Abdominal Radical Hysterectomy Research Articles

Effect of laparoscopic versus abdominal radical hysterectomy on major surgical complications in women with stage IA-IIB cervical cancer in China, 2004–2015

ObjectivesTo report the trends in surgical approaches and compare the major surgical complication rates of laparoscopic and abdominal radical hysterectomy for cervical cancer. MethodsFrom the major surgical complications of cervical cancer in China (MSCCCC) database, we obtained the demographic, clinical, treatment hospital and complication data of patients with cervical cancer who underwent radical hysterectomy from 2004 to 2015 at 37 hospitals. The patients were assigned to the laparoscopic and abdominal surgery groups. The differences in the complication rates were analyzed using univariate and multivariable logistic regression models. ResultsWe identified a total of 18447 patients; 5491 (29.8%) underwent laparoscopic surgery and 12956 (70.2%) underwent abdominal surgery. The proportion of laparoscopic surgery rose from 0.35% in 2004 to 49.31% in 2015. In the multivariate analysis, the laparoscopic group had increased odds of intraoperative and postoperative complications (OR = 3.88, 95% CI = 2.47–6.11; OR = 1.42, 95% CI = 1.11–1.82). A more detailed analysis showed that laparoscopic surgery was associated with increased rates of intraoperative ureteral injury (OR = 3.83, 95% CI = 2.11–6.95), bowel injury (OR = 14.83, 95% CI = 1.32–167.25), vascular injury (OR = 3.37, 95% CI = 1.18–9.62), postoperative vesicovaginal fistula (OR = 4.16, 95% CI = 2.08–8.32), ureterovaginal fistula (OR = 4.16, 95% CI = 2.08–8.32), rectovaginal fistula (OR = 8.04, 95% CI = 1.63–39.53), and chylous leakage (OR = 10.65, 95% CI = 1.18–95.97), while abdominal surgery was more likely to cause bowel obstruction (OR = 0.55, 95% CI = 0.35–0.87). The two groups had similar rates of bladder injury, obturator nerve injury, pelvic hematoma, rectovaginal fistula and venous thromboembolism (P > 0.05). ConclusionLaparoscopic surgery was associated with more major surgical complications, especially intraoperative ureteral injury and postoperative fistula, than abdominal surgery among women with cervical cancer.

Laparoscopic vs. Abdominal Radical Hysterectomy for Locally Advanced Cervical Cancer

This study is to compare the survival outcomes of laparoscopic radical hysterectomy (LRH) to those of abdominal radical hysterectomy (ARH) for patients with locally advanced cervical cancer (LACC). Patients with the International Federation of Gynecology and Obstetrics (FIGO) 2009 stage IB2 to IIB LACC who underwent radical hysterectomy between 2001 and 2015 were identified. The disease-free survival (DFS) and overall survival (OS) were compared according to the surgical approach and were adjusted based on clinicopathologic characteristics. A total of 396 patients were included in the study, with 179 (45.2%) and 217 (54.8%) patients in the ARH and LRH groups, respectively. The LRH group showed a significantly lower amount of estimated blood loss, lower blood transfusion rate and shorter length of hospital stay. Overall, there were no significant differences in the 5-year DFS and 5-year OS between the LRH and ARH groups with the Kaplan-Meier method. However, multivariate analyses identified LRH as an independent prognostic factor for a poor DFS (hazard ratio [HR] 2.5; 95% confidence interval [95% CI] 0.19 to 0.87; p = 0.02). The analysis of stage IB2 disease and the squamous subtype (61.9% and 87.9% of all participants, respectively) reached the same conclusion. When stratifying by FIGO stage, the patients with IB2 (n = 348) in the ARH group had a significantly better DFS (HR 0.14, 95% CI 0.05–0.42, p < 0.01) and OS (HR 0.17, 95% CI 0.04–0.67, p = 0.11) than those in the LRH group in the Cox regression model. However, no differences were found in patient with stage IIA1, IIA2, or IIB in Cox regression model. When stratifying by histological types, for the patients with squamous carcinomas (n = 375), in Cox model, ARH had a significantly superior DFS compared with those who underwent LRH (HR 0.45, 95% CI 0.25–0.82, p = 0.01), but the OS was not statistically significant (HR 0.57, 95% CI 0.27–1.20, p = 0.14). However, no differences were found in patient with adenocarcinoma and adenosquamous carcinomas in the Cox model. Therefore, ARH was associated with a higher DFS than LRH in patients with LACC, especially in patients with stage IB2 disease or the squamous subtype.

