Open Radical Hysterectomy Research Articles

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.

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.

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.

Comparison of radical hysterectomy with pelvic lymphadenectomy and radical prostatectomy with lymphadenectomy: Medicare reimbursement 2010-2019

<h3>Objectives:</h3> To investigate differences in Medicare reimbursement between hysterectomy and prostatectomy (with lymphadenectomy) between Gynecology and Urology <h3>Methods:</h3> The Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid was utilized to extract reimbursement data for the two CPT codes representing open radical hysterectomy with lymphadenectomy and laparoscopic radical hysterectomy with lymphadenectomy. Likewise, the CPT code representing open radical prostatectomy with lymphadenectomy and the two CPT codes representing laparoscopic radical prostatectomy and lymphadenectomy was also collected. There is no code that combines laparoscopic prostatectomy and lymphadenectomy, so the values were combined. Average annual and total percent change in reimbursement was calculated for each hysterectomy with lymphadenectomy and prostatectomy with lymphadenectomy. <h3>Results:</h3> Reimbursement for the open hysterectomy with lymphadenectomy decreased by an average of 13.72%, and for the open prostatectomy with lymphadenectomy by 27.88% from 2010 to 2019 with R-squared values of 0.98 and 0.92, respectively. Reimbursement rates from 2010 to 2019 for open procedures averaged $1,828.59 and $1,649.44, respectively. Reimbursement for laparoscopic hysterectomy with lymphadenectomy decreased by an average of 13.72% with an R-value of 0.98 and by 34.99% with an R-value of 0.94 for the laparoscopic prostatectomy with lymphadenectomy procedure. Reimbursement rates for laparoscopic procedures from 2010 to 2019 averaged $1,860.22 and $2,722.99, respectively. <h3>Conclusions:</h3> This study provides an analysis of trends in procedural Medicare reimbursement for oncologic procedures performed by gynecologic and urologic surgeons. Findings suggest that urologists are reimbursed slightly less for open radical prostatectomy with lymphadenectomy compared to their gynecology counterparts, while being reimbursed more for laparoscopic prostatectomy with lymphadenectomy compared to their gynecology counterparts. This is an area of concern since minimally invasive procedures have become the industry standard. Results suggest continuing disparities surrounding Medicare reimbursements for sex-specific procedures

Minimally invasive versus open surgery for stage 1A1 and 1A2 cervical cancer

<h3>Objectives:</h3> Recent studies comparing minimally invasive versus open radical hysterectomy in patients with early stage cervical cancer have reported a worse overall survival with minimally invasive surgery (MIS). However, in the patients with microscopic disease, there was no survival difference and the optimal surgical approach for microscopic cervical cancer remains unclear. Our aim was to compare the overall survival and surgical outcomes between open and MIS in a large cohort of women with stage IA1/IA2 cervical cancer. <h3>Methods:</h3> Using the National Cancer Database, we identified a cohort of women who underwent hysterectomy as the primary treatment for stage IA1/IA2 cervical cancer between January 2010 and December 2016. Outcomes were compared between the cohorts using the Mann-Whitney U test, the chi- squared test or Fisher's exact test. Multivariable logistic regression was used to determine clinical characteristics that were statistically significant predictors of outcome. P values <0.05 were significant. The data was stratified for radical and simple hysterectomy. We also compared the readmission rates and length of stay (LOS) among the groups. <h3>Results:</h3> We identified 6230 patients with stage IA1 and IA2 cervical cancer that underwent hysterectomy as primary treatment. 4054 of these women (65%) underwent MIS and 1931 women had a radical hysterectomy. In this group, 1152 had a minimally invasive radical hysterectomy. In the overall cohort, there was no difference in survival between the open and the MIS group (Hazard ratio for the open group 1.23; CI 0.92-1.63). When stratified, the data showed no difference in overall survival for stage IA1 cases (HR 1.15; CI 0.77-1.73). For women with stage IA2, there was a trend towards decreased overall survival in the open group that did not reach statistical significance (HR 1.64; CI 0.84-3.23). Of note, post-operative radiation therapy was more common in the open group (5.24% vs 4.09%, p value <0.02). The mean LOS (1.35 days vs 3.08 days) was shorter in MIS group (pvalue <0.0001). No statistical significance was found in the readmission rates (60% for the MIS group vs 55% for the open group; p value 0.14). For the women who underwent a radical hysterectomy, there was no difference in survival between the open and the MIS cohort (p value 0.31) and as expected, the MIS group was associated with a decreased length of stay. <h3>Conclusions:</h3> Our data suggest that MIS is associated with similar overall survival and shorter length of hospital stay compared to the open hysterectomy in women with stage IA cervical cancer. When the data was stratified to simple and radical hysterectomy, the results were the same. Those women having open surgery were more likely to get post-operative radiation therapy. Based on this large data set, MIS appears to be a safe and effective surgical approach for women with stage IA1/IA2 cervical cancer.

