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Robotic-assisted laparoscopic approach to early-stage cervical cancer
Introduction
Cervical cancer currently is the fourth most common cancer occurring in women. Worldwide, an estimated 570,000 women were diagnosed, and 311,000 women died of the disease in the year 2018. Most (99%) cervical cancers are related to an infection with the human papilloma virus (HPV), resulting in oncogenesis. The World Health Organization (WHO) has made it a goal to eliminate the burden of cervical cancer, stating “that no woman should ever die of cervical cancer.” The elimination approach includes primary vaccination and secondary preventative approaches with screening and treatment of early-stage and precancerous lesions. Within the United States, the National Cancer Institute (NCI): Surveillance, Epidemiology, and End Results (SEER) program approximated that there would be 14,480 new cases of cervical cancer and 4290 deaths occurring in the year 2021. Early recognition and diagnosis are related to an improved disease-free survival (DFS) and overall survival (OS). With localized disease confined to the cervix, SEER approximates the 5-year relative survival at 91.9%. In early-stage and localized disease, surgical treatment may be offered. Surgical approaches may include vaginal, open, traditional laparoscopy, and robotic-assisted laparoscopy. The surgical approach is influenced by the stage and size of the primary lesion. Table 39.1 summarizes the revised International Federation of Gynecology and Obstetrics (FIGO) staging for carcinoma of the cervix uteri. For lesions less than 2 cm, fertility sparing treatment approaches may be offered, as summarized below in Table 39.2 .
KEY STEPS
-
Simple hysterectomy
- 1.
Placement of the manipulator device to provide adequate cephalad traction during development of the bladder flap, uterine artery ligation, and colpotomy. This displaces the ureters from the uterosacral ligaments
- 2.
Visualization of the ureters deep to the infundibulopelvic (IP) ligament
- 3.
Development of the bladder flap below the level of the manipulator ring for adequate tissue to reapproximate on vaginal closure
-
Radical trachelectomy
- 1.
Opening of the retroperitoneum and developing the paravesical and pararectal spaces
- 2.
Identification of the ureter and development of the ureteric tunnel
- 3.
Skeletonizing/exposing the uterine vessels with all attempts made for preservation
- 4.
Rolling the ureter laterally
- 5.
Amputating the cervix 1 cm below the isthmus
- 6.
Ensuring adequate vaginal margin of 2 cm
- 7.
Using an absorbable suture, suturing the isthmus to the vaginal margin
-
Radical hysterectomy
- 1.
Opening of the retroperitoneum and developing the paravesical and pararectal spaces
- 2.
Identification of the ureter and development of the ureteric tunnel
- 3.
Rolling the ureter lateral in a type B or dissecting the entire ureter in a type C with removal of the adjacent parametrium
- 4.
Ensuring adequate vaginal margin of 2 cm
TABLE 39.1
A Summary of the Definitions for the New International Federation of Gynecology and Obstetrics Staging/Substaging System (2018) for Patients With Cervical Cancer
| FIGO 2018 | Substage | Definition |
|---|---|---|
| Stage I | Confined to the cervix | |
| Stage IA1 | Measured stromal invasion ≤3 mm in depth | |
| Stage IA2 | Measured stromal invasion >3 mm and ≤5 mm in depth | |
| Stage IB1 | Invasive carcinoma >5 mm in depth of stromal invasion and ≤2 cm in greatest dimension | |
| Stage IB2 | Invasive carcinoma >2 cm and ≤4 cm in greatest dimension | |
| Stage 1B3 | Invasive carcinoma >4 cm in greatest dimension | |
| Stage II | Invades beyond the uterus, but not extended beyond the lower 1⁄3 of the vagina or pelvic sidewall | |
| Stage IIA1 | Involvement is limited to the upper 2⁄3 of the vagina without parametrial involvement and carcinoma is ≤4 cm | |
| Stage IIA2 | Involvement is limited to the upper 2⁄3 of the vagina without parametrial involvement and carcinoma is >4 cm | |
| Stage IIB | Parametrial involvement but not up to the pelvic sidewall | |
| Stage III | Carcinoma involves lower 1⁄3 of the vagina and/or pelvic sidewall and/or hydronephrosis and/or pelvic or para-aortic nodal disease | |
| Stage IIIA | Carcinoma involves the lower 1⁄3 of the vagina without pelvic sidewall disease | |
| Stage IIIB | Extension to the pelvic sidewall and/or hydronephrosis (or nonfunctioning kidney) | |
| Stage IIIC1 (r or p) | Pelvic nodal metastasis | |
| Stage IIIC2 (r or p) | Para-aortic nodal metastasis | |
| Stage IV | Extension beyond the true pelvis or bladder/bowel involvement | |
| Stage IVA | Spread to adjacent organs | |
| Stage IVB | Spread to distant organs |
FIGO , International Federation of Gynecology and Obstetrics; p , pathologic criteria; r , radiographic criteria.