228O - Comparison of long-term oncologic outcomes between laparoscopy and laparotomy for stage Ia1-Ib3 cervical cancer: A matched cohort study

BackgroundTo compare the long-term oncologic outcome of laparoscopic radical hysterectomy (LRH) versus abdominal radical hysterectomy (ARH) for patients with stage Ia1-Ib3 cervical cancer. MethodsA retrospective data of stage Ia1-Ib1 cervical cancer patients who underwent LRH and ARH at Sun Yat-sen University Cancer Center from Jan. 2012 to Dec. 2015 was collected. Patients were re-classified according to the 2018 FIGO staging system for cervical cancer and screened out 679 cases with stage Ia1-Ib3 cervical cancer. Propensity score matching (PSM) was performed by software SPSS 22.0, and a total of 268 patient pairs (LRH-ARH) were enrolled and analyzed. Oncologic outcomes and prognosis factors were compared between patients undergoing LRH vs. ARH. Results(1) Baseline characteristics after PSM: There were no statistical differences between LRH and ARH, but only in grade (p = 0.001). (2) Operation related data: The operative time [(228±90) vs (210±54) min], estimated blood loss (EBL) [(129.5±138.2) vs (207.8±204.6) ml], and the length of hospital stay [(10.6±3.5) vs (12.6±3.5) days] in the LRH group were significantly shorter compared with ARH group (all P < 0.001). (3) Recurrence and survival data: There was a significant difference in the 5-year disease-free survival (DFS; 86.4% vs 95.6%, p = 0.002) and 5-year overall survival (OS; 92.2% vs 97.5%, p = 0.017) between the LRH group and ARH groups. (4) Prognosis factors: In univariate and multivariat analysis, the results showed that surgical approach was common independent prognostic factor for OS and DFS. (5) Stratified analysis: Stratified analysis in low-risk patients with cervical cancer showed that, even in stage Ib1 patients with tumor size <2 cm, there were significant differences for OS and DFS between LRH and ARH group (all P < 0.05). Besides, ALR group only showed better DFS than LRH group in patients with no lymph vascular space invasion. ConclusionsOur results suggest that, for patients with stage Ia1-Ib3 cervical cancer, ARH results in more benefits for OS and DFS compared with LRH. Even in low-risk patients, ARH is still an oncologically safer alternative. Legal entity responsible for the studySun Yat-sen University Cancer Center. FundingNational Natural Science Fund. DisclosureAll authors have declared no conflicts of interest.

227O - Laparoscopic radical hysterectomy leads to poorer prognosis compared with abdominal radical hysterectomy in patients with locally advanced cervical cancer

BackgroundThis study aimed to explore the survival outcomes of early-stage cervical CC patients treated with laparoscopic/abdominal radical hysterectomy (LRH/ARH). MethodsWe performed a retrospective analysis involving women who had underwent LRH/ARH for CC in early stage during the 2013–2015 period in West China Second University Hospital. The survival outcomes and potential prognostic factors were evaluated using Kaplan-Meier method and Cox regression analysis, respectively. ResultsA total of 678 patients were included in our analysis. The overall survival (OS) and progression-free survival (PFS) between the ARH (n = 423) and LRH (n = 255) groups achieved no significant differences (p = 0.122, 0.285, respectively). However, in the patients with locally advanced CC (LACC), the OS of LRH group was significantly shorter than that of ARH group (p = 0.017). Conversely, in patients with a tumor diameter ≤4 cm, the LRH group had a significantly longer OS than the ARH group (p = 0.013). The multivariate Cox analysis revealed that FIGO stage, histology, parametrial invasion and pelvic lymph node invasion were independent prognostic factors for OS and PFS, whereas surgical method was not a statistically significant predictor of OS (p = 0.806) or PFS (p = 0.236) in CC patients. ConclusionsLRH was associated with poorer prognosis compared with ARH in LACC. Priority should be given to ARH for the surgical treatment of patients with LACC. Editorial acknowledgementThis study was undertaken after approved by the ethics committee of West China Second University Hospital. Legal entity responsible for the studyWest China Second University Hospital. FundingSichuan Youth Foundation of Science of Technology. DisclosureThe author has declared no conflicts of interest.