Radical hysterectomy practice patterns for early-stage cervical cancer: a cross-sectional survey of gynecologic oncologists

Objectives: In this study, we evaluated current practice patterns related to radical hysterectomies for early stage cervical cancer and how they have changed since new literature was released in 2018. Methods: This study was a cross-sectional survey of current gynecologic oncologists. The primary outcome assessed was performance of primarily open radical hysterectomies for FIGO Stages IA1, IA2, IB1, and IB2 cervical carcinoma. A secondary outcome assessed was a change in surgical practice. Multivariable logistic regression analyses were completed to assess for associations of demographic and surgical experience predictors. Additional descriptive analyses were performed to evaluate reasons physicians would consider a minimally invasive radical hysterectomy, specific changes made to surgical technique, concerns regarding the 2018 NEJM trials, and beliefs about the role of future clinical trials. Results: Of 1309 SGO members invited to participate, 249 responded (19.0%) and 218 (87.6%) complete responses were analyzed. Performance of primarily open radical hysterectomies was reported in 61.6%, 80.2%, and 88.9% of Stage IA2, IB1, and IB2 cancers, respectively. For Stage IA2 cancer, the age group of 40-49 was associated with 73% lower odds of performing primarily open hysterectomies compared to the reference group of ages 30-39 (OR 0.27, p=0.01). Female gender was associated with greater odds of performing primarily open radical hysterectomies (OR 2.03, p=0.04 for IA2, OR 3.25, p=0.01 for IB1). For Stage IB2 cancers, no demographic or surgical experience factors were statistically associated with performance of open surgery. Change from minimally invasive to open surgery was reported in 52.3%, 68.4%, and 71.1% of Stage IA2, IB1, and IB2 cancers, respectively. Change in minimally invasive technique was reported in 5.5%, 6.42%, and 5.96% of Stage IA2, IB1, and IB2 cancers, respectively. For Stage IA2 cancer, each decrease of 1 year in practice (i.e. since fellowship graduation) was associated with 10% greater odds of changing surgical route or technique. Time since fellowship graduation was associated with 23% greater odds of a change for Stage IB2 cancers. For Stage IB1 cancer, each increase in case volume by 1 radical hysterectomy annually was associated with 6% lower odds of changing surgical route or technique. Most (66.7%) physicians reported they would consider a minimally invasive hysterectomy for one or more reasons. The majority of respondents (84.7%) reported believing there is a role for additional studies evaluating the topic of route of surgery for early stage cervical cancer. Download : Download high-res image (239KB) Download : Download full-size image Conclusions: Despite emerging research demonstrating worse oncologic outcomes for minimally invasive radical hysterectomies in early stage cervical cancer, our research shows that current practices remain heterogeneous. In this study, female surgeons had greater odds of performing open surgery compared to their male colleagues for Stage IA2 and IB1 cancers. The odds for performing open surgery were lower in middle age surgeons compared to younger physicians. More recent fellowship graduation was associated with greater odds of change, indicating that more senior surgeons reported being less likely to change practice. Many individuals reported feeling there is room for additional randomized clinical trials to inform evidence-based practices. Given the high rates of practice change reported, there will also be a role for future epidemiologic studies to evaluate oncologic outcomes in the current practice environment.

