Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

doi:10.1016/j.clon.2021.05.001

Clinical Oncology

Volume 33, Issue 9, September 2021, Pages e372-e382

https://doi.org/10.1016/j.clon.2021.05.001 Get rights and content

Highlights

•
Minimally invasive surgery is increasingly used in gynaecological oncology.
•
Obesity is prevalent in endometrial cancer and is associated with significant surgical morbidity.
•
Minimally invasive surgery is associated with reduced postoperative complications.
•
Robotic surgery supports increased rates of minimally invasive surgery.
•
The future of minimally invasive surgery for cervix remains uncertain.

Abstract

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

Section snippets

Statement of Search Strategies Used and Sources of Information

An electronic search of Medline and the Cochrane database of systematic reviews was carried out (from January 1990 to date, with the last search carried out on 4 January 2021) to identify trials that compared the effectiveness and safety of minimally invasive surgery either robotic or laparoscopic with laparotomy for endometrial and cervical cancer. We also checked the reference lists of relevant identified papers to identify further studies. Randomised controlled trials, quasi-randomised

Background

Uterine cancer is the sixth most common cancer in women worldwide and the fourth most common cancer in women in the UK. Uterine cancer incidence is increasing, in part due to its association with obesity and type 2 diabetes, rates of which are increasing [1]. If diagnosed in the early stages, prognosis is good. Overall, the 5-year survival for women diagnosed with endometrial cancer in England is 75.6%, ranging from 92.2% with stage I disease at presentation to 15.1% in those with stage IV

Cervical Cancer

Cervical cancer is the 14th most common cancer in females in the UK. However, worldwide it is the fourth most common cancer in women and the most common gynaecological cancer. Surgery for early stage cervical cancer (ECC) is with curative intent. Early stage disease has excellent survival, with 87.8% of women treated with stage I disease in England surviving over 5 years [2]. MIS has a part to play in many aspects in the management of cervical cancer; from primary treatment, staging,

Conclusions

MIS has many benefits, in the form of reduced postoperative morbidity, improved recovery and reduced inpatient stay, and remains the standard of care for endometrial cancer. The future of MIS for cervix cancer, however, remains uncertain. Current recommendations based on the available evidence are that the open approach should be considered the gold standard for the surgical management of ECC and that MIS should only be adopted in the context of research. Careful counselling of patients on the

Conflicts of interest

S. Butler-Manuel is a Proctor for Intuitive Surgical and Plasma Surgical and Ethicon. A. Tailor is a Proctor for Intuitive Surgical and Plasma Surgical and Ethicon. J. Chatterjee occasionally gives paid lectures on behalf of pharmaceutical companies.

Acknowledgement

This work was supported by GRACE Charity (Gynae-oncology Research and Clinical Excellence), registered charity no. 1189729 (https://grace-charity.org.uk/).

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Cited by (19)