Laparoscopic vs. Open Abdominal Radical Hysterectomy for Cervical Cancer: A Single-Institution, Propensity Score Matching Study in China.

Study Objective: To compare the surgical and oncologic outcomes between open abdomen radical hysterectomy (ARH) and laparoscopic radical hysterectomy (LRH) for cervical cancer.Methods: Retrospective observational study with propensity score matching was used to ensure balanced groups for ARH and LRH. One-hundred-and-ninety-eight women with cervical cancer, 99 treated using ARH and 99 using LRH, between January 2012 and December 2014. Outcomes included disease-free survival (DFS), overall survival (OS), intra-operative factors, post-operator recovery, urinary retention, and adverse events. Moreover, the inverse probability of the treatment weighting (IPTW) method was also used.Main Results: Compared with ARH, LRH was associated with a lower volume of blood loss (P < 0.001) and transfusion rate (P < 0.001), with a broader resection of the parametrium (P < 0.001). Post-operatively, the time to first flatus was shorter for LRH than ARH (P < 0.001) but the rate of urinary retention was higher for LRH (22.2%) than ARH (8.1%; P = 0.009). DFS and OS were similar between groups. By IPTW, laparoscopy was also not associated with poorer survival in terms of DFS (HR 1.52, CI 0.799–2.891, P = 0.202) or OS (HR 0.942, HR 0.425–2.09, P = 0.883).Conclusion: Compared with ARH, LRH provided better intra-operative and post-operative outcomes, with no significant difference in oncologic outcomes and survival. Urinary retention remains a clinical issue to improve with LRH. The technology of LRH has been improved in China to address the inconsistent results of oncologic outcomes in previous studies. Whether these improvements could be effective needs to be investigated in the future.

2898 200 Cases of Endometrial Cancer – 10 Year Outcomes

Study Objective To investigate the outcomes of 200 women with early stage Endometrial Cancer managed at a District General Hospital over a 10 year period. Design Retrospective audit of 200 patients with confirmed endometrial cancer, within one Trust in Northern Ireland, from 2009-2018. Information was collected from Northern Ireland Electronic Care Record, and subsequently analyzed using Microsoft Excel. Setting Southern Health and Social Care Trust, Northern Ireland Patients or Participants 200 patients were identified from one surgeon's database of recorded cases Interventions N/A Measurements and Main Results 88% were overweight or obese, 74% presented with postmenopausal bleeding, 54% women underwent total laparoscopic hysterectomy (TLH), 28.5% abdominal hysterectomy, 13.5% vaginal hysterectomy (VH), 3.5% Laparoscopic assisted vaginal hysterectomy (LAVH), 0.5% transcervical resection and mirena. Overall complication rate was 5% for both laparoscopic and abdominal hysterectomy groups, 1% for vaginal and LAVH. Breakdown of specific complications available. Conversion rate from laparoscopic to open hysterectomy was 3.6%. Pre-operative histology compared with hysterectomy specimen matched in 78% cases. 3% were significantly upgraded from low to high grade. Pre-operative radiological staging matched the hysterectomy specimen in 69% of cases. 6% were upstaged from Stage 1, to Stage 2 or 3. Overall confirmed recurrence rate was 2.5%. None were detected through standard follow-up pathways. Conclusion This study supports the strong association between high BMI and endometrial cancer. Despite obesity presenting significant surgical challenges, complication rates are low considering the patient demographic. The shortest median length of stay was with vaginal and laparoscopic hysterectomy. Preoperative grading and staging are relatively accurate in our department. Confirmed recurrence rates are low, although a significant proportion of patients are still in follow-up. Clinical follow-up is not useful in detecting recurrence in the majority of patients, which supports a Self Directed Aftercare approach in the majority of early stage endometrial cancers.

