Minimally Invasive Radical Hysterectomy Research Articles

Comparison of outcomes of laparotomic and minimally invasive radical hysterectomy in women with early-stage cervical cancer.

This study compared the outcomes of laparotomic radical hysterectomy (LRH) and minimally invasive radical hysterectomy (MISRH) in patients with early-stage cervical cancer. The clinical data of patients with early-stage cervical cancer who underwent LRH or MISRH (laparoscopic/robotic) at Chang Gung Memorial Hospital, Linkou Branch, from 2002 to 2017 were retrospectively reviewed. The surgical safety (operation time, blood loss, blood transfusion rate, length of postoperative stay, and perioperative complications), overall survival (OS), disease-free survival (DFS), and recurrence pattern were analyzed. Propensity score matching (PSM) at a 3:1 ratio was performed to balance prognostic variables. Of the 760 patients (entire cohort), 614 underwent LRH and 146 underwent MISRH. After PSM, 394 and 140 patients were included in the LRH and MISRH groups, respectively. The 5-year OS rate was significantly lower in the MISRH group than in the LRH group (85.6% vs. 93.2%, p=0.043), and the 5-year DFS rate (p=0.21) did not differ significantly. After PSM, the 5-year OS rates did not differ significantly between the MISRH and LRH groups (87.1% vs. 92.1%, p=0.393). The MISRH group had a significantly shorter operation time (p<0.001), lower intraoperative blood loss (p<0.001), lower blood transfusion rate (p<0.001), and shorter postoperative stay (p<0.001) but a significantly higher rate of intraoperative bladder injury (p<0.001) than the LRH group. After PSM, MISRH is associated with nonsignificantly lower OS but a significantly higher risk of intraoperative urological complications than LRH.

Laparotomic radical hysterectomy versus minimally invasive radical hysterectomy using vaginal colpotomy for the management of stage IB1 to IIA2 cervical cancer: Survival outcomes.

This study compared survival outcomes for patients with stage IB1 to IIA2 (International Federation of Gynecology and Obstetrics stage 2009) cervical cancer who underwent open radical hysterectomy (ORH) versus those who underwent minimally invasive radical hysterectomy (MIRH) using vaginal colpotomy (VC).Data for 550 patients who were diagnosed with cervical cancer at our institution during the period August 2005 to September 2018 was retrospectively reviewed. Of these, 116 patients who underwent radical hysterectomy (RH) were selected after applying the exclusion criteria. All MIRH patients underwent VC. Clinicopathological characteristics and survival outcomes between the ORH and MIRH groups were compared using appropriate statistical testing.Ninety one patients were treated with ORH and 25 with MIRH during the study period. Among the MIRH patients, 18 underwent laparoscopy-assisted radical vaginal hysterectomy and 7 underwent laparoscopic RH. Preoperative conization was performed more frequently in MIRH patients than in ORH patients (44% vs 22%, respectively, P = .028). The incidence of lymph node invasion was higher in the ORH group than in MIRH group (37.4% vs 12.0% respectively; P = .016). Following RH, ORH patients underwent adjuvant treatment more frequently than MIRH patients (71.4% vs 56.0%, respectively, P = .002). There were no significant differences between ORH and MIRH patients for either progression-free survival (PFS) (91.3% vs 78.7%, respectively; P = .220) or 5-year overall survival (OS) (96.6% vs 94.7%, respectively, P = .929). In univariate analysis, lympho-vascular space invasion was the only clinicopathological feature associated with decreased PFS. No other clinicopathological factors was significantly associated with PFS or OS in univariate and multivariate analyses.Despite a higher incidence of unfavorable prognostic factors in ORH patients, their survival outcomes were not different to those of MIRH patients with VC.

