Total laparoscopic nerve-sparing radical hysterectomy versus open abdominal nerve-sparing radical hysterectomy

The large, multi-center retrospective study reports that TL-NSRH has benefits for early and locally advanced cervical cancer patients over OA-NSRH. While TL-NSRH has been thought to be a promising procedure for cervical cancer patients, clinical, surgical, oncological, and functional outcomes have not been previously examined in depth.

Marcello Ceccaroni, MD, PhD, of the department of obstetrics and gynecology and gynecologic oncology and minimally-invasive pelvic surgery at the International School of Surgical Anatomy, and director of gynecology and obstetrics at the IRCCS Sacro Cuore Don Calabria Hospital in Verona, Italy, conducted the research along with colleagues. They emphasized post-surgical pelvic function outcomes.

Radical hysterectomy is a difficult procedure, and often leads to postoperative complications for patients, the authors said. Laparoscopic surgery improves short-term outcomes by decreasing pain and post-operative complications. It also enhances recovery. However, authors noted concern that laparoscopic surgery has its flaws: “recent publications…particularly the Laparoscopic Approach to Cervical Cancer [LACC] trial have raised serious concerns regarding the oncological safety of endoscopic surgery in cervical cancer, describing a significant and alarming increase in the rate of recurrence.” From a technical standpoint, TL-NSRH is a challenging procedure, which increases risk.

For the study, 301 consecutive patients who had class C1-NSRH plus bilateral pelvic + para-aortic lymphadenectomy for stage IA2–IIB cervical cancer were enrolled at gynecologic oncologic centers in the Italian cities of Negrar, Varese, Bologna, and Avellino. Patients were divided into two groups: TL-NSRH (170) and OA-NSRH (131) and given preoperative questionnaires to gather data about rectal, urinary, and sexual function. The authors reported no differences in demographics or pathological characteristics between the 2 groups. They noted a trend for fewer adenocarcinomas and a higher cancer stage in the OA-NSRH group. “No difference was noted in terms of the proportion of patients who underwent neoadjuvant chemotherapy,” the authors said.

After surgery, patients completed another questionnaire to assess their quality of life, including sexual function and psychological status. In addition, the authors used the Kaplan-Meyer method to determine oncological outcomes.

Ceccaroni and colleagues reported that patients in the OA-NSRH group had a higher chance of experiencing urinary incontinence. They added that this group also experienced urinary retention after a 12-month follow-up. Five patients in this group (5.5%) had complete urinary retention after more than 24 months of follow-up. The study authors said no patients who had the laparoscopic procedure experienced complete urinary retention.

Anal incontinence was uncommon, and rates between the two groups were comparable, the authors said. Rates of constipation were also similar through a 2 -year follow-up but were more common in the OA-NSRH group.

Seventy-one patients (41.7%) who were sexually active prior to the procedure completed a sexual activity questionnaire in the TL-NSRH group and 65 (49.6%) completed it in the OA-NSRH group at the 12-month follow-up. Of these patients, 87.3% (62) in the TL-NSRH group and 87.7% (57) in the OA-NSRH group recovered the ability to be sexually active. “Forty-eight (77.4%) and 39 (68.4%) of the women who recovered sexual activity after surgery considered their sexual life as ‘satisfactory’ in 2 groups, respectively (p=0.30),” the authors noted.

The authors reported a median follow-up time of 30 months in the TL-NSRH group (6-88) and 39 months in the OA-NSRH group (8-85). Twenty patients in the TL-NSRH group (11.8%) had disease recurrence, while 11 patients (8.4%) had recurrence in the OA-NSRH group. “The first relapse of disease was in the pelvis in 14 patients (70%) and at distant sites in 6 (30%) patients in the TL-NSRH. In the OA-NSRH group the first location of recurrence was the pelvis in 7 (63.6%) cases and distant sites in 4 (36.4%) cases,” the authors said.

Fourteen patients in the laparoscopic group died (8.2%), while 9 patients in the open abdominal group died (6.9%). The authors reported that 3 deaths in the TL-NSRH group were unrelated to cervical cancer.

Ceccaroni and colleagues concluded that the risks of laparoscopic surgery due to technical difficulty were worthwhile. They noted the large amount of data that indicates a low rate of pelvic dysfunction, and said that, “preservation of the neural autonomic fibers has actually a positive effect on patients' post-operative well being and quality of life.” The authors reported that pelvic dysfunction is lower with laparoscopic surgery, and that “oncological outcomes and the survival rates of TL-NSRH well compare with the available series of non-nerve-sparing laparoscopic procedures.”

Reference

Ceccaroni M, Roviglione G, Malzoni M, et al. Total laparoscopic vs. conventional open abdominal nerve-sparing radical hysterectomy: clinical, surgical, oncological and functional outcomes in 301 patients with cervical cancer. J Gynecol Oncol. 2021;32(1):e10. doi:10.3802/jgo.2021.32.e10. Accessed 4 January 2020.