Histogram analysis of apparent diffusion coefficients for predicting pelvic lymph node metastasis in patients with uterine cervical cancer.

To investigate the value of apparent diffusion coefficient (ADC) histogram analysis in predicting pelvic lymph node (LN) metastasis in patients with cervical cancer undergoing surgery. A total of 162 cervical cancer patients who underwent radical abdominal hysterectomy with pelvic LN dissection performed with pelvic 3T-MRI including diffusion-weighted imaging were enrolled in this study. The ADC histogram variables (minimum, mean, median, 97.5th percentile [ADC97.5], and maximum) of the tumors were developed using in-house software. For predicting pelvic LN metastasis, clinical and imaging variables were evaluated using logistic regression and receiver-operating characteristic (ROC) analyses. Pelvic LN metastasis was identified histopathologically in 50 patients (30.9%). In patients with LN metastasis, all ADC histogram variables were significantly different from those without LN metastasis (all p < 0.01). Univariate analysis demonstrated that long- and short-axis diameter of LN, MRI T-stage, squamous cell carcinoma antigen, tumor size, and the ADC97.5 were significantly associated with pelvic LN metastasis (all p < 0.05). However, multivariate analysis demonstrated that the ADC97.5 was the only independent predictor of pelvic LN metastasis (odds ratio, 0.996; p = 0.001). The area under the ROC curve of ADC97.5 was 0.782, which was the greatest among all variables. Interobserver agreement of all ADC histogram variables was fair to good. The ADC97.5 from histogram analysis may be a useful marker for the prediction of pelvic LN metastasis in patients with cervical cancer.

Urinary tract morbidity after nerve-sparing radical hysterectomy in women with cervical cancer

Nerve-sparing radical hysterectomy (NSRH) has been developed as a method of cervical cancer treatment to reduce surgical morbidity compared with radical abdominal hysterectomy. The aim of this study was to analyze the short- and long-term effects of NSRH on urinary tract function. A study group of 117 patients underwent NSRH type C1 with pelvic lymphadenectomy for cervical cancer stages IB1-IB2 without adjuvant radiotherapy at our department. A total of 106 patients aged 21-74years (mean age 44.8) were available for follow-up at 1year after surgery. A transurethral catheter was left in place for 48h after surgery, and the postvoid residual (PVR) volume was measured after its removal. One week before surgery and 12months after NSRH, lower urinary tract function was evaluated by an urodynamic examination. Five days after surgery, the PVR volume was greater than 100ml in 5 patients (4.7%) and a suprapubic catheter was inserted into these women for bladder training over the following days. Within 14days after surgery, urination without PVR was achieved in all women who underwent surgery. Postoperatively, a slight increase in the average maximum bladder cystometric capacity was recorded from 420 to 445ml (p value 0.009) without prolonging the voiding time. Other urodynamic parameters were not significantly different before and 12months after NSRH. In this series, NSRH preserved voiding function and bladder sensation at 1year and did not appear to compromise oncological outcome.

Does Surgeons' Experience Affect the Oncological Outcomes of Laparoscopic Radical Hysterectomy for Cervical Cancer?

