Discussion
Main findings
This study analyzed clinical data of early-stage cervical cancer treated by four different surgical approaches (ARH, LRH, RRH and VRH groups) in a single center of our hospital for 5 years, and we noted that the difference of DFS was not statistically significant among the four groups. However, LRH and VRH were associated with shorter OS than ARH and RRH. Therefore, this study showed that not all the survival outcome indicators of MIS are inferior to ARH, RRH can obtain similar survival outcome as the ARH. Furthermore, the intraoperative blood loss and postoperative exhaust time of the three MIS are better than that in ARH. The intraoperative blood loss in RRH is the least, but hospital cost is highest.
Strengths and limitations
The standard approach for radical hysterectomy is open abdominal approach. According to the Guidelines, radical hysterectomy could be performed via open surgery and MIS. However, recent retrospective reviews and prospective observational studies demonstrated that MIS were associated with lower rate of DFS and OS than open surgery for cervical cancer patients. Controversially, robotic-assisted MIS obtained similar oncologic outcomes compared with open surgery. Therefore, the clinical advantages of robotic-assisted MIS for the treatment of cervical cancer remain to be confirmed. This study is the first retrospective analysis to compare clinical characteristics and survivals of ARH, LRH, RRH and VRH simultaneously in a single center by the same medical team. Based on our study results, we demonstrated that both ARH and RRH obtained higher rate of 5-year DFS and 5-year OS compared with LRH for early-stage cervical cancer, and the survival outcomes between ARH and RRH were similar.
There are several limitations in this study. First of all, we collected 517 patients to analysis the oncological outcomes of different radical hysterectomy approaches. However, based on the inclusive and exclusive criteria, we excluded approximate half of the whole data, which might decrease credibility of this result. Another major limitation was that each group enrolled different number of cases, especially ARH group (n=32) and RRH group (n=100), leading to deficiency of results on statistical difference.
Interpretation
Radical hysterectomy is the standard procedure for the treatment of early-stage cervical cancer (FIGO 2009 IA2-IB stage). Since researchers reported the first case of laparoscopic radical cervical cancer,13 laparoscopic surgery and robotic surgery have been widely used in the treatment of cervical cancer patients and have been reported in many relevant clinical studies.14-16 Most studies focus on perioperative conditions such as intraoperative blood loss, postoperative hospital stay, postoperative exhaust time, and survival outcomes. Previous retrospective analysis results have shown that neither laparoscopic approach nor robotic-assisted laparoscopic approach reduces patients’ 5-year progression free survival (PFS) and OS compared with abdominal approach.17, 18 The LACC trial provided a definitive comparison of MIS and ARH including 631 patients with early-stage cervical cancer in 33 medical centers worldwide, and the results showed no significant difference in the occurrence of intraoperative complications and serious adverse events in the two groups. Additionally, 4.5-year PFS and 3-year OS in MIS group were significantly lower than that in ARH, and the recurrence rate of early-stage cervical cancer patients who underwent MIS (15.6% robotic surgery) was approximate four times of ARH.19 Nevertheless, controversies remain as to whether bias in the study due to case selection, surgeon level and duration of recruited time. Whether the heterogeneity of the two MIS approaches had an impact on the conclusions is worth pondering. A multicenter study from Canada included 958 cases of cervical cancer in 10 years (2006-2016) (including 485 cases in the open surgery group and 473 cases in the MIS group), and 5-year follow-up showed that the open surgery group was significantly better than the MIS group. However, the laparoscopic surgery accounted for 89.6% of the MIS group and 10.4% of robotic surgery.20 A retrospective study from China analyzed the complications of open surgery (n=12956) and laparoscopic surgery (n=5491) from 2004 to 2015, and the results showed that the incidence of intraoperative and postoperative complications in laparoscopic surgery was significantly higher than that of open surgery (5.55% vs 2.76%).21 Therefore, NCCN, FIGO, and ESGO have updated their guidelines and unanimously recommended ARH as the standard surgical modality for patients with early-stage cervical cancer.22-24 On the contrary, clinical data from the Memorial Sloan Kettering Cancer Center showed that there was no significant difference in survival outcomes from MIS (90% robotic surgery) and open surgery for patients with cervical cancer, while complication rates for MIS were significantly reduced.25 Another study of 1125 cervical cancer patients in Denmark from 2005 to 2017, of which 595 were MIS (94.9% robotic surgery), showed that the 5-year disease-specific survival rate (95.9% vs.94.1%) and recurrence rate (6.3% vs.8.2%) in the MIS group were non-inferior compared with the control group.26 A meta-analysis related to robotic surgery, laparoscopic surgery, and open surgery for cervical cancer showed that robotic surgery had advantages over open surgery in terms of bleeding, duration, lymphadenectomy, average hospital stays, and complications intra- and post- operation.27
Currently, an international multicenter randomized control trial (Robot-Assisted Approach to Cervical Cancer, NCT03719547) evaluate the efficacy of robotic surgery and open surgery is underway in China.28 In addition, although there is limited research on vaginal surgery for cervical cancer, it is still one of surgical treatment options for patients with early-stage cervical cancer. Thus, in this study we analyzed the clinical data of patients with early-stage cervical cancer who underwent ARH, LRH, RRH and VRH in a single center by the same medical team for 5 years, compared the perioperative indicators and survival outcomes.