Role of Surgery with Curative Intent

Courtesy of FIGO

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Dr. Daniel Dargent:  “Thank you very much, Mr. Chairman, good-morning everyone.  The first laparoscopic lymph node assessment was performed in Leon in 1986.  Twelve years later, in 1999, a survey made in the U.S.A. demonstrated that less than 10% of uterine cancers are managed in this country with the laparoscope.  What is the cause of this mess?  One of the reasons of the lack of success of the laparoscopic strategy in gynecologic oncology is the fear of port site recurrences and peritoneal seating.  Scharff in 1998 demonstrated after an extensive survey of the literature that the port site recurrences after laparoscopic surgery were much more frequent than the abdominal metastasis after laparoscopic surgery.  Kruitvagon, two years before, demonstrated that in the patient with umbilical port site metastasis the chance of death was significantly increased.  Both of the two authors have demonstrated that this concerned not exclusively but mostly the adenocarcinoma.  For this reason, I think that laparoscopic extirpative surgery for ovarian cancer and endometrial cancers stage 1C and more has to be prohibited.  As far as stage 1A and 1B endometrial cancer and cancer of the cervix, laparoscopic extirpative surgery is lowered but we have to respect the rules of prudence.  

The first rule of prudence is avoiding debulking with the laparoscope.  If at laparoscopy we find a lymph node enlarged and fixed to the blood vessels, it is technically possible to dissect this mass.  It is technically possible to remove it but we have to avoid that, and the second rule is assistance to vaginal surgery is better than purely laparoscopic surgery.  As a matter of fact, if we follow a purely laparoscopic technique, it is mandatory to use a uterine mobilizer.  Now the use of these uterine mobilizers includes a chance of tumor cell defusion.  The Memorial Sloan-Kettering team in New York at the last SGO meeting reported a survey which demonstrated that the chance of positive peritoneal cytology during surgery for endometrial cancer were significantly increased in the patient managed with this code.  The clinical significance of this fact is unknown but it is surely better to avoid taking this chance.  

The main advantage of the vaginal approach is it makes it possible to close the cervix at the very beginning of the surgery.  If we are undertaking a hysterectomy for endometrial cancer, we can close the cervix by a stitch.  If we are undertaking a radical hysterectomy for cervical cancer, the first step will be making the vaginal cuff and closing this vaginal cuff and, therefore, the uterine orifice will be completely closed, and the chance of contamination of the operative field is lessened.  The optimal approach for us is the laparoscopic vaginal approach rather than the purely laparoscopic approach.  My lecture will be for clues on the laparoscopic vaginal radical hysterectomy; I will at first address the technique and then give you the data.  There are many techniques as you’ll see, and each of them starts with a laparoscopic pelvic lymphadenectomy.  

This laparoscopic pelvic lymphadenectomy enables us to select the patients who can enjoy the Coelio-Schauta.  As far as Schauta is concerned, at least four techniques exist and all of them include the same steps that aim at making free the two aspects of the paracervical ligaments or perimetrium.  These steps are:  first - making the vaginal cuff, two – closing the vaginal cuff, three – opening the vesicouterine space, four – opening the paravesical spaces, five – managing the bladder pillars, six – opening the pouch of Douglas, and seven – managing the rectum pillars.  You can see here that is the making of the vaginal cuff, the closing of the vaginal cuff, the opening of the vesicouterine space, the opening of the paravesical space on the left side of the patient, setting apart the lateral fibers of the bladder pillar on the left side of the patient, dividing these lateral fibers, dividing the medial fibers, the knee of the ureter is visible here, and then managing the uterine artery which arise here.  