Trends in immediate postoperative complications of trachelectomy for early-stage cervical cancer by surgical approach

Objectives: Given recent data demonstrating improved cervical cancer outcomes for open radical hysterectomy, further understanding of surgical and cancer outcomes for fertility-sparing trachelectomy is needed. We examined trends in the use of minimally-invasive (MIS) versus open approach to trachelectomy for early-stage cervical cancer and compared post-operative complications during the index hospitalization. Methods: We performed a retrospective cohort study of women age 45 years and younger with cervical cancer undergoing fertility-sparing trachelectomy in the 2010-2015 National Inpatient Sample. Hospital-level data was used to obtain nationwide estimates of patient characteristics, surgical complications, and length of stay. We compared MIS versus open approach to trachelectomy and compared complications for each using logistic regression models. Results: Nationwide, 523 women underwent fertility-sparing trachelectomy for cervical cancer. The mean age of women undergoing trachelectomy was 33, and 38% (95% CI 29-47) of trachelectomies were done using MIS. Mean length of stay was 2.0 days (95% CI 1.6-2.4) for MIS and 3.5 days (95% CI 3.0-4.0) for open trachelectomies. The overall complication rate was 23% (95% CI 15-31), and there was no statistically significant difference in the odds of a post-op complication for MIS versus open trachelectomy for cervical cancer (14 vs. 29%, OR 0.39, 95% CI 0.14-1.10). Bleeding complications were the most common (10%, 95% CI 4-16). Conclusions: While there was a trend towards slightly lower immediate post-operative complication for MIS trachelectomy, there was no statistically significant difference in immediate post-operative morbidity between open and MIS approaches. Until further data is available to compare cancer outcomes between these approaches, preference may be for open trachelectomy given similar post-operative morbidity.

Minimally invasive radical hysterectomy for cervical cancer: a systematic review and meta-analysis

<h3>Objectives:</h3> Recent studies have identified higher recurrence and lower survival with a minimally-invasive approach (MIS) versus abdominal approach to radical hysterectomy for early-stage cervical cancer. We aim to compare recurrence rate, progression-free survival, and overall survival for cervical cancer after MIS versus abdominal radical hysterectomy. <h3>Methods:</h3> We searched Medline, Embase, Central, and the Cochrane Library to identify studies from 1990 to 2020 that included women with stage 1 or higher cervical cancer treated with primary radical hysterectomy and compared recurrence and/or progession-free survival (PFS) and overall survival with MIS versus abdominal hysterectomy (PROSPERO 2020 CRD42020173600). <h3>Results:</h3> 50 studies, including 22,593 women with cervical cancer, met inclusion criteria. 29% of studies had less than 30 months of follow-up and 14% had 60+ months of follow-up. Of the 37 studies reporting PFS, 29 reported no difference and 8 reported decreased PFS with MIS approach. Of the 37 studies reporting OS, 2 studies reported improved OS with MIS approach, 31 reported no difference, and 4 reported decreased overall survival with MIS approach. For progression-free survival, the odds were non-significantly worse for women undergoing MIS radical hysterectomy (OR 1.25, 95% CI 0.98-1.52, 14 studies) when all studies were included. When limited to studies with 30+ months follow-up, the odds of progression-free survival were worse with MIS radical hysterectomy (OR 1.39 for 30+ months, 95% CI 1.09-1.70, 12 studies; OR 1.49 for 48+ months, 95% CI 0.94-2.03, 4 studies). For overall survival, the odds were not significantly different for MIS vs. abdominal hysterectomy (OR 0.82, 95% CI 0.58-1.06, 14 studies). When limited to studies with longer follow-up, the odds of overall survival remained non-significantly different for MIS vs. abdominal (OR 0.90 for 30+ months, 95% CI 0.53-1.26, 11 studies; OR 0.94 for 48+ months, 95% CI 0.42-1.46, 4 studies; OR 1.70 for 60+ months, 95% CI 0.62-2.78, 2 studies). <h3>Conclusions:</h3> In our meta-analysis of 50 studies, MIS radical hysterectomy was associated with worse progression-free survival compared to open radical hysterectomy for cervical cancer in studies with 30+ months of follow-up. The emergence of this finding with longer follow-up highlights the importance of high-quality studies to guide cancer and surgical treatment.