Background: The surgical experience of surgeons is often considered to affect the oncological outcomes of surgery for cervical cancer, but there is few studies to confirm it. This study aims to analyse the effect of surgical experience of laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) before the first LRH on the efficacy of LRH for cervical cancer. Methods:We retrospectively analysed the oncological outcomes of 4024 patients with cervical cancer who received LRH performed by 177 surgeons, whose stages were IA1 with LVSI-IIA2. According to the surgical volume of LRH and ARH before the first LRH, patients treated by surgeons with different LRH experience were divided into six groups: 1-30, 31-60, 61-90, 91-120, 121-180, and ≥181; patients treated by surgeons with different ARH experience were divided into five groups: 0, 1-15, 16-30, 31-80, and ≥81. Kaplan-Meier curves and the Cox proportional hazards model were used to estimate the effect of surgical experience on the oncological outcomes of patients. Findings: In different LRH surgical experience analysis, the 5-year OS fluctuated from 85.5% to 93.3%, and the 5-year DFS fluctuated from 80.9% to 90.1%. After adjusting for case mix with a multivariable analysis, LRH experience was not an independent risk factor for shorter OS or DFS (P = 0.268, P = 0.158). In different ARH surgical experience analysis, the 5-year OS and DFS in the 31-80 group were lower than those in other groups. Previously, 31-80 ARH experience was an independent risk factor for lower OS and DFS (P<0.001, HR=2.332, 95% CI 1.544-3.521; P=0.001, HR=1.632, 95% CI 1.218-2.188). Interpretation: The efficacy of LRH for cervical cancer is not affected by the LRH experience of surgeons, but it is affected by the previous ARH experience. Funding: The Science and Technology Support Program of China. Declaration of Interest: All authors have no conflicts of interest to disclose. Ethical Approval: The establishment of the cervical cancer database was reviewed by the Ethics Committee of Nanfang Hospital, Southern Medical University (Ethics number NEEC-2017-135).

Comparison of Laparoscopic versus Abdominal Radical Hysterectomy for Early-Stage Cervical Cancer: Long-Term Oncological Outcome Analysis from 37 Chinese Hospitals and 8470 Patients

Background: Early-stage cervical cancer (CC) is the second leading malignant tumour in China and remains a major public health burden in developing countries. We aimed to determine the long-term oncological outcomes between laparoscopic radical hysterectomy (LRH) and abdominal radical hysterectomy (ARH) in the era of big data and real-world settings. Methods: We conducted a multicentre, retrospective, case-control study of 37 hospitals in mainland China. All consecutive early-stage CC patients with FIGO 2009 stage between IA1 (LVSI-positive), IA2 and IB1 who were treated by LRH or ARH between 2004 and 2016 were included. We compared the overall survival (OS) and disease-free survival (DFS) of the two surgical approaches in real-world and 1:1 case-control matched settings based on prognosis-related factors. Findings: We selected 8630 of 46313 patients from our database. In the real-world setting, the 5-year OS of patients who received LRH (n=2842) and ARH (n=5518) was similar, but LRH was associated with significantly poorer 5-year DFS (LRH 90·3%, ARH 87·8%, p=0·001; HR=1·392). After matching (n=1619/1619), we found that LRH was associated with significantly worse 5-year DFS (LRH 88·1%, ARH 91·2%, p=0·011; HR=1·392). In the subgroup analysis, in non-high-risk patients (n=1205/1205) who did not receive postoperative adjunct therapy (PAT) with LRH, both 5-year OS and 5-year DFS were significantly worse (5-OS: LRH 95·0%, ARH 97·8%, p=0·027; 5-DFS: LRH 95·6%, ARH 90·3%, p<0·001). However, such differences in 5-year OS and 5-year DFS were no longer significant in patients with high-risk factors who received PAT. Interpretation: This strictly matched retrospective cohort study revealed that in early-stage CC patients, LRH was associated with significantly poorer DFS but not OS. However, further subgroup analysis demonstrated that patients with high-risk factors who received standard PAT might be an indication for LRH. Funding: The National Science and Technology Support Program of China (2014BAI05B03), the National Natural Science Fund of Guangdong (2015A030311024), the Science and Technology Plan of Guangzhou (158100075). Declaration of Interest: All authors have no conflicts of interest to disclose. Ethical Approval: This retrospective study was approved by the Ethics Committee of Nanfang Hospital, Southern Medical University (ethical number NEEC-2017-135, clinical trial number CHiCTR1800017778 (International Clinical Trials Registry Platform Search Port).