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

IntroductionRadical hysterectomy (RH) with bilateral pelvic lymph node dissection is the standard treatment for early stage cervical cancer which can be performed either by an abdominal or a minimally invasive (MIS) approach. In 2018, Ramirez et al. presented their randomized-controlled trial data which demonstrated that patients who were treated with minimally invasive surgical (MIS) radical hysterectomy (RH) had higher rates of locoregional disease recurrence and lower rates of overall survival when compared to patients treated with an abdominal approach. The objective of this study is to examine the trends in management of patients diagnosed with cervical cancer in New York State (NYS) and to analyze their perioperative outcomes. MethodsUsing the Statewide Planning and Research Cooperative System (SPARCS) Database, patients undergoing RH for early stage cervical cancer in NYS between the years of 2007–2015 were identified and categorized based on surgical approach. Demographic information was collected and multivariable regression was conducted to assess the impact of hysterectomy approach on perioperative outcomes. ResultsIn NYS, 5575 patients were treated with RH for early stage cervical cancer with 3257 (58.4%) treated by abdominal RH and 2318 (41.6%) treated with MIS RH. Between the years of 2007 and 2015, patients diagnosed with cervical cancer treated with MIS RH increased from 25.7% to 48.3% respectively. Surgeons performing MIS RH were more likely to be younger (average age 47.1 vs 49.2, p < 0.001) and have less time elapsed from their fellowship graduation (20.37 vs 22.64 years, p < 0.001). Patients who saw high volume doctors (OR 1.95, CI 1.65–2.31) and were seen in high volume facilities (OR 1.40, CI 1.18–1.65) were more likely to undergo MIS RH compared to abdominal RH. Patients who underwent MIS RH were more likely to be discharged home as opposed to acute rehab or nursing facility, when compared to patients treated with abdominal RH (98.5 vs 94.2% p < 0.001). When analyzing perioperativce outcomes, patient undergoing MIS RH had a 85% decrease in length of hospital stay compared to abdominal RH, a 40% reduction in 30-day readmission rates, and a 10% reduction in hospital costs respectively. DiscussionIn our study period, between the years of 2007 and 2015, the number of cervical cancer cases treated with MIS RH increased from 25.7% to 48.3%. MIS techniques led to a reduction in length of hospital stay, patient readmission rates, and hospital costs. Based on recent data from Ramirez et al., preliminary data demonstrated decrease in MIS RH for treatment of cervical cancer after presentation of the LACC trial and our data confirmed these reported trends in NYS. With this change in surgical practice, there will be associated changes in perioperative outcomes. Moreover, for patients diagnosed with cervical cancer with microscopic disease or previous treatment with an excisions procedure, MIS approach should be considered for improvement in perioperative outcomes as long as oncologic outcomes are not compromised.

Surgical route and pathological risk factors in early cervical cancer - Node Zero (SURPEC-N0)

Aim: The aim of this study is to compare disease-free survival (DFS) and overall survival (OS) in patients with stage I cervical cancer (≤ 4cms, lymph node-negative) undergoing open radical hysterectomy (ORH) vs. minimally invasive radical hysterectomy (MIRH). Methods: All patients undergoing radical hysterectomy between January 2012-December 2018 from the largest tertiary referral cancer centre were included. A 1:1 propensity matching was done based on four independent prognostic factors to compare DFS and OS with the route of surgery. Results: One hundred and ninety-nine patients were included during the study period. The median age of the cohort was 50 years. The median follow-up of patients was 47 months. Following 1:1 propensity matching, a total of 174 patients were analysed for DFS and OS in ORH (n = 87) and MIRH (n = 87) groups. Protective measure was used in two-thirds of the patients during MIRH. Twenty-nine patients (16.7%) had recurrences. For the matched cohort (n = 174), the DFS at 36 and 60 months was 84.8% (78.1%-89.6%) and 81% (73.4%-86.6%) respectively and the OS was 96.5% (91.7%-98.5%) and 95.6% (90.3%-98%) respectively. There was no statistically significant difference in DFS or OS between ORH and MIRH. Conclusion: The present study showed no difference in oncological outcomes in MIRH compared to ORH. Retrospective audits on patient characteristics such as screening/vaccination history along with surgical technique/load and matching for crucial risk factors should be factored in future studies to eliminate the possible methodological errors.