Lymph node ratio is a strong prognostic factor after minimally invasive surgery radical hysterectomy of early-stage cervical cancer

<h3>Objectives:</h3> To determine whether prognostic impact of lymph node ratio (LNR), defined as the ratio between the number of positive lymph nodes and removed lymph nodes, is different by the surgical approach of radical hysterectomy (RH) in node-positive, early-stage cervical cancer. <h3>Methods:</h3> We retrospectively identified 2009 FIGO stage IB1-IIA2 patients who underwent primary Type C RH between 2010 and 2018 at two tertiary hospitals. Among them, only those with pathologically proven lymph node metastases and received adjuvant radiation therapy were included. Each patient's LNR was calculated, and its prognostic significance was investigated according to the two surgical approaches, open surgery, and minimally invasive surgery (MIS). <h3>Results:</h3> In total, 55 patients were included in this analysis. All patients received concurrent chemoradiation therapy after surgery, and the median LNR (%) was 9.524 (range, 2.083-62.500). Based on receiver operating characteristic-curve analysis, the cut-off value for LNR (%) was determined as 8.831. Overall, patients with high LNR (≥8.831%; n=29) showed worse disease-free survival (DFS) than those with low LNR (<8.831%, n=26) (P=0.027), whereas no difference in overall survival was observed. Multivariate analyses adjusting clinicopathologic factors revealed that DFS was adversely affected by both MIS (HR, 8.132; P=0.038) and high LNR (HR, 10.837; P=0.045). In a subgroup of open RH, LNR was not associated with disease recurrence. However, in a subgroup of MIS, high LNR was identified as an independent poor prognostic factor for DFS (adjusted HR, 14.578; P=0.034). <h3>Conclusions:</h3> In patients with node-positive, early-stage cervical cancer, high LNR was associated with a significantly higher disease recurrence rate. This relationship was further consolidated among patients who received MIS RH.

Impact of adjuvant radiotherapy on survival outcomes in intermediate-risk, early-stage cervical cancer: analyses regarding surgical approach of radical hysterectomy

<h3>Objectives:</h3> This study aimed to investigate the impact of adjuvant radiotherapy (RT) on survival outcomes in patients with intermediate-risk, early-stage cervical cancer who underwent radical hysterectomy (RH). <h3>Methods:</h3> From the cervical cancer cohorts of two tertiary hospitals, patients with 2009 FIGO stage IB-IIA who underwent primary RH between 2010 and 2018 were identified. Patients with intermediate-risk factors that met the Sedlis criteria were included. Survival outcomes were compared between the patients who received adjuvant RT (study group; n=53) and those who did not receive adjuvant treatment (control group; n=30). <h3>Results:</h3> Compared to the control group, the study group showed significantly better recurrence-free survival (RFS; 5-year survival rate, 85.6% vs. 61.0%; p=0.009). In multivariate analysis, adjuvant RT was associated with a significantly lower risk of disease recurrence (adjusted HR, 0.241; 95% CI, 0.082-0.709; p=0.010). In a subgroup that underwent open RH (n=33), adjuvant RT showed a trend toward improved RFS with borderline statistical significance (adjusted HR, 0.098; 95% CI, 0.009-1.027; p=0.053). However, in a subgroup of minimally invasive surgery (n=50), adjuvant RT did not improve RFS. <h3>Conclusions:</h3> In conclusion, the implementation of adjuvant RT significantly reduced the disease recurrence rate in patients with intermediate-risk, stage IB-IIA cervical cancer treated primarily with surgery. A survival benefit from adjuvant RT differed according to the surgical approach.

