Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer

doi:10.1016/j.ygyno.2008.06.011

Gynecologic Oncology

Volume 111, Issue 1, October 2008, Pages 18-21

https://doi.org/10.1016/j.ygyno.2008.06.011 Get rights and content

Abstract

Objective

We describe a series of patients diagnosed with invasive cervical cancer after undergoing simple hysterectomy who subsequently underwent robotic radical parametrectomy and bilateral pelvic lymphadenectomy. The goal of this study is to report on the safety and feasibility of robotic radical parametrectomy.

Methods

A retrospective review was performed of all patients who underwent robotic radical parametrectomy and bilateral pelvic lymphadenectomy at our institution during the period December 2006 to February 2008. We analyzed our data to evaluate the safety and feasibility of performing robotic radical parametrectomy.

Results

This analysis included 5 patients with invasive squamous cell carcinoma of the cervix. The median body mass index was 23.8 kg/m² (range, 17.7 to 26.5). The median operative time was 365 min (range, 331 to 430). The median estimated blood loss was 100 mL (range, 50 to 175). There were no conversions to laparotomy. There was 1 intraoperative complication—cystotomy. No patient required blood transfusion. The median length of hospital stay was 1 day (range, 1 to 2). One patient experienced two postoperative complications, a vesicovaginal fistula and a lymphocyst. No patient had residual tumor in the parametrectomy specimen, and no patient underwent adjuvant therapy. The median number of pelvic lymph nodes removed was 14 (range, 6 to 16). The median follow-up for all patients was 7.5 months (range, 1.3 to 13.8). There were no recurrences.

Conclusion

Robotic radical parametrectomy and bilateral pelvic lymphadenectomy is feasible and safe and can be performed with an acceptable complication rate.

Introduction

The usual treatment for patients with early-stage (IA2–IB1) cervical cancer remains radical hysterectomy with bilateral pelvic lymphadenectomy. Unfortunately, a number of patients with such disease receive suboptimal treatment in the form of simple hysterectomy. Reasons include lack of preoperative Pap smear screening, failure to check cytology prior to surgery, inadequate evaluation of abnormal findings on Pap smear or cervical biopsy, failure to perform a cone biopsy or endocervical curettings when indicated, and deliberate hysterectomy for obvious invasive cervical cancer [1].

Treatment options for patients with invasive cervical cancer who undergo suboptimal simple hysterectomy typically include adjuvant radiation therapy or further surgery in the form of radical parametrectomy. Adverse effects of radiation therapy include loss of ovarian function resulting in menopausal symptoms, as well as radiation cystitis, proctitis, possible fistula formation and vaginal stricture.

Radical parametrectomy was first described by Daniel and Brunschwig in 1961 [2]. The aim of this procedure is to remove the upper vagina, parametrium, and regional lymphatics. Traditionally, radical parametrectomy has been performed by laparotomy. More recently, the use of robotic surgical systems has allowed surgeons the opportunity to perform complex gynecologic oncology procedures through a minimally invasive approach. To our knowledge, the series we describe here is the first series describing the use of robotic surgery to perform radical parametrectomy and bilateral pelvic lymphadenectomy in patients with cervical cancer. We analyzed our data to evaluate the safety and feasibility of this approach.

Section snippets

Methods

This study was approved by the institutional review board of The University of Texas M. D. Anderson Cancer Center. A retrospective review was performed of all patients who underwent robotic radical parametrectomy and bilateral pelvic lymphadenectomy at M. D. Anderson Cancer Center from December 2006 to February 2008. Clinicopathologic information gathered included patient age and body mass index, tumor histologic subtype, the presence or absence of lymph-vascular space involvement, reasons for

Results

Five patients underwent robotic radical parametrectomy and bilateral pelvic lymphadenectomy at our institution during the study period. All patients were counseled for treatment with radical parametrectomy versus radiation therapy. The median patient age was 42 years (range, 38 to 52). The median body mass index was 23.8 kg/m² (range, 17.7 to 26.5). The average time from simple hysterectomy to radical parametrectomy was 54 days (range, 51 to 68). All patients were diagnosed with invasive

Discussion

The prognosis of patients with International Federation of Gynecology and Obstetrics stage IA2 to IIA cervical cancer who undergo simple hysterectomy is significantly compromised: the estimated 5-year survival rate is less than 50%, compared to 90% for patients who undergo either radical surgery or radiation therapy [3]. The primary reason for recommending radical parametrectomy as opposed to radiation therapy after suboptimal simple hysterectomy is to avoid radiation-related bowel, bladder,

Conflict of interest statement

The authors have no conflicts of interest to declare.