Afterwards when moved to the dorsal face, the Douglas is opened and the rectum pillar is divided.  As far as the management of the perimetria is concerned, two types of techniques do exist.  In the first type the perimetria are managed using the vaginal approach only.  Two variants do exist - the Amreich procedure, Amreich was the follower of Schauta in the Vienna Clinic, and the Stoeckel procedure, Stoeckel described a variant of the Schauta operation in Berlin, Germany.  Let’s start with the Amreich procedure.  This operation starts with the paravaginal incision, thanks to this incision, we get large access to the periuterine tissues, and we can put the clamps at the very origin of the paracervical ligaments or perimetrium.  That is a photograph used for this drawing, and you see here the knee of the ureter and the stump of the uterine artery and here the way the two clamps are put onto the paracervical ligament.  That is a specimen and as you’ll see on this picture, the amount of vagina and the amount of parauterine tissue is very important.  

In the Stoeckel procedure, the paravesical and pararectal spaces are opened in a very limited way.  No paravaginal incision is made, and the clamps are put one to 2 cm from the insertion onto the cervix.  Here you see the knee of the ureter, and here you see the uterine artery.  As a consequence, the vaginal and paracervical resection is less radical.  Using the laparoscope, we can make both the Amreich procedure and the Stoeckel procedure easier and safer.  These two operations are the laparoscopic Amreich procedure and the laparoscopic Stoeckel procedure.  

Let’s start with the laparoscopic Amreich.  It is based onto the use of an endo GIA, a stapler, introduced through the ipsilateral port.  Here you see the paravesical space and the pararectal space, and that is a first shot, which is done onto the common trunk of the superior vesical and uterine arteries.  The second shot is done onto the vessels in the depths and after this second shot, as you can see, the paracervical ligament or parametria is cut very close to its pelvic origin.  Coming from below due to the obliquity of the pelvic wall, one gets these results more easily and the paravaginal incision is useless.  Let’s move now to the specimen, which is as large as the Schauta or Amreich specimen, as you can see.  Let’s move now to the laparoscopic Stoeckel.  In this operation, we try to obtain the same radicality while preserving the vascular narrow skeleton of the perimetrium.  This can be obtained thanks to the lateral paracervical lymphadenectomy.  Using the laparoscopic instrument, as you can see, we can remove all the tissues located into the vascular narrow skeleton of the lateral part of the paracervical ligament.  After this perimetrial lymphadenectomy, the lateral root of the perimetrium is completely free of any tissues, which can be the source of a pelvic sidewall recurrence.  This view is better; that is the lateral root of the perimetrium.  The external iliac vein and the external iliac artery are pushed medially, and you see here the obturator nerve and the lumbrosacral trunks, which is the first root of the sciatic plexus.  As you can see, this part of the pelvic sidewall is completely free of any tissue, and now the data.  

During the years 1996-99, we used the Coelio-Schauta procedure in 251 patients, and 241 of them being affected by a previous cervical infiltrative cancer.  During the first year we used the laparoscopic lymphadenectomy followed by the Amreich operation or the Stoeckel operation.  During the years of 1992-1994, we used the laparoscopic Amreich, and then from 1994 until now, we use the laparoscopic Stoeckel.  For the stage 1A, 1B less than 2 cm in diameter, we never saw any recurrence or any failure when we used this technique including the classical Stoeckel technique.  For the stage 1B1, 2 to 4 cm in diameter, variations are observed depending on the technique.  As you can see on this slide, if the laparoscopic Stoeckel is opposed to the Amreich operation, there is a difference in favor of the first operation but this difference is not statistically significant.  If the laparoscopic Stoeckel is opposed to the Stoeckel without laparoscopic preparation, the same differences are observed, and as far as the pelvic sidewall recurrences are concerned, this difference is statistically significant.  For the 2 most 4 cm or more, the same phenomenon is observed; the laparoscopic Stoeckel is better than the Amreich procedure but the difference is not significant and the reasons are much better than the reasons observed with the Stoeckel without laparoscopic preparation and this difference is significant.  The series for the 2 more 4 and more centimeter large is very short, however, if we add to this type patient the 27 cases of tumor stage 1B1, 2 to 4 cm in diameter and the 40 tumors less than 2 cm it appears that not any pelvic sidewall recurrence was observed among 77 patients submitted to the laparoscopic Stoeckel.  