Machine Learning Models to Predict Survival Outcomes According to the Surgical Approach of Primary Radical Hysterectomy in Patients with Early Cervical Cancer

Simple SummaryAn increased risk of relapse and death from minimally invasive radical hysterectomy has been reported in some patients with early cervical cancer. Thus, the development of an intuitive and precise decision-aid tool, which estimates recurrence and mortality rates by surgical approach, is necessary. To develop models predicting survival outcomes according to the surgical approach, we collected clinicopathologic and survival data of patients with 2009 FIGO stage IB cervical cancer who underwent a radical hysterectomy. Using only variables that could be obtained preoperatively, we developed various models predicting the probability of 5-year progression-free survival and overall survival. Among them, hybrid ensemble models, combined with logistic regression and multiple machine learning models, achieved the best predictive performance. The developed models are expected to help physicians’ and patients’ decision making related to the surgical approach for primary radical hysterectomy.We purposed to develop machine learning models predicting survival outcomes according to the surgical approach for radical hysterectomy (RH) in early cervical cancer. In total, 1056 patients with 2009 FIGO stage IB cervical cancer who underwent primary type C RH by either open or laparoscopic surgery were included in this multicenter retrospective study. The whole dataset consisting of patients’ clinicopathologic data was split into training and test sets with a 4:1 ratio. Using the training set, we developed models predicting the probability of 5-year progression-free survival (PFS) and overall survival (OS) with tenfold cross validation. The developed models were validated in the test set. In terms of predictive performance, we measured the area under the receiver operating characteristic curve (AUC) values. The logistic regression models comprised of preoperative variables yielded AUCs of 0.679 and 0.715 for predicting 5-year PFS and OS rates, respectively. Combining both logistic regression and multiple machine learning models, we constructed hybrid ensemble models, and these models showed much improved predictive performance, with 0.741 and 0.759 AUCs for predicting 5-year PFS and OS rates, respectively. We successfully developed models predicting disease recurrence and mortality after primary RH in patients with early cervical cancer. As the predicted value is calculated based on the preoperative factors, such as the surgical approach, these ensemble models would be useful for making decisions when choosing between open or laparoscopic RH.

Survival Outcomes in Patients With 2018 FIGO Stage IA2-IIA2 Cervical Cancer Treated With Laparoscopic Versus Open Radical Hysterectomy: A Propensity Score-Weighting Analysis.

ObjectiveTo compare the survival and recurrence outcomes between open and laparoscopic radically hysterectomy (RH) for stage IA2-IIA2 cervical cancer based on Federation International of Gynecology and Obstetrics (FIGO) 2018.MethodsData of 1,373 early cervical cancer patients undergoing open or laparoscopic radically hysterectomy at ShengJing Hospital of China Medical University between January 1, 2013, and December 31, 2016, were retrospectively reviewed. Propensity score-based inverse probability of treatment weighting (PS-IPTW) was used to balance the covariates between the two groups.ResultsA total of 705 cervical cancer patients of FIGO 2009 stage IA2-IIA2 were finally enrolled in this study. After IPTW adjustment, the OS (HR = 2.095, 95% CI: 1.233-3.562, P = 0.006) and PFS (HR = 1.950, 95%CI: 1.194-3.184, P = 0.008) rates were significantly higher in the open RH (ORH) group compared with the laparoscopic RH (LRH) group. Then after re-staging according to the FIGO 2018 staging system, 561 patients still belonged to stage IA2-IIA2, 144 patients were upgraded to stage IIIC1p-IIIC2p. The ORH group had a significantly superior OS (HR = 1.977, 95%CI: 1.077-3.626, P = 0.028) and PFS (HR = 1.811, 95%CI: 1.046-3.134, P = 0.034) compared with the LRH group after PS-IPTW analysis. Furthermore, in patients with no high and intermediate risks, difference of the OS (HR = 1.386, 95%CI: 0.287-6.69, P = 0.684) and PFS (HR = 1.524, 95%CI: 0.363-6.396, P = 0.565) rates between the two groups were with no statistical meaning.ConclusionsOutcomes of this retrospective cohort study were in compliance with indications for ORH recommended by the National Comprehensive Cancer Network guidelines Version 1, 2021. However, LRH showed non-inferiority for patients with no prognostic risk factors compared with ORH.

Laparoscopic Radical Hysterectomy Results in Higher Recurrence Rate Versus Open Abdominal Surgery for Stage IB1 Cervical Cancer Patients With Tumor Size Less Than 2 Centimeter: A Retrospective Propensity Score-Matched Study.