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Cited by (36)

Complementary surgery for cervical cancer patients inadequately treated with extrafacial hysterectomy
2020, Journal of Gynecology Obstetrics and Human Reproduction
Citation Excerpt :
According to the published retrospective study results, rate of recurrence is lower in the case series managed with minimal invasive surgery. Previous studies reported rate of any grade complication related to complementary surgery between 5.9%–88.9% [2–8,13–15,17–23,31,34,35]. Rate of grade ≥ 3 complications was between 0%–33.3% in the published data.
To evaluate surgical outcomes and survival outcomes of cervical cancer patients who underwent complementary surgery after an extrafacial hysterectomy
Patients with cervical cancer, who underwent extrafacial hysterectomy initially and thereafter underwent complementary surgery were reviewed retrospectively. Complementary surgery consisted of radical parametrectomy, proximal vaginectomy and pelvic lymphadenectomy.
Twenty patients were evaluated. Histopathologic subtype was squamous cell carcinoma in twelve patients, adenocarcinoma in six patients and adenosquamous carcinoma in two patients. Route of surgery was laparotomy in 19 patients and laparoscopy in one patient. Two patients were staged as stage 1A2, nine were staged as stage 1B1, four were staged as stage 1B2, one was staged as stage 2A1, one was staged as stage 2B and three were staged as stage 3C1. The median tumor size was 16.5 (Range, 4–40) mm. Grade ≥ 3 complications related to surgery occured in 8 (40%) patients. Four of them were managed intraoperatively and recovered problem free. Remaining four (20%) needed reoperation. Pathology reports revealed involvement of parametrium in one (5%) patient, involvement of the proximal vagina in one (5%) patient, matastasis to pelvic lymph nodes in 3 (15%) patients. Five (25%) patients received adjuvant radiotherapy. Consequently, 5-year and 10-year cumulative survival was calculated as 94%.
Complementary surgery and radiotherapy show similar oncologic outcomes in patients with early-stage cervical cancer who had undergone simple hysterectomy initially. Complementary surgery is associated with slightly higher rate of morbidity compared with radiotherapy, however significant proportion of complications can be noticed and repaired intraoperatively.
Radical parametrectomy after ‘cut-through’ hysterectomy in low-risk early-stage cervical cancer: Time to consider this procedure obsolete
2018, Gynecologic Oncology
Citation Excerpt :
The technique of the abdominal procedure has been described elsewhere [21,22]. The procedure also has been reported by standard laparoscopy [23,24], and by the robotic approach, as described by Ramirez et al. in 2008 [25]. Inclusion criteria included patients who had undergone a simple ‘cut-through’ hysterectomy, stage IA2 or IB1 tumors, squamous carcinoma, adenocarcinoma, or adenosquamous carcinoma, documented depth of tumor invasion, and tumor size < 2 cm.
The goal of this study is to identify predictive factors in patients with a diagnosis of early-stage cervical cancer after simple hysterectomy in order to avoid a radical parametrectomy.
A retrospective review was performed of all patients who underwent radical parametrectomy and bilateral pelvic lymphadenectomy at MD Anderson Cancer Center and at the Instituto de Cancerologia Las Americas in Medellin, Colombia from December 1999 to September 2017. We sought to determine the outcomes in patients diagnosed with low-risk factors (squamous, adenocarcinoma or adenosquamous lesions < 2 cm in size, and invading < 10 mm) undergoing radical parametrectomy and pelvic lymphadenectomy.
A total of 30 patients were included in the study. The median age was 40.4 years (range; 26–60) and median body mass index (BMI) was 26.4 kg/m² (range; 17.7–40.0). A total 22 patients had tumors < 1 cm and 8 had tumors between 1 and 2 cm. A total of 6 (33%) of 18 patients had evidence of lymph-vascular invasion (LVSI). No radical parametrectomy specimen had residual tumor, involvement of the parametrium, vaginal margin positivity, or lymph node metastasis. None of the patients received adjuvant therapy. After a median follow-up of 99 months (range; 6–160) only one patient recurred.
Radical parametrectomy may be avoided in patients with low-risk early-stage cervical cancer detected after a simple hysterectomy. Rates of residual disease (parametrial or vaginal) and the need for adjuvant treatments or recurrences are very low.
Robotic Radical Parametrectomy With Upper Vaginectomy and Pelvic Lymphadenectomy in Patients With Occult Cervical Carcinoma After Extrafascial Hysterectomy
2017, Journal of Minimally Invasive Gynecology
Citation Excerpt :
In addition, our study confirms that most women who undergo radical parametrectomy do not require any further adjuvant treatment. Of the 17 patients in our cohort undergoing RRPV with bilateral pelvic lymphadenectomy, only 3 required adjuvant treatment (17.6%), whereas 14 (82.4%) avoided further treatment, matching the percentages that we found in our literature review [5,6,9–12,17–19,21–24,31]. The sole possible indicator of adjuvant treatment in this group of patients was identification of lymph node metastasis, but no pathological features could predict metastatic disease in patients who underwent previous extrafascial hysterectomy.
To confirm the safety and feasibility outcomes of robotic radical parametrectomy and pelvic lymphadenectomy and compare the clinicopathological features of women requiring adjuvant treatment with the historical literature.
Retrospective cohort study and review of literature (Canadian Task Force classification II-2).
Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill.