While being more radical, the laparoscopic Stoeckel is better tolerated.  The OR time is not lessened, it is just the opposite; it lasts something like three hours to perform a laparoscopic Stoeckel.  The blood loss is not lessened, but as you can see, less than 20% of the patients require transfusion and we never observed injuries during the surgery.  As far as the post-operative course is concerned, we never observed any fistula, the rate of re-operation is very low, and there is no difference between the different types of surgery.  Conversely, the rate of bladder dysfunction that is urinary retention or urinary incontinence or both, is highly dependent on the technique, and there is no difference between the classical Stoeckel and the laparoscopic Stoeckel but the difference between the laparoscopic Stoeckel and the Amreich surgery is highly significant.  So the laparoscopic Stoeckel seems to be the adequate solution for managing the stage 1B1 cervical cancer.  In young patients, the laparoscopic Stoeckel can be modified in the sense of a more conservative approach and that is the laparoscopic vaginal radical trachelectomy.  As you can see, the specimen in this operation is exactly the same as you have observed after the Stoeckel hysterectomy.  

The difference is the uterine body, the tubes, and the ovaries are left in the belly and afterwards a stitch is made between the uterine isthmus and the vagina.  During the period of September 1987 to December 1999, 71 patients were submitted to this operation - 20 of them were affected by a stage 1A cervical cancer, stage 1A2 in most of the cases, and 51 were affected by a stage 1B or more.  Three failures were observed, all of them in the sub-series of 25 patients affected by a cancer stage 1B, 2 cm or larger, stage 2 or stage 3.  No failures in this series of 46 patients affected by stage 1A or 1B1 but less than 2 cm large.  Among the 71 patients, 40 could become pregnant and actually tried to, 30 have a follow-up more than one year, and as you can see, 27 of them succeeded in obtaining pregnancy, and 20 of them obtained one or more babies.  These results are in themselves a strong indication for a larger use of laparoscopy but there is another reason for being converted to laparoscopy and that is the assessment of the sentinel node.  

For assessing the sentinel node, we infiltrate the cervix with 4 ml of patent blue violet then we undertake a laparoscopy.  We open the broad ligament and we immediately identify the main lymphatic channel, following this lymphatic channel, we arrive to the main lymphatic node and we remove it.  During the first two years of our experience, we performed 71 successful dissections, in 11 cases the main lymph node was positive, in 60 cases it was negative, and in all cases a systematic dissection was performed.  In the 11 positive lymph node cases, one or two more positive lymph nodes were found in half of the patients.  In the 60 patients with negative main lymph node, we never found any distant nodes, which were positive.  

It seems after this short series, the accuracy of this assessment is perfect.  Obviously, larger series are required to confirm these reasons but one can say that the management of early stage cervical cancer and maybe of endometrial cancer should be in the near future based on the laparoscopic assessment of the lymphatic node.  In the sentinel node positive patient, we will undertake the classical treatment.  In the sentinel node negative patient, we will operate using the vaginal approach.  Now selecting the sentinel node positive and sentinel node negative patient will be extremely simple with using the laparoscope, I hope, on every person in the management of uterine cancer.  

Now I arrive to my conclusion; the first hysterectomy for uterine cancer was made in 1829 in Paris, it was made using the vaginal approach, and it was as you can see a stage 1B2 cervical cancer.  That is a picture of the surgeon, Joseph Recamier.  One year after the operation, the patient was alive and well, unfortunately, that was not the case for the patients operated on in the following decades.  More than 80 people died from recurrences.  Today, thanks to the laparoscope, it is just the opposite, 85% of the patients survive disease free.  And now for the ones who like St. Thomas have to see and touch to believe, they can come to Leon on 18^th of September where two Coelio-Schauta procedures will be performed.  

Thank you very much for your attention and see you soon in Leon"