Presently, for those diagnosed with early cervical cancer who wish to conserve their fertility, there is the option of radical trachelectomy. Although successful, this procedure is associated with significant obstetric morbidity. The recurrence risk of early cervical cancer is low and in tumors measuring less than 2 cm; if the lymphatics are negative, the likelihood of parametrial involvement is less than 1%. Therefore, pelvic lymph nodes are a surrogate marker of parametrial involvement and radical excision of the parametrium can be omitted if they are negative. The aim of this study was to report our experience of the fertility conserving management of early cervical cancer with repeat large loop excision of the transformation zone and laparoscopic pelvic lymph node dissection. Between 2004 and 2011, a retrospective review of cases of early cervical cancer who had fertility conserving management within Glasgow Royal Infirmary was done. Forty-three patients underwent fertility conserving management of early cervical cancer. Forty were screen-detected cancers; 2 were stage IA1, 4 were stage IA2, and 37 were stage IB1. There were 2 central recurrences during the follow-up period. There have been 15 live children to 12 women and there are 4 ongoing pregnancies. To our knowledge, this is the largest case series described and confirms the low morbidity and mortality of this procedure. However, even within our highly select group, there have been 2 cases of central recurrent disease. We, therefore, are urging caution in the global adoption of this technique and would welcome a multicenter multinational randomized controlled trial.

Total laparoscopic Wertheim’s radical hysterectomy versus Wertheim’s radical abdominal hysterectomy in the management of stage I cervical cancer in Singapore: a pilot study

For many decades, Wertheim's radical hysterectomy via laparotomy, also known as Wertheim's radical abdominal hysterectomy (RAH), has been the traditional surgical approach for operable stage IB cervical cancer. However, many established cancer centres worldwide have recently shown total laparoscopic Wertheim's radical hysterectomy (TLRH) to be a safe and feasible alternative to the conventional abdominal route for early cervical cancer management. This technique was introduced in Singapore in 2009. This was a prospective pilot study comparing TLRH with RAH in a single large tertiary institution in Singapore. Inclusion criteria included surgically fit patients with early cervical cancer and no radiological evidence of regional or distant metastases. From November 2009 to February 2011, a total of 18 TLRHs and 30 RAHs were performed. The median blood loss in the TLRH group was significantly lower than that in the RAH group (300 mL vs. 500 mL; p = 0.04). However, there was no statistically significant difference found between the two techniques in terms of operative time, hospital stay, bladder recovery, total lymph node yield or adjuvant treatment. No intraoperative bladder, ureteric or bowel complications were observed in the two groups. Postoperative complications occurred in 2 (11.1%) TLRH patients and 4 (13.3%) RAH patients. With a median follow-up of 37.3 (range 10-68) weeks, the rate of recurrence was found to be 5.6% for the TLRH group and 10.0% for the RAH group. The results of our study suggest that with appropriate patient selection and increased experience, TLRH can be a safe and effective procedure for the management of early cervical cancer in Singapore.

Laparoscopically assisted radical vaginal hysterectomy versus radical abdominal hysterectomy for the treatment of early cervical cancer

