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Advancing the 'Comfort Zone' with Laparoscopic Gynecologic Oncology
Abstract & Commentary
By Robert L. Coleman, MD, Associate Professor, University of Texas; M.D. Anderson Cancer Center, Houston, is Associate Editor for OB/GYN Clinical Alert.
Synopsis: Laparoscopic radical hysterectomy appears to be a potentially viable alternative to open radical hysterectomy for women with early stage cervix cancer amenable to surgical therapy.
Source: Frumovitz M, et al. Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer. Obstet Gynecol. 2007;110:96-102.
Advances in laparoscopic instrumentation and surgical skill have enabled the adoption of oncologic procedures traditionally approached via ceiliotomy to the minimally invasive modality. However, little comparative data are available on some of the most complex of these operations. Frumovitz and colleagues looked retrospectively, over a 3-year period, at patients undergoing radical hysterectomy and pelvic lymphadenectomy for invasive primary cervix cancer. Comparative groups were those patients undergoing laparotomy vs laparoscopy to complete the procedure. Physician preference dictated which patients received which approach; however, few surgeons at the primary center performed both approaches. This was highlighted by the tendency to more frequently offer open radical hysterectomy (n = 54) as compared to laparoscopic radical hysterectomy (n = 35). Both groups were comparable in patient (age, weight, BMI, race) and tumor (Stage, histology) characteristics. Surgical outcomes demonstrated while laparoscopy was associated with longer OR times and higher rates of vascular injury (n = 3), it was associated with lower intraoperative blood loss and post-operatively with significantly lower infectious morbidity and hospitalization. Pathology specimens were equivalent relative to size of the parametrium, vaginal cuff length, negative margins, and nodal metastases. There was a significantly higher number of nodes (19 vs 14) in the open cohort. Equal rates of bladder atony, resolution of normal voiding function, and readmission to the hospital was observed between the two cohorts. Median follow-up was 13 months, during which 3 recurrences were documented (2 abdominal, 1 laparoscopic); survival was immature. The authors concluded the cohorts provided equivalent surgical specimens but that the laparoscopic approach, albeit longer in duration, was associated with more favorable operative morbidity.
Definitive operative management of most early stage cervix cancer consists of removal of the uterus with margins encompassing the parametrium, upper vaginal and utero-sacral ligaments along with a pelvic lymphadenectomy. In selected patients, the procedure has been associated with high cure rates but its complexity requires precise mobilization of the bladder and ureter as well as preservation of a portion of the pelvic nerves to reduce potential morbidity ranging from intraoperative blood loss to prolonged neurogenic bladder and bowel dysfunction. Recent adaptation of laparoscopic techniques and improvement in surgical instrumentation has enabled a spectrum of procedures to be approached with minimal access points. Although prophylactic oophorectomy and treatment reassessment procedures have been performed in patients at risk or diagnosed with gynecologic cancer for more than 40 years, extirpative surgery was only first explored less than 20 years ago. Both laparoscopic hysterectomy and radical hysterectomy were described in the early 1990s; the former has been validated as an alternative to open hysterectomy for endometrial cancer patients by phase III investigation. By contrast, laparoscopic radical hysterectomy is still largely performed in select centers. However, interest and expertise is rapidly increasing and plans are underway to perform a similar validation study for radical hysterectomy. This worldwide effort is necessary to clearly elucidate the safety of offering the procedure in the general community. Despite the obvious academic and practical impact of this trial, the greatest challenge may lie in getting the "believers" to commit to performing "standard" arm.