ObjectiveTo compare the oncologic outcomes between laparoscopic and open radical hysterectomy in patients with stage IB1 cervical cancer lesion less than 2 cm.MethodsPatients diagnosed FIGO (2009) stage IB1 (tumor diameter <2 cm) and underwent radical hysterectomy in our hospital between March 2008 and November 2018 were studied. A propensity-matched comparison (1:2) was conducted to minimize selection biases. Demographic and baseline oncologic characteristics were balanced between groups. Overall survival (OS) and disease-free survival (DFS) were assessed using the Kaplan–Meier model, along with univariable and multivariable regression analysis.ResultsA total of 261 patients were enrolled in this study after propensity-matching, with 174 in the open group and 87 in the laparoscopic group. Disease relapsed in seven patients in laparoscopy group, and the recurrence rate was 8.0% (7/87). There were eight patients underwent abdominal radical hysterectomy experienced recurrence, and the recurrence rate was 4.6% (8/174). The multivariate analysis model revealed that laparoscopic operation was associated with higher risk of recurrence than abdominal radical hysterectomy (HR, 3.789; 95% CI, 1.143–12.559; p = 0.029). There were five patients or 2.9% (5/174) died in open surgery group and the corresponding percentage in laparoscopy group was 2.3% (2/87). No difference was found in OS between the two groups (HR, 1.823; 95% CI, 0.2673–12.44; log-rank p = 0.5398). All the recurrence occurred within two years after operation in the laparoscopy group, among which pelvic recurrence (85.7%) was dominant.ConclusionTraditional laparotomy radical hysterectomy has a lower recurrence rate when compared with laparoscopic operation in those cervical cancer patients with a foci diameter less than 2 cm. However, no detrimental effect on survival was found in minimal invasive operation group. Further multi-center prospective trials are needed to confirm our results on a large scale.

Oncologic outcomes of minimally invasive versus open radical hysterectomy for early stage cervical carcinoma and tumor size

ObjectiveTo investigate the oncologic outcomes of patients with early-stage cervical carcinoma and tumor size <2 cm who underwent open or minimally invasive radical hysterectomy.MethodsThe Pubmed/Medline, Embase, and Web-of-Science databases were...

Results of a German wide survey towards current surgical approach in early stage cervical cancer NOGGO MONITOR 11

Minimally invasive surgery (MIS) has become the standard approach in early stage cervical cancer (ECC). However, the recently published “LACC” trial and even others could show inferior PFS and OS of MIS compared to open radical hysterectomy. The results led to a widespread debate about the best surgical approach in ECC. The present survey aimed to get first insights after publication. NOGGO and AGE conducted a nationwide digital survey among 186 Gynecological Cancer Centers. Descriptive statistics and t-tests were performed using SPSS. A majority of the centers were of high expertise and/or experience in treatment of ECC and were highly aware of the LACC trial results. Trial quality and scientific value were rated as very good/good. However, still 40% would not change the standard of care to open surgery. Centers with higher volume and participating in clinical trials were more likely to change. This survey represents insights after the surprising results of recently published trials towards the surgical approach of ECC. There still seems to be a high need of future trials and possible explanations for the unexpected worse outcomes in the MIS group.

Standardization and experience may influence the survival of laparoscopic radical hysterectomy for cervical cancer