Comparison of laparoscopic and abdominal radical hysterectomy in early stage cervical cancer patients without adjuvant treatment: Ancillary analysis of a Korean Gynecologic Oncology Group Study (KGOG 1028)

ObjectiveWe compared two groups of early stage cervical cancer patients treated with different surgical methods without adjuvant treatment using retrospective multicenter data previously collected for Korean Gynecologic Oncology Group (KGOG) study designed for developing prognostic models. MethodWe initially assessed data from the multi-institutional cohort with early stage (IB-IIA) cervical cancer patients treated with radical hysterectomy without adjuvant treatment between 2000 and 2008. Propensity score matching was performed to compare disease-free survival (DFS) and overall survival (OS) of patients with laparoscopic to abdominal radical hysterectomy. Additionally, survival comparison was performed in patients with tumor size <2 cm. ResultsAfter matching, 119 patients with laparoscopic radical hysterectomy were compared with 357 patients with abdominal radical hysterectomy (median follow-up of 63.9 months). Inferior DFS was observed in the laparoscopy group (HR 2.738 [95% CI 1.326–5.650], p = 0.005) with a significant difference in pelvic (HR 5.110 [95% CI 1.817–14.473], p < 0.001) and hematogenous recurrence (HR 3.171 [95% CI 1.059–9.494], p = 0.03), but OS was not significantly different between two groups (p = 0.624). In subgroup analysis in the patient with tumor size <2 cm (laparoscopy 62 vs. laparotomy 186, median follow-up of 69.1 months), laparoscopy was associated with lower rate of DFS (HR 12.987 [95% CI 1.451–116.244], p = 0.003), but no significant difference in OS was observed between groups. Regarding OS, number of events is lacking, and inferior DFS in the laparoscopy group may be compensated by better response to radiation therapy in pelvic recurrence. ConclusionsIn this analysis, laparoscopic radical hysterectomy was associated with lower rates of DFS but not OS in early stage cervical cancer patients without adjuvant treatment. Further larger scale studies are needed.

Efficacy of different surgical approaches in the clinical and survival outcomes of patients with early-stage cervical cancer: protocol of a phase III multicentre randomised controlled trial in China

IntroductionIn the last three decades, minimally invasive surgery (MIS) for radical hysterectomy (RH) has become a popular treatment option for early-stage cervical cancer. However, a recently published randomised controlled trial...

Learning curve of laparoscopic hysterectomy and comparison with abdominal hysterectomy

Introduction: Laparoscopic hysterectomy is the most emerging route with major drawback of long learning curve and longer initial time taken for surgery. Objectives: 1) To compare two different routes of hysterectomy: abdominal and laparoscopic in terms of surgical outcomes and complications. 2) To see the learning curve of laparoscopic hysterectomy. Material and Methods: 100 patients admitted for hysterectomy were divided into two groups of 50 each, first group planned for abdominal hysterectomy and second group planned for laparoscopic route. Data was collected regarding amount of blood loss, duration of surgery, post operative requirement of analgesics, duration of hospital stay, and post operative complications in both groups. Results: The main indications for hysterectomy were fibroid, AUB, adenomyosis, endometrial hyperplasia and polyp in both groups. The average blood loss in TAH group (n=50) was 285 ml and in TLH group (n=50) was 246 ml (p=0.0588). Average blood loss in first 25 cases of TLH was 348 ml and in next 25 cases was 144 ml, which was highly significant. The average time taken in TAH group was 95 minutes, and in TLH group was 141 minutes (p=1.415E-13) which was highly significant. In TLH group, the average time taken in first 25 cases was 166 minutes and in next 25 cases it was 116 minutes which is significant. Requirement of analgesics and duration of stay was less in TLH group. Minor complications like fever, UTI were comparable in both groups. Conclusion: Learning curve of laparoscopic hysterectomy can be reduced with good team work, a proper selection of patients, and the use of good instruments.