TABLE 39.2
A Summary of the Surgical Approaches for Fertility Sparing and Non-Fertility Sparing as Per the International Federation of Gynecology and Obstetrics 2018 Staging System
| FIGO 2018 Stage | Fertility Sparing | Non-Fertility Sparing |
|---|---|---|
| 1A1 without LVSI | Cold knife cone | Simple hysterectomy |
| 1A1 with LVSI | Radical trachelectomy with pelvic lymphadenectomy a | Modified radical hysterectomy with pelvic lymphadenectomy a |
| 1A2 | Radical trachelectomy with pelvic lymphadenectomy a | Modified radical hysterectomy with pelvic lymphadenectomy a |
| 1B1 | Radical trachelectomy with pelvic lymphadenectomy a | Radical hysterectomy with pelvic lymphadenectomy a |
| 1B2 | N/A | Radical hysterectomy with pelvic lymphadenectomy a |
FIGO , International Federation of Gynecology and Obstetrics; LVSI , lymphovascular space invasion; N/A , not applicable.
Hysterectomy types
There are several hysterectomy types (as adequately described in Tables 39.3–39.5 ). In 1992, the first case report of a laparoscopic radical hysterectomy for early-stage cervical cancer was performed. With the evolution of minimally invasive techniques, the robotic approach was developed. Since 2005, the robotic-assisted laparoscopic approach has been utilized for the treatment of early-stage cervical cancer, with case series noting the advantage of 360 wristed capabilities. The Laparoscopic Approach to Cervical Cancer (LACC) trial was a noninferiority study comparing open radical hysterectomy and laparoscopic (and robotic) radical hysterectomy. The trial was closed early due to a statistically significant difference between the two groups with DFS and OS (4.5-year DFS: 86.0% vs. 96.5%; 3-year OS: 93.8% vs. 99%).
TABLE 39.3
A Summary of the Piver-Rutledge-Smith Classification for Hysterectomy Options
| Type | Description |
|---|---|
| Class I | Extrafascial hysterectomy. Uterine artery is ligated at the isthmus. No vaginal portion is excised. |
| Class II | Modified radical hysterectomy . Ureters are dissected in the parametrium but are not resected from the pubovesical ligament. Uterine arteries are ligated medial to the ureter. Uterosacral ligaments are excised midway from the insertion. Removal of the upper third of the vagina (2 cm). |
| Class III | Radical hysterectomy . Ureters are dissected and the pubovesical ligament is partially removed. Uterine arteries are ligated at the origin of the hypogastric artery. Uterosacral ligaments are excised at the insertion. Upper half of the vagina is removed. |
| Class IV | Similar to a Class III hysterectomy. Complete removal of the pubovesical ligament when dissecting the ureters. Umbilical vesical artery sacrificed. Up to ¾ of the vagina may be removed. |
| Class V | Reimplantation of the ureter into the bladder with removal of portion of the bladder. |
TABLE 39.4
A Summary of the European Organization for Research and Treatment of Cancer Gynecologic Cancer Group Description for Hysterectomy Options
| Type | Description |
|---|---|
| Type I | Simple hysterectomy |
| Type II | Modified radical hysterectomy. Ureters are dissected up to where they enter the bladder. Uterine arteries are ligated at the medial half of the parametrium. Proximal uterosacral ligaments are excised. Removal of the vagina (1–2 cm). |
| Type III | Radical hysterectomy . Ureters are dissected and parametrium resected near the pelvic wall. Uterine arteries are ligated at the origin of the hypogastric artery. Uterosacral ligaments are excised at the insertion. Upper 1⁄3 rd of the vagina is removed. |
| Type IV | Extended radical hysterectomy . Up to 3⁄4 th of the vagina may be removed. |
| Type V | Partial pelvectomy . Terminal ureter, portion of bladder, or rectum resected with the uterus and parametrium. |
EORTC , European Organization for Research and Treatment of Cancer; GCG , Gynecologic Cancer Group.