ObjectiveMinimally invasive radical hysterectomy has been shown to be associated with poorer outcome in an influential prospective, randomized trial. However, many centers worldwide performing minimally invasive radical hysterectomy have data and experience that prove otherwise. We aim to review surgical and oncologic outcomes of patients operated by Laparoscopic Radical Hysterectomy in a tertiary hospital, by experienced surgeons and standardization in radicality, for cervical carcinoma Stage 1A1-1B1 from January 2009 to May 2014. Materials & methodsStandardised surgical technique with Parametrium & Paracolpium resection approach was adopted by qualified and experienced Gynecologic/Gyne-Oncologic Endoscopic & Minimally Invasive Surgeons in performing Laparoscopic Radical Hysterectomy for Cervical Cancer stage 1A1-1B1 from January 2009–May 2014, involving 53 patients. Electronic Medical Record system (EMR) Of Chang Gung Memorial Hospital(Tertiary Referral Centre), Department of Obstetrics & Gynecology was accessed for surgical and oncologic outcomes. ResultsFifty-Three patients operated from January 2009 to May 2014 were followed up for an average of 96.7 months with longest follow-up at 127 months. There were no cases of recurrence or death reported. 5 Year – Survival Rate and 5 Year Disease-Free Survival Rate were 100%. Two patients received post-operative pelvic radiation concurrent with chemotherapy using Cisplatin due to greater than 1/3 cervical stromal invasion. ConclusionIt is vital to standardize minimally invasive surgical techniques for early stage cervical cancer, with focus on adequate radicality and resection which may contribute to excellent survival outcomes. Further international multi-center randomized trial (Minimally Invasive Therapy Versus Open Radical Hysterectomy In Cervical Cancer) will provide justification for continued practice of MIS in early stage cervical cancer.

Effect of the Number of Removed Lymph Nodes on Survival in Patients with FIGO Stage IB-IIA Cervical Squamous Cell Carcinoma following Open Radical Hysterectomy with Pelvic Lymphadenectomy: A Retrospective Cohort Study.

Objective To determine whether the number of removed lymph nodes (RLN) is associated with survival in patients with International Federation of Gynecology and Obstetrics (FIGO) stage IB-IIA cervical squamous cell carcinoma (CSCC). Methods We reviewed the medical records of FIGO stage IB-IIA CSCC patients who underwent standardized radical hysterectomy with pelvic lymphadenectomy (RHPL) in our center between 2006 and 2014. The X-tile software was performed to calculate the optimal grouping of cutoff points for RLN. The impact of RLN on progression-free survival (PFS) and overall survival (OS) was analyzed using Cox regression analysis. Results Among 3,127 patients, the mean number of RLN was 22, and positive lymph node (LN) was found in 668 (21.4%) patients. X-tile plots identified “21” and “16” as the optimal cutoff value of RLN to divide the patients into two groups in terms of PFS and OS separately. In all patients, the number of RLN was not associated with PFS (P=0.182) or OS (P=0.193). Moreover, in both LN positive and negative patients, the number of RLN was not associated with either PFS (P=0.212 and P=0.540, respectively) or OS (P=0.173 and P=0.497, respectively). Cox regression analysis showed that the number of RLN was not an independent prognostic factor for PFS or OS. Conclusion If standardized RHPL was performed, the number of RLN was not an independent prognostic factor for survival of patients with FIGO stage IB-IIA CSCC.

Results of a German Wide Survey by NOGGO and AGE towards Current Surgical Approach in Early Stage Cervical Cancer after the LACC Trial- NOGGO MONITOR 11

Purpose: Minimally Invasive Surgery (MIS) has become the standard approach in Early Stage Cervical Cancer (ECC). However, the recently published “LACC” trial and even others could show inferior PFS and OS of MIS compared to open radical hysterectomy. The results led to a widespread debate about the best surgical approach in ECC. The present survey aimed to get first insights after publication. Methods: NOGGO and AGE conducted a nationwide digital survey among 186 Gynecological Cancer Centers. Descriptive statistics and t-tests were performed using SPSS. Results: A majority of the centers were of high expertise and/or experience in treatment of ECC and were highly aware of the LACC trial results. Trial quality and scientific value were rated as very good/good. However, still 40% would not change the standard of care to open surgery. Centers with higher volume and participating in clinical trials were more likely to change. Conclusion: This survey represents some first insights after the surprising results of recently published trials towards the surgical approach of ECC. There still seems to be a high need of future trials and possible explanations for the unexpected worse outcomes in the MIS group.

Oncological Results of Laparoscopically Assisted Radical Vaginal Hysterectomy in Early-Stage Cervical Cancer: Should We Really Abandon Minimally Invasive Surgery?