Recurrence patterns among women with early-stage cervical cancer following minimally invasive versus abdominal radical hysterectomy

Recurrence patterns among women with early-stage cervical cancer following minimally invasive versus abdominal radical hysterectomy

Mode of lymphadenectomy may be responsible for inferior oncologic outcome of laparoscopic radical hysterectomy compared to abdominal radical hysterectomy in cervical cancer

Mode of lymphadenectomy may be responsible for inferior oncologic outcome of laparoscopic radical hysterectomy compared to abdominal radical hysterectomy in cervical cancer

Outcomes of robotic-assisted versus abdominal radical hysterectomy for early stage cervical cancer

Outcomes of robotic-assisted versus abdominal radical hysterectomy for early stage cervical cancer

The two Achilles heels of surgical randomized controlled trials: differences in surgical skills and reporting of average performance

Randomized controlled trials of surgery are fundamentally different from randomized controlled trials of medications because it is difficult to blind or mask a surgical procedure or perform "sham" operations. An additional challenge is the variation in skills and surgical proficiency of participating centers and surgeons. Addressing heterogeneity in surgical proficiency remains of paramount importance, especially when randomized controlled trials involve a new or complex procedure such as minimally invasive radical surgery. In the presence of such heterogeneity, it is very cumbersome to evaluate objectively and monitor surgical skills so that most trials simply report associations that are averaged across surgeons and hospitals/centers. Such reporting is not transparent because the rates of complications and adverse outcomes are reported only as averages, and these averages may not apply to the individual participating surgeons or centers. These factors, coupled with the inherent nongeneralizability of findings from such randomized controlled trials, because of the strict inclusion and exclusion criteria for enrollment, may lead to conclusions that no longer apply to real life for individual surgeons or centers. Case in point is a recently published noninferiority randomized controlled trial that reported that minimally invasive radical hysterectomy was associated with lower rates of disease-free survival (86% vs 96.5% at 4.5 years) and overall survival (93.8% vs 99% at 3 years) than open abdominal radical hysterectomy in patients with cervical cancer. However, randomized controlled trials that involve 2 competing complex or new procedures may be affected by tremendous confounding because of variations in surgical proficiency and also nonstandardization for other confounding factors such as patient selection categories (ie, stage of cancer) and adjuvant postoperative therapies that may affect long-term survival. The purpose of this Viewpoint is not to provide an exhaustive review of the trial's shortcomings but to use it as an illustration to focus on 2 challenging areas that most randomized controlled trials of a new complex surgical procedure suffer from: (1) unadjusting or not correcting for surgical skill variability and (2) nontransparent reporting of averaged results. We provide suggestions to overcome these deficiencies through robust methods and statistical approaches.

Using Low-Cost Virtual Reality Simulation to Build Surgical Capacity for Cervical Cancer Treatment.

PURPOSEWorldwide, more than 80% of people diagnosed with cancer will require surgery during their disease course, but only 5% to 20% of low- and middle-income countries have access to safe, affordable, and timely surgery. Developing surgical oncology skills requires significant time and mentoring. Virtual reality (VR) simulators can reduce the time required to master surgical procedures but are prohibitively expensive. We sought to determine whether a VR simulator using low-cost computer gaming equipment could train novice surgeons in Africa to perform a virtual radical abdominal (open) hysterectomy (RAH).METHODSOur RAH VR simulator used the Oculus Rift (Oculus VR, Menlo Park, CA), a VR headset with hand controllers that costs less than $1,500. Surgical novices learned to perform five key steps of a virtual RAH. We measured and identified predictors of movement and time efficiency for the simulation.RESULTSTen novice surgeons in Lusaka, Zambia, enrolled in the study. Movement and time efficiency greatly improved over time. Independent predictors of movement efficiency were number of simulations, surgical experience, and time since college graduation. Independent predictors of time efficiency were number of simulations, surgical experience, days between simulation sessions, age, sex, and an interaction between number of simulations and surgical experience.CONCLUSIONLow-cost VR may be an effective tool to help surgical novices learn complex surgical oncology procedures. If learning to perform VR surgical procedures with low-cost hardware leads to faster mastery of surgical procedures in the operating room, low-cost VR may represent one of the solutions to increasing access to surgical cancer care globally.