Impact of facility volume on the outcomes of minimally invasive radical hysterectomy for early-stage cervical cancer

<h3>Objectives:</h3> Investigate the average facility volume of minimally invasive radical hysterectomy (MIRH) and the impact of facility volume on the outcomes of patients with apparent early-stage cervical carcinoma. <h3>Methods:</h3> The National Cancer Database was accessed and patients with a cervical malignancy who underwent MIRH between 2010 and 2016 were identified. Annual facility volume was calculated, and high-volume centers were defined as those who performed at least 6 procedures per year. Impact of facility volume on inpatient stay, readmission rate and overall survival (OS) was evaluated for patients with apparent early-stage disease and no history of another tumor with available survival data. OS was compared with the log-rank test while a multivariate Cox model was constructed to control for confounders. <h3>Results:</h3> A total of 5806 patients with cervical cancer underwent MIRH between 2010-2016 in 669 facilities. Median facility volume was 1.5 cases per year; only 19 facilities performed at least 6 MIRH per year. A total of 3529 patients with apparent early-stage disease who underwent MIRH were selected; 16.7% were managed at a high-volume center. Patient age, race, and presence of co-morbidities and tumor extension was comparable between high and low-volume centers. Rate of robotic-assisted surgery was 22.7% and 20.9% for patients undergoing surgery at high and low-volume centers, p=0.33. Conversion to open surgery (2% vs 2.9%, p=0.24), and 30-day readmission (5.4% vs 4%, p=0.12) rates were comparable between high and low-volume centers. Patients at high-volume centers were more likely to be discharged within 1 day (65.6% vs 60.5%, p=0.022). There was no difference in the OS between patients who had MIRH at a high or low- volume centers, p=0.14; 3-year OS rates were 92.5% and 94.2% respectively. After controlling for confounders, patients who had MIRH at a high-volume center did not have better survival (HR: 1.32, 95% CI: 0.96, 1.33). <h3>Conclusions:</h3> Given the rarity of cervical cancer, MIRH was a highly de-centralized procedure with the vast majority of centers not achieving a large annual surgical volume. However, we could not observe a direct impact of hospital volume on outcomes for patients with apparent early stage disease.

Does obesity influence the preferred treatment approach for early-stage cervical cancer? A cost-effectiveness analysis