TABLE 39.5
A Summary of the Hysterectomy Descriptions Based on Querleu Classification
| Type | Subtype | Description |
|---|---|---|
| A | - | Extrafascial hysterectomy. Uterine arteries, uterosacral ligament, and cardinal ligaments are resected as close as possible to the uterus. No removal of the vagina. |
| B | B1 | The ureters are stripped and rolled to the lateral side. Partial resection of the uterosacral and vesicouterine ligaments. At least 1 cm of the vagina from the cervical tumor removed. No removal of lateral paracervical lymph nodes. |
| B2 | The ureters are stripped and rolled to the lateral side. Partial resection of the uterosacral and vesicouterine ligaments. At least 1 cm of the vagina from the cervical tumor removed. Removal of lateral paracervical lymph nodes. | |
| C | C1 | Ureters are fully mobilized. The uterosacral ligaments are resected at the level of the rectum. Complete resection of paracervical tissue. The vesicouterine ligaments are resected at the level of the bladder. 1.5 to 2 cm of the vagina is resected from the cervical tumor. The hypogastric plexus (autonomic) nerves are preserved. |
| C2 | Ureters are fully mobilized. The uterosacral ligaments are resected at the level of the rectum. Complete resection of paracervical tissue. The vesicouterine ligaments are resected at the level of the bladder. 1.5 to 2 cm of the vagina is resected from the cervical tumor. The hypogastric plexus (autonomic) nerves are resected. | |
| D | D1 | Full resection of the paracervical tissue to the bony pelvis with the hypogastric vessels to expose the sciatic nerve roots. Ureters fully mobilized. |
| D2 | Full resection of the paracervical tissue to the bony pelvis with the hypogastric vessels to expose the sciatic nerve roots. Ureters fully mobilized. Removal of adjacent muscle and fascia. |
Following the results of the LACC trial, many groups recommended against utilizing minimally invasive approaches to early-stage cervical cancer. Upon retrospective review, the increased risk of recurrence may be related to tumor handling and resulting contamination. This prompted the new trial of Robotic Versus Open Hysterectomy Surgery in Cervix Cancer (ROCC) to reevaluate for noninferiority with containment of the tumor and mitigation techniques. These mitigation techniques include isolation prior to colpotomy with either an Endoloop, stapling the vagina, or a “no-look no-touch” technique.
The art of robotic radical hysterectomy is an important procedure that should be maintained, not only in its potential continued role with cervical cancer, but also for endometrial and ovarian cancers.
Indications
Indications for simple hysterectomy
Simple hysterectomy can be offered to women who have stage 1A1 cervical cancer without evidence of vascular space invasion on a cold knife biopsy and do not desire future fertility.
Indications for radical trachelectomy
Radical trachelectomy can be offered to women who have stage 1A1 with evidence of lymphovascular space invasion (LVSI) to 1B1 (less than and including 2 cm) cervical cancer and desire future fertility. The ovaries would be preserved.
The goal of trachelectomy is to remove the cervical tumor and the adjacent vaginal margin to allow tumor free margins while maintaining the uterine fundus as well as up to 1 cm of cervical stump. This should allow the patient to maintain fertility with the possibility of future childbearing, with some providers placing a cerclage at the time of trachelectomy. Pelvic lymph node sampling is also recommended. Prior to performing trachelectomy, we recommend preoperative imaging to evaluate the pelvic and para-aortic nodal material as well as to confirm tumor size.
A recent collaborative international retrospective study compared the 4.5-year DFS rate, 4.5-year OS rate, and recurrence rate in early-stage cervical cancer patients treated with either open or minimally invasive radical trachelectomy. There was not a statistical difference between open and minimally invasive techniques with DFS (94.3% vs. 91.5%), OS (99.2% vs. 99.0%), or recurrence rates (4.8% vs. 6.3%), which suggests that a minimally invasive approach is noninferior.
For women with tumors greater than 2 cm who desired fertility sparing procedures, the options were limited to ovarian preservation. New evidence and trials are investigating the role of neoadjuvant chemotherapy (NACT) before fertility sparing surgery in those women. A recent meta-analysis, which included 249 patients with 1B2 (2 to 4 cm tumors) who were treated with NACT and fertility sparing surgery, showed a recurrence rate of 6.1% and a death rate of 1.8%. There were 49 viable deliveries within this cohort. These findings are currently being validated in ongoing studies and can be considered for those women desiring fertility.
Indications for radical hysterectomy
Radical hysterectomy can be offered to women who have stage 1A1 cervical cancer with evidence of LVSI on a cold knife biopsy and do not desire future fertility to 1B2 tumors.
Given the above discussion on the LACC trial, we recommend the full oncologic workup prior to offering a minimally invasive approach. We recommend pelvic magnetic resonance imaging (MRI) and conization to better determine lesion size, as well as depth of invasion. Positron emission tomography–computed tomography (PET/CT) should be considered to evaluate the nodal status and adjacent parametrium.
Role of bilateral salpingo-oophorectomy
We typically recommend maintaining the ovaries if the patient is not postmenopausal or near the average age of menopause (52 years). Cervical tumors (squamous cell carcinoma and adenocarcinoma) are typically not hormone receptor related, and it is safe to leave the ovaries. A review of 900 patients’ surgical pathology showed metastasis to the ovaries in 0.5% of squamous cell carcinoma patients and 1.7% of adenocarcinoma patients. There were no ovarian metastases seen in patients with adenosquamous or other carcinomas. Despite careful patient selection, adjuvant radiation therapy following surgical treatment may be recommended based on final pathologic assessment. For this reason, at the time of surgery, bilateral oophoropexy may be considered. The goal of oophoropexy is to elevate the ovaries to a level above the pelvic brim in hopes to prevent them from being within the radiation field. This would better help the patient maintain ovarian function and delay menopause.
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