Cervical cancer is the second most common cancer among women and is the most frequent cause of death from gynaecological cancers worldwide. Standard surgical management for selected early-stage cervical cancer is radical hysterectomy. Traditionally, radical hysterectomy has been carried out via the abdominal route and this remains the gold standard surgical management of early cervical cancer. In recent years, advances in minimal access surgery have made it possible to perform radical hysterectomy with the use of laparoscopy with the aim of reducing the surgical morbidity and promoting a faster recovery. To compare the effectiveness and safety of laparoscopically assisted radical vaginal hysterectomy (LARVH) and radical abdominal hysterectomy (RAH) in women with early-stage (1 to 2A) cervical cancer. We searched the Cochrane Gynaecological Cancer Group Trials Register, and Cochrane Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE, and EMBASE up to July 2013. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field. Randomised controlled trials (RCTs) that compared laparoscopically assisted radical hysterectomy and radical abdominal hysterectomy, in adult women diagnosed with early (stage 1 to 2A) cervical cancer. Two review authors independently abstracted data and assessed risk of bias. We found one RCT, which included 13 women, that met our inclusion criteria and this trial reported data on LARVH versus RAH.Women who underwent LARVH for treatment of early-stage cervical cancer appeared to have less blood loss compared with those who underwent RAH. The trial reported a borderline significant difference between the two types of surgery (median blood loss 400 mL (interquartile range (IQR): 325 to 1050) and 1000 mL (IQR: 800 to 1025) for LARVH and RAH, respectively, P value = 0.05). RAH was associated with significantly shorter operation time compared with LARVH (median: 180 minutes with LARVH versus 138 minutes with RAH, P value = 0.05).There was no statistically significant difference in the risk of perioperative complications in women who underwent LARVH and RAH. The trial reported two (29%) and four (57%) cases of intraoperative and postoperative complications, respectively, in the LARVH group and no (0%) reported cases of intraoperative complications and five (83%) cases of postoperative complications in the RAH group. There were no reported cases of severe perioperative complications.Bladder and bowel dysfunction of either a transient or chronic nature remain major morbidities after radical hysterectomy, and the one included study showed that there may be significantly less after LARVH. The included trial lacked statistical power due to the small number of women in each group and the low number of observed events. Therefore, the absence of reliable evidence, regarding the effectiveness and safety of the two surgical techniques for the management of early-stage cervical cancer, precludes any definitive guidance or recommendations for clinical practice. The trial did not report data on long-term outcomes, but was at moderate risk of bias due to very low numbers of included women.

Total Microlaparoscopic Radical Hysterectomy in Early Cervical Cancer

In less than 2 decades, laparoscopy has contributed to modification in the management of early cervical cancer patients, and all comparisons between open and laparoscopic-based radical operations showed an identical oncological outcome. The aim of this study is to describe surgical instrumentations and technique to perform total microlaparoscopy radical hysterectomy in early cervical cancer patients and report our preliminary results in terms of operative time and perioperative outcomes. Between January 1, 2012, and March 25, 2012, 4 consecutive early cervical cancer patients were enrolled in this study. We performed 3 type B2 and 1 type C1-B2 total microlaparoscopy radical hysterectomy, and in all cases concomitant bilateral salpingo-oophorectomy and pelvic lymphadenectomy were carried out. Median operative time was 165 minutes (range: 155 to 215) (mean: 186), and median estimated blood loss was 30 mL (range: 20 to 50). Median number of pelvic lymph nodes removed was 12 (range: 11 to 15). All procedures were completed without 5-mm port insertion and without conversion. No intraoperative or early postoperative complications were reported. This report suggests a role of microlaparoscopy in the surgical management of early cervical cancer with adequate oncological results, superimposable operative time, and perioperative outcomes with respect to standard laparoscopy.

Fertility-Preserving Surgery in Patients with Early Stage Cervical Carcinoma

Fertility preservation is an important issue for patients in reproductive age with early stage cervical cancer. In view of recent developments, our purpose was to review and discuss available surgical alternatives. A literature search was conducted using PUBMED, including papers between 1980 and December 2011. In patients with stage IA1 cervical cancer, conization is a valid alternative. Patients with stage IA2-IB1 disease can be conservatively treated by radical trachelectomy. This is as well-established conservative approach and appears to be safe and effective in allowing a high chance of conception. Prematurity is the most serious issue in pregnancies following trachelectomy. Less invasive options such as simple trachelectomy or conization seem to be feasible for stages IA2-IB1, but more and better evidence is needed. Neoadjuvant therapy might allow conservative surgery to be performed also in patients with more extensive lesions. Ovarian transposition is important when adjuvant radiation is needed. In conclusion, available literature shows that there are interesting fertility-sparing treatment alternatives to the “golden standard” for the management of early cervical cancer in young women.