<h3>Objectives:</h3> Obesity is a major public health concern and can have a negative impact on surgical outcomes. In 2018, a large, randomized control trial evaluated outcomes of minimally invasive radical hysterectomy (MIH) versus open abdominal radical hysterectomy (TAH) for treatment of early stage cervical cancer finding lower rates of disease free and overall survival in TAH. Regarding cost, previous studies have investigated outcomes and costs between MIH and TAH as well as between primary radiation and TAH, yet limited data exists on the outcomes and cost effectiveness of these treatments when compared among different body mass index (BMI) levels. The objective of this study was to examine how outcomes varied by BMI between treatment options for early stage cervical cancer and to ascertain which option was cost effective. <h3>Methods:</h3> A Markov decision analytic model was designed using TreeAge Pro software to compare the outcomes and costs of primary radiation versus surgery in women with stage IA1-IB1 cervical cancer. We used a theoretical cohort of 6,000 women who were definitively treated with either (1) TAH, (2) MIH, or (3) primary radiation therapy. We compared results for three BMI ranges: <30 kg/m², 30-39.9 kg/m², and ≥40 kg/m². Model inputs were derived from the literature and the model was run over a 5-year time period. Outcomes included complications, recurrence, death, costs, and quality-adjusted life years (QALYs). Sensitivity analyses were performed to determine the robustness of the results. An intervention was deemed cost effective with an incremental cost-effectiveness ratio (ICER) of less than $100,000 per QALY. <h3>Results:</h3> Among our cohort of 6,000 women with stage IA1-IB1 cervical cancer, TAH was associated with fewer cervical cancer recurrences and deaths compared to MIH; however, TAH resulted in more complications at each BMI level. Surgical complications outnumbered radiation-related complications as BMI increased. Recurrence rates were similar between TAH and radiation therapy, while there were more deaths associated with surgery. Comparing TAH to MIH, women with a BMI less than 30 had an ICER of $6,800 per QALY and women with a BMI 30-39.9 had an ICER of $739 per QALY. In women with a BMI ≥ 40, TAH was dominant. Comparing TAH to radiation therapy, women with a BMI less than 30 had an ICER of $191,000/QALY and women with a BMI 30-39.9 had an ICER of $133,000/QALY, which were not cost effective. In women with a BMI ≥ 40, the ICER was $88,000/QALY, making radiation therapy cost effective. <h3>Conclusions:</h3> Increasing BMI affects surgical morbidity as well as cost effectiveness of treatment modality for early stage cervical cancer. We found that at a BMI ≥ 40, TAH is both cost effective and provides cost savings when compared to MIH. When compared to primary radiation, TAH is cost effective at a BMI < 30 and 30-39.9. When the BMI is ≥ 40, primary radiation becomes cost-effective. This suggests that for women with early stage cervical cancer with the greatest BMI, primary radiation may be the optimal management strategy.

Tumor histology and survival after minimally invasive radical hysterectomy for early-stage cervical cancer: a systematic review and meta-analysis

Objectives: A recent randomized controlled trial of minimally invasive (MIS) radical hysterectomy versus open surgery for early-stage cervical cancer has demonstrated higher recurrence and lower survival with MIS. However, given the lower operative morbidity of MIS, multiple groups have attempted to define subgroups of patients who may be able to undergo laparoscopic or robotic radical hysterectomy safely in retrospective cohort studies. Methods: We conducted a systematic review and meta-analysis of cohort studies and randomized controlled trials from 1990 to 2020 comparing MIS radical hysterectomy to open radical hysterectomy in early-stage cervical cancer (PROSPERO 2020 CRD42020173600). Cancer histology, laparoscopic or robotic approach, and overall survival (OS), progression-free survival (PFS), and recurrence rate were recorded for each study. We conducted a random-effects meta-analysis with inverse-probability weighting. Results: 41 studies including 22,593 unique women (10,686 MIS, 47%) were eligible for analysis; 6 reported outcomes by histology. Squamous cell carcinoma was the most common histology (79%). For adenocarcinoma, meta-analysis of 3 studies no differences in recurrence (RR 0.87, 95% CI 0.41-1.85), PFS (RR 0.98, 95% CI 0.07-1.89), or OS (RR 1.41, 95% CI 0.56-2.27) between open and MIS surgery. For SCC, two studies showed no change in PFS, and one large study reported decreased OS (HR 1.65, 95% CI 1.17-2.33). One small study found no difference in PFS or OS for neuroendocrine tumors of the cervix. One large study showed decreased OS with robotic versus open radical hysterectomy (HR 1.61, 95% CI 1.2-2.2), but no difference with laparoscopic versus open surgery (HR 1.50, 95% CI 0.97-2.3). Download : Download high-res image (132KB) Download : Download full-size image Conclusions: This meta-analysis contributes to examination of current evidence on surgical approach to early-stage cervical cancer. Our results suggest that there is no histological group for which MIS radical hysterectomy is superior to open radical hysterectomy, and equivalent to inferior outcomes with robotic or conventional laparoscopic surgery versus open surgery. Subgroup analysis generally showed equivocal or inferior outcomes with MIS compared to open surgery, though results remain limited by sample size.