All patients who underwent robotic radical parametrectomy with upper vaginectomy (RRPV), and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy at our institution between January 2007 and December 2015.
RRPV and pelvic lymphadenectomy for occult cervical cancer discovered after an extrafascial hysterectomy. We also performed a literature review of the literature on radical parametrectomy after occult cervical carcinoma.
Seventeen patients with invasive carcinoma of the cervix discovered after extrafascial hysterectomy underwent RRPV with bilateral pelvic lymphadenectomy. There were 2 intraoperative complications, including 1 bowel injury and 1 bladder injury. One patient required a blood transfusion of 2 units. Three patients underwent adjuvant treatment with chemoradiation with radiation-sensitizing cisplatin. One of these patients had residual carcinoma on the upper vagina, 1 patient had positive parametria and pelvic nodes, and 1 patient had positive pelvic lymph nodes. No patients experienced recurrence, and 1 patient died from unknown causes at 59.4 months after surgery. We analyzed 15 studies reported in the literature and found 238 women who underwent radical parametrectomy; however, no specific preoperative pathological features predicted outcomes, the need for adjuvant treatment, or parametrial involvement.
RRPV is a feasible and safe treatment option. As reflected in the literature, RRPV can help avoid empiric adjuvant chemoradiation; however, no pathological features predict the need for adjuvant treatment after surgery.
Bowel injury in robotic gynecologic surgery: risk factors and management options. A systematic review
2017, American Journal of Obstetrics and Gynecology
We sought to analyze the published literature on bowel injuries in patients undergoing gynecologic robotic surgery with the aim to determine its incidence, predisposing factors, and treatment options.
Studies included in this analysis were identified by searching PubMed Central, OVID Medline, EMBASE, Cochrane, and ClinicalTrials.gov databases. References for all studies were also reviewed. Time frame for data analysis spanned from November 2001 through December 2014.
All English-language studies reporting the incidence of bowel injury or complications during robotic gynecologic surgery were included. Studies with data duplication, not in English, case reports, or studies that did not explicitly define bowel injury incidence were excluded.
The Guidelines for Meta-Analyses and Systematic Reviews of Observational Studies were used to complete the systematic review with the exception of scoring study quality and a single primary reviewer.
In all, 370 full-text articles were reviewed and 144 met the inclusion criteria. There were 84 bowel injuries recorded in 13,444 patients for an incidence of 1 in 160 (0.62%; 95% confidence interval, 0.50–0.76%). There were no significant differences in incidence of bowel injury by procedure type. The anatomic location of injury, etiology, and management were rarely reported. Of the bowel injuries, 87% were recognized intraoperatively and the majority (58%) managed via a minimally invasive approach. Of 13,444 patients, 3 (0.02%) (95% confidence interval, 0.01–0.07%) died in the immediate postoperative period and no deaths were a result of a bowel injury.
The overall incidence of bowel injury in robotic-assisted gynecologic surgery is 1 in 160. When the location of bowel injuries were specified, they most commonly occurred in the colon and rectum and most were managed via a minimally invasive approach.
Robotic radical parametrectomy with pelvic lymphadenectomy: Our experience and review of the literature
2012, European Journal of Surgical Oncology
Citation Excerpt :
During the last years, a growing body of the literature is highlighting the feasibility of radical parametrectomy with upper colpectomy also for the management of the local recurrence of endometrial cancer.4,6,7 However, probably because of the low rate of these events, only small-scale retrospective studies are available and official guidelines for the treatment of these patients are currently lacking.3,5 Radical parametrectomy can be successfully accomplished by laparoscopy as reported by some studies.4,6–11
To evaluate the feasibility and safety of robotic radical parametrectomy (RRP) and pelvic lymphadenectomy for the management of occult invasive cervical cancer or local recurrence of endometrial cancer and to compare our outcomes with the evidence available in the literature.
Starting from 07/2008 consecutive patients submitted to RRP have been included in this study. A comprehensive literature review of published papers about this subject was carried out.
During the study period 11 patients were managed; 7 and 4 patients had an occult cervical cancer and a vaginal recurrence of endometrial cancer, respectively. One intra-operative and one post-operative complications were recorded. Neither conversion to laparotomy, nor blood transfusions occurred. Three women required further adjuvant therapies. After a median follow-up of 19 months (range 8–36) one recurrence has been detected. The outcomes of other 200 women from 15 different papers have been collected and compared to our findings.
Robotic surgery represents an effective alternative to accomplish radical parametrectomy with comparable results of those reported in the literature in terms of feasibility and safety. RRP is certainly a demanding procedure which however avoids radiotherapy in more than 80% of cases.
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2021, Robotic Surgery: Second Edition

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Robotic radical parametrectomy and pelvic lymphadenectomy in patients with invasive cervical cancer

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

Conflict of interest statement

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.

Gynecol. Oncol.