Short- and long term outcomes after abdominal radical trachelectomy versus radical hysterectomy for early stage cervical cancer: a systematic review of the literature and meta-analysis.

Cervical cancer (CC) ranks 2nd for mortality among women of reproductive age in the United States. Abdominal radical trachelectomy (ART) is a fertility sparing approach that has been proposed in women with early stage CC who wish to preserve their fertility. The aim of the present meta-analysis was to evaluate the short- and long-term outcomes of RH vs ART for early stage CC. A total of 5 electronic databases were searched for articles published up to December 2018. Prospective and retrospective trials reporting outcomes for women who underwent ART or RH for the management of early stages CC, were considered eligible for inclusion. Statistical meta-analysis was performed using the RevMan 5.3 software. A total of 5 studies which included 840 women who underwent ART or radical trachelectomy (RH) were included in the present meta-analysis. Among them, 324 underwent ART whereas the remaining 516 had RH. Despite the fact that ART was associated with significantly prolonged operative time compared to RH (840 patients MD 36.82min, 95% CI 20.15-53.49, p < 0.001), neither 5-year OS nor 5-year DFS were different among the two groups (714 patients OR 1.39, 95% CI 0.53-3.62, p = 0.51 and 682 patients OR 1.08, 95% CI 0.52-2.25, p = 0.84, respectively). ART is a more complex and time consuming technique, but equally safe compared to RH in terms of oncological outcomes for selected women with early stage CC and allows for more CC survivors of childbearing age to preserve their fertility.

Comparison of Different Surgical Approaches for Hysterectomy: A Single-Institution Experience

Objective: We aimed to compare surgical outcomes and postoperative complications among different hysterectomy approaches such as total abdominal hysterectomy, vaginal hysterectomy, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy.Study Design: This retrospective, single institution, case control study was carried out at the Obstetrics and Gynecology Department of Baskent University in Ankara, Turkey. We evaluated 86 consecutive patients who underwent hysterectomy for benign gynecological conditions.Results: A total of 86 women underwent hysterectomy: 20 (23.3%) total abdominal hysterectomy, 20 (23.3%) vaginal hysterectomy, 27 (31.3%) multiport access laparoscopic hysterectomy, and 19 (22.1%) single-port access laparoscopic hysterectomy using a transumbilical single-port system. There was no significant difference in uterine size between groups (Z=5.705; p=0.127). A statistically significant (p&lt;0.001) difference in operation time (duration of surgery) was observed among the following groups. The duration of surgery for the multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups was similar, with these two laparoscopic procedures requiring significantly more time than total abdominal hysterectomy and vaginal hysterectomy procedures. There was no statistically significant difference in between hemoglobin levels before and after operation between groups. There was no statistically significant difference between groups in intraoperative and postoperative complications. Six patients experienced complications, one intraoperative and five postoperative. Intraoperative complication was ureter injury in single-port access laparoscopic hysterectomy group. The postoperative complication rate was 5.8% (5 cases) in 86 patients. Perirectal abscess in one patient and wound infection in two patients occurred in total abdominal hysterectomy group (15%). Urinary tract infection in one patient and vaginal cuff cellulitis in one patient occurred in vaginal hysterectomy group (4%). No complications were reported in multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy groups. Post-surgery, all patients who underwent single-port access laparoscopic hysterectomy reported that they were satisfied with their incision and cosmetic results.Conclusions: When technically feasible, multiport access laparoscopic hysterectomy, and single-port access laparoscopic hysterectomy may be performed instead f total abdominal hysterectomy because of rapid recovery and shorter hospitalization however there are longer operating time.