Minimally-invasive hysterectomy versus open radical hysterectomy in early-stage cervical cancer: a cost-effective analysis of the LACC trial

<h3>Objectives:</h3> To determine the cost-effectiveness of minimally-invasive hysterectomy versus open radical hysterectomy in patients with early-stage cervical cancer. <h3>Methods:</h3> We created a model to evaluate the cost-effectiveness of minimally-invasive radical hysterectomy compared to open radical hysterectomy in women with newly diagnosed stage 1A1 (with lymphovascular invasion) thru IB2 (FIGO 2018) cervical cancer. We included 6,000 patients in the model which approached cost from a societal perspective. Surgical costs were calculated using the average Medicare reimbursement for the procedures with and without associated complications. Lost wages were calculated using return to normal daily activity per surgical approach and information from the Bureau of Labor Statistics. Estimated complication rates were calculated using the LACC trial data. Effectiveness was calculated as disease-free survival (DFS) at 4.5 years. We calculated incremental cost-effectiveness ratios (ICERs) to determine the cost per 4.5 year survivor. Univariate sensitivity analyses were performed. The willingness to pay threshold was $100,000 per year of DFS. <h3>Results:</h3> In the minimally-invasive radical hysterectomy cohort, the cost was $87.4 million (M) and yielded 5,160 4.5 year survivors. Comparatively, open radical hysterectomy cost $108.1 M and resulted in 5,760 4.5 year survivors. The ICER for open radical hysterectomy compared to minimally-invasive radical hysterectomy was $32,824 which fell well below our predetermined willingness to pay threshold of $450,000 per 4.5 year survivor. Sensitivity analyses were performed to determine the effect of complication rates on the model. The baseline rate of major complications with open radical hysterectomy was similar to minimally invasive radical hysterectomy (18.0 vs 16.0%). In order to evaluate the impact of medically compromised patients (comorbidities, obesity, and age >65), we varied the complication rates from 10-80% in the sensitivity analysis. With increasing complication rates in the open radical hysterectomy cohort, both the total costs and ICER increases ($64,044) but remains below the willingness to pay threshold. <h3>Conclusions:</h3> For patients with early-stage cervical cancer, open radical hysterectomy is cost-effective relative to minimally-invasive hysterectomy. Medical comorbidities and complication rates do not impact the results of the model. Open radical hysterectomy appears to be the preferred surgical approach for all patients with early-stage cervical cancer.

Impact of surgeon learning curve in minimally invasive radical hysterectomy on early stage cervical cancer patient survival.

Recently, it has been sustained that only surgeons skilled in minimally invasive radical hysterectomy (MI-RH) could provide valuable oncological outcomes in early-stage cervical cancer. Still, literature lacks data correlating surgeon experience with patient survival rate. We aimed to investigate the impact of surgeon training on this rate. This is a retrospective study of 243 early-stage cervical cancer treated with MI-RH. Multiple regression analyses were undertaken to investigate the impact of the surgeons learning curve, according to the number of MI-RH, on patients prognosis. A steady trend of reduction in disease recurrence risk is associated with increased surgeon experience. The peak of the learning curve was shown at the 19th MI-RH (hazard ratio of disease-free survival: 0.321; 95%CI: 0.140-0.737; p= 0.007). The 3 years disease-free survival that a surgeon could provide to patients is significantly lower at the beginning of his/her learning path comparing to what he/she could guarantee once adequate experience had been achieved (75.4% and 91.6% respectively, p=0.005). Surgeon experience appears to be an independent prognostic factor. The experience that a surgeon can achieve practicing in MI-RH significantly influences oncological outcomes of early-stage cervical cancer patients. Future studies comparing minimally invasive and open surgery should take this into account. It would be advisable that the scientific community precisely establishes the minimum training required in the field of MI-RH for early-stage cervical cancer.