Sentinel lymph node biopsy in endometrial cancer: When, how and in which patients
2024, European Journal of Surgical Oncology
The role of nodal dissection in patients with endometrial cancer has been intensively studied in several studies. Historically, systematic pelvic and para-aortic lymphadenectomy represented the gold standard surgical treatment to assess potential nodal involvement and consequently define the appropriate stage of the tumor. Over the last years, sentinel node biopsy (SLNB) has been introduced as a more targeted alternative to lymph node dissection for lymph node staging and it has become popular among gynecologic oncologists. However, no level A evidence is still available, and several features of the SLNB technique have been matter of discussion among clinicians and a universally accepted methodology is still not currently available. This narrative review aims to summarize the body of knowledge on SLNB to offer the reader a complete picture about the evolution of this technique over the last decades.
Oncologic outcomes of robot-assisted laparoscopy versus conventional laparoscopy for the treatment of apparent early-stage endometrioid adenocarcinoma of the uterus
2023, Gynecologic Oncology
To compare long-term oncologic outcomes in patients with clinically uterine-confined endometrioid endometrial cancer who underwent surgical staging with robot-assisted (RA) versus conventional laparoscopy.
We performed a retrospective chart review of patients with newly diagnosed, uterine-confined endometrioid endometrial cancer who were treated and had primary surgery at our institution between 1/1/2009–1/1/2018. Clinicopathologic, surgical, and survival data were collected. Appropriate statistical methods were applied.
Of 1728 patients identified, 1389 (80.4%) underwent RA and 339 (19.6%) conventional laparoscopy. At diagnosis, median age was 60 years (range, 24–92) and median BMI was 30.2 kg/m² (range, 15.1–71.5). In the RA group, patients had longer operative time (170 vs 152 min, P < .001), lower conversion rate to laparotomy (0.6% vs 4.7%, P < .001), and a higher proportion had a BMI > 40 kg/m² (17.2% vs 11.5%, P = .01) and same-day discharge (19.2% vs 5.3%, P < .001). Overall, 93% (RA) and 90% (conventional) of patients underwent lymph node assessment (P = .1). Comparing the RA versus conventional groups, final surgical stage on pathology (P = .6), median follow-up (55.7 vs 52.9 months, P = .4), and rates of perioperative complications (9.9% vs 7.7%, P = .6), recurrence (9.5% vs 7.4%, P = .3), 5-year PFS (88.5% vs 91.0%, P = .3), and 5-year OS (92.5% vs 92.4%, P = .7) were not significantly different. No significant increase in risk of recurrence (HR = 1.2, 95% CI: 0.8–1.9, P = .3) or poorer OS outcomes (HR = 0.9, 95% CI: 0.6–1.4, P = .7) were observed in the RA group.
In uterine-confined endometrioid endometrial cancers, surgical staging using RA laparoscopy was not associated with adverse survival outcomes compared to conventional laparoscopy.
A Nomogram for Predicting Progression-free Survival in Patients with Endometrial Cancer
2023, Clinical Oncology
Endometrial cancer is one of the most widely known gynaecological malignancies that lacks a prognostic prediction model. This study aimed to develop a nomogram to predict progression-free survival (PFS) in patients with endometrial cancer.
Information for endometrial cancer patients diagnosed and treated from 1 January 2005 to 30 June 2018 was collected. The Kaplan–Meier survival analysis and multivariate Cox regression analysis were carried out to determine the independent risk factors and a nomogram was constructed by R based on analytical factors. Internal and external validation were then carried out to predict the probability of 3- and 5-year PFS.
In total, 1020 patients with endometrial cancer were included in the study and the relationship between 25 factors and prognosis was analysed. Postmenopause (hazard ratio = 2.476, 95% confidence interval 1.023–5.994), lymph node metastasis (hazard ratio = 6.242, 95% confidence interval 2.815–13.843), lymphovascular space invasion (hazard ratio = 4.263, 95% confidence interval 1.802–10.087), histological type (hazard ratio = 2.713, 95% confidence interval 1.374–5.356), histological differentiation (hazard ratio = 2.601, 95% confidence interval 1.141–5.927) and parametrial involvement (hazard ratio = 3.596, 95% confidence interval 1.622–7.973) were found to be independent prognostic risk factors; these factors were selected to establish a nomogram. The consistency index for 3-year PFS were 0.88 (95% confidence interval 0.81–0.95) in the training cohort and 0.93 (95% confidence interval 0.87–0.99) in the verification set. The areas under the receiver operating characteristic curve for the 3- and 5-year PFS predictions are 0.891 and 0.842 in the training set; the same conclusion also appeared in the verification set [0.835 (3-year), 0.803(5-year)].
This study established a prognostic nomogram for endometrial cancer that provides a more individualised and accurate estimation of PFS for patients, which will help physicians make follow-up strategies and risk stratification.
Minimally invasive pelvic exenteration for gynaecological malignancy: A single-centre case series and review of the literature
2022, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
Numbers of open PE performed have remained small due to the tendency to refer onwards to tertiary referral centres with more centralised open exenteration services. For procedures such as Radical Hysterectomy [30], the robotic approach is the primary approach used within gynae oncology and as such, minimally invasive PE was a natural development [26]. The presence of highly skilled robotic urology and laparoscopic/robotic colorectal services further enhanced this development.
For those with certain recurrent gynaecological cancers where primary management such as chemo-radiotherapy has failed, or in cases of recurrence following primary surgery, pelvic exenteration (PE) is considered the only curative option. Whilst initially considered a morbid procedure, improved surgical techniques, advancing technology, and nuanced reconstructive options have facilitated more radical resections and improved morbidity and mortality. Open PE remains the gold standard approach, however, minimally invasive techniques for PE may lessen morbidity whilst achieving the same oncological outcomes. The objective of this study was to assess the feasibility and safety of minimally invasive PE with a laparoscopic or robot-assisted approach. We also performed a review of the literature on robot-assisted PE which has not been widely reported for cases of recurrent gynaecological malignancy.
Between 2015 and 2021 six minimally invasive PE were performed. All patients underwent extensive multi-disciplinary assessment and counselling pre-operatively. Patient characteristics, treatment indication, perioperative data, short-term complications, and histological outcomes were recorded. There were two anterior exenterations, three posterior exenterations and one total exenteration performed. The primary cancer stage varied from stage 1a-3b. Five out of six patients had pre-operative chemo-radiotherapy. The average operative time (including surgical docking) was 600 min. Mean blood loss was 400 mL and the average length of stay was eight days. Enhanced recovery practices were used where possible. There were no intraoperative complications and one major post-operative complication which was breakdown of an inferior gluteal artery perforator flap perineal reconstruction. All patients had negative margins at post-operative histopathology. All patients are alive and recurrence free at follow-up, but long-term outcome data is needed.
This initial case series suggest that minimally invasive pelvic exenteration can feasibly be performed in place of open pelvic exenteration. Furthermore, our findings suggest this may be a safe alternative as we report similar findings to the existing literature, however no firm conclusions can be drawn at such an early stage. Long term follow-up data and a larger cohort study will be needed to establish non-inferiority to open PE.
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The effects of laparoscopic and laparotomy extensive hysterectomy on the safety of ureterovaginal fistula infection in patients with cervical cancer
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Laparoscopic and Robotic Surgery for Endometrial and Cervical Cancer

