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.