Long-term oncological outcomes and recurrence patterns in early-stage cervical cancer treated with minimally invasive versus abdominal radical hysterectomy: The Norwegian Radium Hospital experience

ObjectiveTo compare long-term oncological outcomes in early-stage cervical cancer (CC) patients treated with minimally invasive radical hysterectomy (MIRH) versus abdominal radical hysterectomy (ARH), with a focus on recurrence patterns, tumor sizes, and conization. MethodsThis single-institution, retrospective study consisted of stage IA1-IB1 (FIGO 2009) squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma of the cervix, who underwent radical hysterectomy between 2000 and 2017. ResultsOf the 582 patients included, 353 (60.7%) underwent ARH, and 229 (39.3%) MIRH. The median follow-up was 14.4 years in the ARH group and 6.1 years in the MIRH group (p < 0.0001). Among the 96 stage IA patients, only 3 (3.1%) experienced recurrence. Among stage IB1 patients, the risk of recurrence, after adjusting for standard prognostic variables, was twofold higher in the MIRH group versus the ARH group (HR 2.73, 95% CI: 1.56–4.80), and the relative difference was similar in terms of risk of cancer-specific survival (CSS) (HR 3.04, 95% CI: 1.28–7.20) and overall survival (OS) (HR 2.35, 95% CI: 1.21–4.59). In stage IB1 ≤ 2 cm patients without conization MIRH was associated with reduced time to recurrence (TTR) (HR 4.00, 95% CI: 1.67–9.57), CSS (HR 3.71, 95% CI: 1.19–11.58) and OS (HR 3.02, 95% CI: 1.24–7.34). Intraperitoneal combined recurrences accounted for 12 of 30 (40.0%) recurrences in the MIRH group but were not identified after ARH (p = 0.0001). ConclusionsMIRH was associated with reduced TTR, CSS and OS versus ARH in stage IB1 CC patients. The risk of peritoneal recurrence was high, even for tumors ≤2 cm without conization.

Comparison of abdominal and minimally invasive radical hysterectomy in patients with early stage cervical cancer

Purpose: The aim of this study was to compare survival outcomes of open radical hysterectomy and minimally invasive radical hysterectomy (MIS) in early stage cervical cancer.Methods: A retrospective analysis of 148 patients with stage IB1 - IIA2 cervical cancer who underwent either minimally invasive or open radical hysterectomy. Tumor characteristics, recurrence rate, disease-free survival (DFS), and overall survival (OS) were compared according to surgical approach.Results: In total, 110 and 38 patients were assigned to open surgery and MIS groups. After a medical follow-up of 42.1 months, the groups showed similar survival outcomes (recurrence rate, DFS, and OS). However, in patients with tumor size >2 cm, recurrence rate was significantly higher in MIS group (22.5% vs 0%; p=0.008). And in patients with tumor size >2 cm, MIS group showed significantly poorer DFS than open surgery group (p=0.017), although OS was similar between the two groups (p=0.252).Conclusion: In patients with tumor size >2 cm, MIS was associated with higher recurrence rates and poorer DFS than open surgery. However, in patients with tumor size ≤2 cm, MIS did not seem to compromise oncologic outcomes.

Impact of the Learning Curve on the Survival of Abdominal or Minimally Invasive Radical Hysterectomy for Early-Stage Cervical Cancer.