Highlights

Abstract

Section snippets

Statement of Search Strategies Used and Sources of Information

Background

Cervical Cancer

Conclusions

Conflicts of interest

Acknowledgement

Gynecol Oncol

Gynecol Oncol

J Minim Invasive Gynecol

Eur J Cancer

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Am J Obstet Gynecol

Gynecol Oncol

Gynecol Oncol

Gynecol Oncol

Eur J Cancer

Lancet Oncol

J Minim Invas Gynecol

J Minim Invas Gynecol

Eur J Surg Oncol

Gynecol Oncol

Gynecol Oncol

J Minim Invas Gynecol

Eur J Surg Oncol

Surg Oncol

J Minim Invas Gynecol

Gynecol Oncol

J Minim Invas Gynecol

Eur J Surg Oncol

Gynecol Oncol

Eur J Obstet Gynecol Reprod Biol

Taiwan J Obstet Gynecol

J Minim Invas Gynecol

Eur J Surg Oncol

Gynecol Oncol

Eur J Cancer

Estimating the global cancer incidence and mortality in 2018: GLOBOCAN sources and methods

Int J Cancer

Cancer survival by stage at diagnosis for England

BGCS uterine cancer guidelines: recommendations for practice

ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma

Int J Gynecol Cancer

Laparoscopy compared with laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group Study LAP2

J Clin Oncol

Quality of life of patients with endometrial cancer undergoing laparoscopic International Federation of Gynecology and Obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study

J Clin Oncol

Thirty-day postoperative mortality for endometrial carcinoma in England: a population-based study

BJOG

Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: a retrospective cohort study

BMJ Open

Venous thromboembolism in minimally invasive compared with open hysterectomy for endometrial cancer

Obstet Gynecol

Laparoscopy versus laparotomy for surgical treatment of obese women with endometrial cancer: a cost-benefit comparative analysis

Mol Clin Oncol

Recurrence and survival after random assignment to laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer: Gynecologic Oncology Group LAP2 Study

J Clin Oncol

Effect of total laparoscopic hysterectomy vs total abdominal hysterectomy on disease-free survival among women with stage I endometrial cancer: a randomized clinical trial

JAMA

Robotic corpus cancer surgery: ten year mortality data from the UK epicentre in Guildford

Int J Gynecol Cancer

Laparoscopy versus laparotomy for the management of early stage endometrial cancer

Cochrane Database Syst Rev

Total laparoscopic hysterectomy for early stage endometrial cancer in obese and morbidly obese women

J Obstet Gynaecol

Robotic surgery is less physically demanding than laparoscopic surgery: paired cross sectional study

Ann Surg

Comparison of surgical skills in laparoscopic and robotic tasks between experienced surgeons and novices in laparoscopic surgery: an experimental study

Ann Coloproctol

Comparison of the learning curves and frustration level in performing laparoscopic and robotic training skills by experts and novices

Int Urol Nephrol