Survey on the Management of Early Cervical Cancer Among Members of the GCIG

To establish the different imaging and treatment options offered to patients with early cervical cancer by members of the Gynecologic Cancer Intergroup. A questionnaire was developed and disseminated electronically to members of the Gynecologic Cancer Intergroup and was completed online. One hundred sixty-two members viewed the questionnaire; 88 members started it; however, only 64 members fully completed it. Most (89.9%) of respondents used the International Federation of Gynecology and Obstetrics classification system when staging cervical cancer, using adjuncts to clinical staging: 33 respondents (37.5%) advocated computed tomography, 61 respondents (69.3%) advocated magnetic resonance imaging, 26 respondents (29.6%) positron emission tomography-computed tomography, and 36 respondents (40.9%) advocated staging lymphadenectomy, with 69.4% (50) performing lymphadenectomies laparoscopically. The external iliac nodal group was the nodal group that was consistently part of the lymphadenectomy with other nodal groups variably removed depending on the stage. All centers offered fertility-conserving surgery in stage IA1 cervical cancer and most up to and including stage IB1 with no lymphovascular space invasion. The fertility-conserving procedures performed varied among respondents: 20.3% (15 respondents) abdominal radical trachelectomy, 47.35 (35 respondents) radical vaginal trachelectomy, 58.1% (43 respondents) trachelectomy, 97.3% (72 respondents) cone biopsy, and 67.6% (50 respondents) large loop excision of the transformation zone. When fertility conservation was not desired, there was variation in the surgical techniques offered. Chemotherapy was used to downstage tumors preoperatively in 16.4% (11) before fertility-conserving surgery and 50.8% (34) before radical surgery. There are wide variations in the use of preoperative imaging, when pelvic and para-aortic lymph nodes are removed, and as to which surgical procedure should be offered in the management of cervical cancer both when fertility conservation is and is not an issue.

Surgical Management of Early Cervical Cancer: The Shape of Future Studies

Early cervical cancer, in particular in the presence of favorable pathologic risk factors, accounts for a very low incidence of parametrial involvement and lymph node metastasis. This means that a less radical surgery may be an oncologically safe treatment in selected cases, with the aim of preserving fertility and/or reducing morbidity without compromising survival. The extensiveness of surgery has decreased relatively in recent decades, the "modified" radical hysterectomy still being the current gold standard by most international guidelines. Vaginal (or abdominal) radical trachelectomy, simple hysterectomy, or cervical conization has been proposed in association with pelvic lymphadenectomy. Sentinel lymph node mapping may be an option to avoid a complete pelvic lymphadenectomy. Ongoing research efforts are especially being made in properly identifying the patient subset suitable for a conservative/less radical approach and prospectively confirming the oncological safety of the proposed clinical-pathological algorithms.

Bilateral Negative Sentinel Nodes Accurately Predict Absence of Lymph Node Metastasis in Early Cervical Cancer: Results of the SENTICOL Study

Sentinel lymph node (SLN) biopsy may be used to target lymph node metastases in patients with early cervical cancer. Whether SLN biopsy only is acceptable in the staging and surgical management of early cervical cancer remains unknown. This prospective multicenter study (SENTICOL [Ganglion Sentinelle dans le Cancer du Col]) assessed the sensitivity and negative predictive value (NPV) of SLN biopsy. Adults with cervical carcinoma who met the International Federation of Gynecology and Obstetrics criteria for stage IA1 with lymphovascular space invasion to stage IB1 underwent technetium 99 lymphoscintigraphy and Patent Blue injection followed by laparoscopic lymph node mapping, SLN removal, and lymph node dissection. Only surgeons trained in SLN biopsy in cervical carcinoma participated in the study. SLNs and nonsentinel lymph nodes underwent routine staining. Negative SLNs were subjected to ultrastaging. The reference method was pelvic and/or para-aortic lymphadenectomy with histologic examination of all nodes. One hundred forty-five patients were enrolled, and 139 were included in a modified intention-to-diagnose analysis. Intraoperative radioisotope-blue dye mapping detected at least one SLN in 136 patients (97.8%; 95% CI, 93.8% to 99.6%), 23 of whom had true-positive results and two who had false-negative results, yielding 92.0% sensitivity (23 of 25; 95% CI, 74.0% to 99.0%) and 98.2% NPV (111 of 113; 95% CI, 74.0% to 99.0%) for node metastasis detection. No false-negative results were observed in the 104 patients (76.5%) in whom SLN were identified bilaterally. Combined labeling for node mapping was associated with high rates of SLN detection and with high sensitivity and NPV for metastasis detection. However, SLN biopsy was fully reliable only when SLNs were detected bilaterally.