Simple SummarySome recently published studies in early-stage cervical cancer patients have shown that minimally invasive surgery (MIS), including laparoscopic and robotic approaches, might offer lower survival rates than classic open surgery. We evaluated the oncological results of a series of patients treated by laparoscopically assisted radical vaginal hysterectomy (LARVH), an infrequently used MIS technique. We included 115 patients with early-stage cervical cancer (IA1 with lymphovascular invasion, IA2, IB1, and IIA < 2 cm; International Federation of Gynecology (FIGO), 2008). The 3- and 4.5-year disease-free survival rates were 96.7% and 93.5%, respectively, and the overall survival was 97.8% and 94.8%, respectively. These survival data are comparable with those reported with the open radical hysterectomy but presented the advantages of MIS. LARVH offers excellent disease control in women with early-stage cervical cancer and can be considered as an adequate MIS alternative to open radical hysterectomy.Background: Recent evidence indicates that some minimally invasive surgery approaches, such as laparoscopic and robotic-assisted radical hysterectomy, offer lower survival rates to patients with early-stage cervical cancer than open radical hysterectomy. We evaluated the oncological results of a different minimally invasive surgery approach, that of laparoscopically assisted radical vaginal hysterectomy (LARVH) in this setting. Methods: From January 2001 to December 2018, patients with early-stage cervical cancer were treated by LARVH. Colpotomy and initial closure of the vagina were performed following the Schauta operation, avoiding manipulation of the tumor. Laparoscopic sentinel lymph node (SLN) biopsy was performed in all cases. Women treated between 2001 and 2011 also underwent pelvic lymphadenectomy. Results: There were 115 patients included. Intraoperative complications occurred in nine patients (7.8%). After a median follow-up of 87.8 months (range 1–216), seven women (6%) presented recurrence. Four women died (mortality rate 3.4%). The 3- and 4.5-year disease-free survival rates were 96.7% and 93.5%, respectively, and the overall survival was 97.8% and 94.8%, respectively. Conclusion: LARVH offers excellent disease-free and overall survival in women with early-stage cervical cancer and can be considered as an adequate minimally invasive surgery alternative to open radical hysterectomy.

Lymph-Vascular Space Invasion in Patients with Stages IA2-IIA2 Cervical Cancer Treated with Laparoscopic versus Open Radical Hysterectomy.

ObjectiveTo explore the relationship between laparoscopic radical hysterectomy (LRH) and cervical cancer lymph-vascular space invasion (LVSI) by comparing the prevalence of LVSI in cervical cancer patients who underwent LRH versus open radical hysterectomy (ORH).MethodsThe study participants were 1087 cervical cancer patients (FIGO 2009 stages IA2-IIA2) with pathologically confirmed with or without LVSI who underwent radical hysterectomy at Shengjing Hospital of China Medical University from 2013 through 2018. The patients were divided according to the type of surgical procedure into an LRH group (n=148) and an ORH group (n=939).ResultsIn the LRH group, 31.76% of patients (47/148) had LVSI-positive tumors compared to 33.23% of patients (312/939) in the ORH group; the difference was not significant (p=0.724). No between-group differences in LVSI prevalence according to lymph node metastasis, interstitial infiltration depth, differentiation degree, and parametrial infiltration were found. However, the number of LVSI-positive patients whose cervical cancer lesions >4 cm (stage I B2 and II A2) was significantly higher in the LRH group than in the ORH group (Odds Ratio [OR] 0.333, 95% confidence interval [CI] 0.157–0.706, p=0.005). The 3-Year disease-free survival (DFS) in the LRH group is lower than that in the ORH group (94.75% vs 97.27%), but there was no significance (P=0.187). Furthermore, the percentage of LVSI-positive tumors in patients with lymph node metastases was significantly higher than those without lymph node metastases (OR 2.897, 95% CI 2.129–3.942, p=0.000). The 3-Year DFS were 98.22% in the LVSI negative patients and 93.78% in the LVSI positive patients, the difference was significant (P=0.002).ConclusionA higher risk of lymph node metastasis and a lower 3-Year DFS was found in the LVSI-positive patients. In case of LVSI, it would be dangerous to treat patient in laparoscopy, especially in case of cervical cancer lesions >4cm.