The basic principles of oncologic surgery during minimally invasive radical hysterectomy

Patients with early cervical cancer can be treated either by surgery or by chemoradiation [1]. International guidelines recommend treatment by one oncologic modality rather than combined therapy to avoid treatment-related toxicity (European Society of Gynaecological Oncology, National Comprehensive Cancer Network) [2,3]. Consequently, pretreatment decision for one of these treatment options has to be made by an interdisciplinary tumor board council. Indeed, this recommendation reflects not only tumor-stage and histology-related factors but also “unspoken” arguments like surgical skills, national traditions, availability of radiation oncology and others. Moreover, best treatment for patients with tumor stages IB (±lymphovascular invasion) ≥4 cm, IIA and IIB is not defined yet, that opens the door for a wide spectrum of different strategies. Patients with these potentially operable stages are often undergo adjuvant chemoradiation (up to 85%) according to Peters et al. [4] or Sedlis et al.'s criteria [5], whereas primary chemoradiation could be a single treatment alternative [6]. High-risk features for adjuvant chemoradiation are known as lymph-node positivity, parametrial involvement and R1/R2-resection. Lymph node metastases can be confirmed or excluded with high accuracy by intraoperative frozen section and consequently radical hysterectomy can be continued or abandoned. Transvaginal creation of a tumor-adapted vaginal cuff in iodine-positive area is an ideal tool to avoid vaginal tumor involvement. The most problematic parameter preoperatively is parametrial spread. In accordance to a previously published study by Kong et al. [7] and Woo et al. [8] could demonstrate a pooled sensitivity and specificity of 0.73 and 0.93 for the detection of parametrial invasion.

Radical hysterectomy is the state-of-the-art surgery for patients with early cervical cancer. A standardized surgical approach with curative intent was defined in the last century in Vienna. Whereas Schauta [9] used a transvaginal approach, his disciple, Wertheim [10] propagated a transabdominal route. Both techniques underwent several modifications over the next decades and with the advent of laparoscopic surgery the advantages of an abdominal and transvaginal access could be combined [11,12]. Thereafter a historical change and onco-surgical tragedy occurred: gynecologic surgeons renounced the transvaginal part of radical hysterectomy completely, the main reason being lack of training in vaginal surgery [13,14,15]. Up to that point the principles of oncologic hygiene were guaranteed by sealing off all tumor cells using transvaginal sutures as initially described by Schauta [9]. Now laparoscopic surgeons inserted transtumoral manipulators and performed transabdominal colpotomy exposing the pelvic peritoneum to vital tumor cells, a procedure never recommended by Wertheim (Table 1) [9,10,11,12,15,16,17,18].

Table 1. Use of transtumoral manipulators and tumor sealing-off according to procedure method.

Method	Relation	Sealing off tumor	Transtumoral manipulator	References
Radical abdominal HE	Abd	Yes - transabdominal clamp	No	Wertheim [10]
Radical vaginal HE	Vag	Yes - transvaginal sutures	No	Schauta [9]
LARVH	Vag - Lap	Yes - transvaginal sutures	No	Dargent et al. [11], Hertel et al. [16]
VALRH	Lap - Vag	Yes - transvaginal sutures	No	Koehler et al. [12]
TLRH	Lap	No - intracorporeal colpotomy	Yes	Ramirez et al. [17], Melamed et al. [18]
RRH	Robotic	No - intracorporal colpotomy	Yes	Sert et al. [15], Ramirez et al. [17]

Abd, abdominal; Lap, laparoscopic; LARVH, laparoscopic-assisted radical vaginal hysterectomy; RRH, robotic right hemicolectomy; TLRH, total laparoscopic hemicolectomy; Vag, vaginal; VALRH, vaginal-assisted laparoscopic radical hysterectomy.

This obvious lack of oncologic hygiene was no obstacle for the propagation of laparoscopic radical hysterectomy since the obvious advantages of laparoscopic surgery such as minimal invasiveness, easy preservation of autonomic nerves, bloodless dissection and quick recovery were advantageous for the patients [13,14,15].

Fortunately for future patients a prospective randomized trial (Laparoscopic Approach to Cervical Cancer; LACC) was performed which showed a significant higher disease-free survival for women after open abdominal surgery as compared to laparoscopic or robotic surgery (99% vs. 94%) [17]. This cornerstone trial brought down the existing opinion of oncologic equivalency of minimal-invasive radical hysterectomy and abdominal radical hysterectomy. Further studies confirmed LACC results [18]. Resulting discomfiture and disbeliefs among gynecologic oncologists worldwide have been addressed in many editorials and comments, trying to explain the unexpected results [19]. Many possible arguments for minimally-invasive inferiority have been debated as different radicality, smaller vaginal cuff, ethnic differences, tumor size as selection criteria, robotic versus straight stick laparoscopy, learning curves, different schools of surgery, data completeness and video review in LAAC trial, circulating CO2, use of intratumoral manipulators, etc.

In our answer to the results of LACC, we collected prospectively actual data on consecutive 389 patients who underwent combined vaginal-laparoscopic radical hysterectomy with a median follow-up period of 10 years [20]. These patients had a risk profile comparable to the LACC cohort and their recurrence free survival rate is identical to the patients who underwent open surgery in LACC (98.5%). These results can be achieved by avoiding manipulator and transvaginal closure to seal off the cervical cancer cells. Preliminary results from other studies (NCT03958305) support this theory.

These findings are now corroborated by the study of Kong et al. [21]. Authors have evaluated the oncologic outcome of patients with early-stage cervical cancer who underwent minimally invasive radical hysterectomy before and after the application of parametrial invasion criteria defined as disruption of the cervical stroma ring on MRI scans, and patients with intracorporal or vaginal colpotomy.

In agreement with Kong et al. [21] we conclude that patients with early parametrial involvement visible in high solution MRI should rather undergo laparoscopic staging followed by primary chemoradiation [22]. In patients without parametrial spread that undergo laparoscopic or robotic radical hysterectomy transabdominal intracorporeal colpotomy must be avoided and use of any uterine manipulators should be forbidden. The announced Chinese phase III randomized multicentric trial will prove again if minimally invasive radical hysterectomy is equivalent to open radical hysterectomy and also addresses use of uterine manipulators [23].