Robotic surgery in gynecologic oncology

The goal of this paper is to review the current data documenting the advantages of robotic surgery over open or laparoscopic surgery. The aim of this study is to compare the complications and perioperative outcome of robotic surgery with open and laparocopic surgery, in gynecologic oncology. The terms radical robotic or robot- assisted hysterectomy in PubMed search lead to 41 references. We excluded one review of literature, ten studies with benign and malignant cases, eight cases reports, one letter to the editor. We kept the prospective studies and comparative studies (total abdominal hysterectomy (TAH) vs. total robotic hysterectomy (TRH), total laparoscopic hysterectomy (TLH) vs. TRH or TAH vs. TRH vs. TLH). The results are separated for endometrial cancers, early cervical cancers, pelvic and paraaortic lymph node dissections, radical parametrectomy and trachelectomy, and pelvic exenteration. The literature on robotic-assisted radical hysterectomy supports its safety and feasibility for the surgical management of early cervical cancer and endometrial cancer. However, the results of a phase III randomized clinical trial testing the equivalence of outcomes after laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy are expected.

Recurrence during pregnancy of a conservatively treated early-stage cervical squamous cell carcinoma

To evaluate the safety of conservative management of early cervical cancer. Case report and analysis of literature guidelines. Academic teaching hospital. A 35-year-old, nulliparous woman treated by simple trachelectomy and pelvic lymphadenectomy for a well-differentiated, 12-mm squamous cell carcinoma infiltrating to a depth of 3 mm (stage Ib1) without lymphovascular space involvement. Follow-up. Recurrence and disease evolution. Sixteen months after surgery, at 32 weeks' gestation, a local recurrence of 5 cm in diameter was diagnosed, associated with pelvic and interaortocaval lymph node involvement. Despite extensive radiotherapy, chemotherapy, and radical surgery, disease progression could not be halted. We report a case of early-stage cervical cancer, conservatively treated by simple trachelectomy and lymphadenectomy, that recurred although none of the known risk factors for recurrence were initially present, and despite the fact that literature guidelines were followed.

Recent Advances in the Surgical Management of Cervical Cancer

Recent advances in the surgical management of early cervical cancer, including abdominal, laparoscopic, vaginal, and robotic approaches to radical hysterectomy as well as fertility-sparing radical trachelectomy, are reviewed. The nerve-sparing abdominal radical hysterectomy technique allows for a significant reduction in postoperative bladder morbidity. Radical vaginal hysterectomy with laparoscopic lymph node dissection is a well-recognized technique that offers excellent cure rates without abdominal entry as well as reduced postoperative febrile and gastrointestinal morbidity. Total laparoscopic radical hysterectomy is a minimally invasive alternative to the traditional abdominal radical hysterectomy approach and yields a comparable safety profile with a significant reduction in blood loss and hospital stay. Robotic surgery is becoming more widely accepted in the management of gynecologic cancers, including radical hysterectomy for early cervical cancer. Young women desiring to bear children in the future may be candidates for fertility preservation options, and the radical trachelectomy operation has been described and performed with abdominal, vaginal, laparoscopic, and robotic techniques. There are a number of surgical options for the treatment of women with early cervical cancer. The feasibility and safety of some of these techniques have been well established, whereas for others, the oncological outcome data are only preliminary. The decision to use newer techniques should be directed by patient variables as well as the surgeon's training and competence with laparoscopy, robotics, or vaginal surgery.