PurposeThe objective of this study was to define the learning curve required to attain satisfactory oncologic outcomes of cervical cancer patients who were undergoing open or minimally invasive surgery for radical hysterectomy, and to analyze the correlation between the learning curve and tumor size.Materials and MethodsCervical cancer patients (stage IA–IIA) who underwent open radical hysterectomy (n=280) or minimal invasive radical hysterectomy (n=282) were retrospectively reviewed. The learning curve was evaluated using cumulative sum of 5-year recurrence rates. Survival outcomes were analyzed based on the operation period (“learning period,” P1 vs. “skilled period,” P2), operation mode, and tumor size.ResultsThe 5-year disease-free and overall survival rates between open and minimally invasive groups were 91.8% and 89.0% (p=0.098) and 96.1% and 97.2% (p=0.944), respectively. The number of surgeries for learning period was 30 and 60 in open and minimally invasive group, respectively. P2 had better 5-year disease-free survival than P1 after adjusting for risk factors (hazard ratio, 0.392; 95% confidence interval, 0.210 to 0.734; p=0.003). All patients with tumors < 2 cm had similar 5-year disease-free survival regardless of operation mode or learning curve. Minimally invasive group presented lower survival rates than open group when tumors ≥ 2 cm in P2. Preoperative conization improved disease-free survival in patients with tumors ≥ 2 cm, especially in minimally invasive group.ConclusionMinimally invasive radical hysterectomy required more cases than open group to achieve acceptable 5-year disease-free survival. When tumors ≥ 2 cm, the surgeon’s proficiency affected survival outcomes in both groups.

Survival after minimally invasive surgery in early cervical cancer: Is the uterine manipulator to blame?

Objective: Minimally invasive radical hysterectomy (MIS-RH) has been shown to be associated with decreased survival in patients with early cervical cancer. The objective of this study was to determine whether the use of a uterine manipulator at the time of laparoscopic or robotic radical hysterectomy has an impact on patient outcomes.

Trends in mortality after surgery for early-stage cervical cancer in the United States after introduction of minimally invasive radical hysterectomy: An interrupted time series analysis

Objective: The aim of this study was to examine trends in 4-year all-cause mortality among women undergoing radical hysterectomy for cervical cancer during the period of rapid adoption of minimally invasive radical hysterectomy (MIRH), and to compare these trends with those of other surgically treated solid tumor malignancies.

Minimally invasive radical hysterectomy for early-stage cervical cancer: Association between hospital surgical volume and perioperative outcomes

Objective: U.S. surgeons began adopted minimally-invasive radical hysterectomy (MIS-RH) for early-stage cervical cancer in the mid-late 2000s. This study examined the association between hospital surgical volume for MIS-RH and perioperative outcomes for early-stage cervical cancer.

Regional trends of minimally invasive radical hysterectomy for cervical cancer and exploration of perioperative outcomes

Objective: Radical hysterectomy with bilateral pelvic lymph node dissection is the standard treatment for early-stage cervical cancer. Until recently, in addition to the standard open approach, the procedure was frequently performed by a minimally invasive (MIS) approach. Randomized control trial data presented in 2018 demonstrated that patients who underwent MIS radical hysterectomy had higher rates of disease recurrence and worse overall survival when compared to open radical hysterectomy. The aim of this study was to examine practice trends in New York state.

The Development of a New Uterine Manipulation Method during Minimally Invasive Radical Hysterectomy

The use of a vaginal uterine manipulator may compromise the oncological outcomes of patients with cervical cancer undergoing minimally invasive radical hysterectomy (MIS-RH). We aimed to describe the safety and efficacy of a novel uterine manipulation device during MIS-RH. Retrospective study. A university hospital and a tertiary care hospital. Patients with early-stage cervical cancer who were treated with MIS-RH. We developed the U-traction, a new device that consists of a 65-mm half-curved cutting needle with a 2.5-mm polyester tape (45-cm long), and investigated its utility to manipulate the uterus during MIS-RH. This study describes the utility and safety of the U-traction for uterine manipulation during laparoscopic or robotic RH in 8 patients with cervical cancer. Uterine manipulation was successfully and safely performed using the U-traction during laparoscopic or robotic RH in patients with cervical cancer without any complications. The application time was less than 5 minutes. In all cases, the use of a vaginal manipulator, an additional incision for an extra port, or the need for assistant surgeons for uterine manipulation was avoided. The novel U-traction device allows for easy and reproducible uterine manipulation during MIS-RH. With this device, the use of a vaginal uterine manipulator can be avoided, and MIS-RH can be safely performed without the need for an assistant surgeon for uterine manipulation.

Efficacy of different surgical approaches on survival outcomes in patients with early-stage cervical cancer: protocol for a multicentre longitudinal study in China

IntroductionRecent studies have revealed that the oncological survival outcomes of minimally invasive radical hysterectomy (MIRH) are inferior to those of abdominal radical hysterectomy (ARH) in early-stage cervical cancer, but the...

Rapid dissemination of practice-changing information: A longitudinal analysis of real-world rates of minimally invasive radical hysterectomy before and after presentation of the LACC trial

ObjectiveCharacterize change in rates of minimally invasive (MIS) radical hysterectomy after presentation of the LACC trial. MethodsLongitudinal analysis of data from Vizient® database for surgically treated patients with invasive cervical cancer from April 2017–March 2019. Covariates studied included patient demographic and obesity categories, dates of LACC trial presentation and publication, and hospital characteristics. Results2102 cervical cancer patients had surgery at 201 hospitals. Most were age 31–50 (51.2%), White (64.8%), and had public (49.2%) health insurance. Annual rates of MIS fell from 51.9% to 27.1% after the LACC trial presentation (RR 0.52, 95% CI 0.47, 0.58; p < 0.0001). Adjusting for within hospital correlation, the odds of MIS dropped by 13% per month (OR = 0.872 per month, 95% CI 0.852, 0.891; p < 0.001), without further change in rates of MIS after the peer-review publication (OR = 1.033 per month, 95% CI 0.897, 1.189; p = 0.65). Rates of MIS declined across all demographics (RR = 0.32–0.65; p < 0.01), except in morbidly obese women (RR = 0.90; p = 0.60). Applying mixed effects model, rates of MIS fell by 3% per month in morbidly obese women versus 18% per month if body mass index<40 kg/m2. NCCN member hospitals and hospitals with gynecologic oncology fellowship training programs significantly reduced rates of MIS radical hysterectomy faster, but not earlier, than other hospitals. ConclusionsRates of MIS radical hysterectomy fell dramatically and pervasively after the LACC trial presentation, despite ongoing substantive controversy. Practice pattern changes were not significant in morbidly obese women.

Introducing nerve-sparing approach during minimally invasive radical hysterectomy for locally-advanced cervical cancer: A multi-institutional experience

ObjectiveTo evaluate the impact of nerve-sparing (NS) approach on outcomes of patients undergoing minimally invasive radical hysterectomy (MRH) for locally advanced stage cervical cancer (LACC). MethodsData of consecutive patients undergoing minimally invasive surgery for LACC were retrospectively retrieved in a multi-institutional setting from 2009 to 2016. All patients included had minimally invasive class III radical hysterectomy (MRH or NS-MRH). Propensity matching algorithm was used to decrease possible allocation bias when comparing outcomes between groups. ResultsOverall, 83 patients were included. The prevalence of patients undergoing NS approach increased aver the study period (from 7% in the year 2009–2010 to 97% in the year 2015–2016; p-for-trend < 0.001). NS-MRH and MRH were performed in 47 (57%) and 36 (43%) patients, respectively. After the application the propensity-matching algorithm, we compared 35 patients' pair (total 70 patients). Postoperative complications rate was similar between groups. Patients undergoing NS-LRH experienced shorter hospital stay than patients undergoing LRH (3.6 vs. 5.0 days). 60-day pelvic floor dysfunction rates, including voiding, fecal and sexual alterations, were lower in the NS group in comparison to control group (p = 0.02). Five-year disease-free (p = 0.77) and overall (p = 0.36) survivals were similar comparing NS-MRH with MRH. ConclusionsThe implementation of NS approach in the setting of LACC improves patients' outcomes, minimizing pelvic dysfunction rates. NS approach has not detrimental effects on survival outcomes.