Abstract
Objectives:
To evaluate whether the timing of postoperative urinary catheter removal is associated with voiding dysfunction after radical hysterectomy for early cervical cancer within contemporary surgical practice.
Methods:
We performed an institutional retrospective cohort study of patients who underwent Piver type II-III open or minimally invasive radical hysterectomy for early-stage cervical cancer (FIGO 2009 stage IA1 with lymphovascular invasion to stage IIA) between January 2006 and December 2019. We compared voiding dysfunction (inability to spontaneously void with a post-void residual <100mL after catheter removal) and outcomes based on postoperative timing of urinary catheter removal using univariate and multivariate logistic regressions.
Results:
Among 234 patients, 86 (36.8%) underwent open surgery and 112 (47.9%) used ERAS pathways. Twenty-nine (12.4%) patients had urinary catheter removal between 1-5 days postoperatively (Group 1), 141 (60.2%) between 6-10 days (Group 2) and 64 (27.3 %) between 11-15 days (Group 3). The overall rate of voiding dysfunction was 11.5%, with no difference between Group 1 (17.2%), Group 2 (11.4%), and Group 3 (9.4%) (p=0.54). Group 1 had a significantly shorter time from surgery to spontaneous voiding (4 days, IQR 3-5 days) compared to Group 2 (8 days, IQR 7-10 days) and Group 3 (13 days, IQR 11-15 days) (p<0.01). There was no difference in hospital length of stay, urinary tract infection, or readmission due to a genitourinary complication within 60 days of surgery based on timing of catheter removal. On multivariate analysis, the odds of voiding dysfunction did not differ by tumor size, type of hysterectomy, cancer stage, surgical approach, ERAS timeframe, or timing of catheter removal group.
Conclusion:
There was no difference in voiding dysfunction or postoperative genitourinary complications based on timing of urinary catheter removal after radical hysterectomy. Early catheter removal should be considered in this population.
Keywords: cervical cancer, radical hysterectomy, postoperative, enhanced recovery after surgery, genitourinary outcomes
PRÉCIS
There was no difference in voiding dysfunction based on timing of urinary catheter removal after radical hysterectomy for early-stage cervical cancer in a single-institution retrospective cohort.
INTRODUCTION
The standard of care for patients with early-stage cervical cancer is Piver type II or III radical hysterectomy with sentinel lymph node mapping with or without bilateral pelvic lymphadenectomy.[1, 2] While early-stage cervical cancer treated with radical hysterectomy is associated with 5-year survival rates of over 90%,[3–5] it is also associated with significant morbidities, including bladder, colorectal and sexual dysfunction.[6–8]
The degree of voiding dysfunction reflects varying degrees of surgical radicality.[6] Extensive dissection during radical hysterectomy may damage pelvic nerves, pelvic floor musculature, and vascular supply of the lower urinary tract resulting in dysfunction, which provides the historical basis for late urinary catheter removal.[7] Nerve-sparing radical hysterectomy[9, 10] has emerged as one solution to reduce the incidence of postoperative lower urinary tract dysfunction and improve quality of life without sacrificing oncologic outcomes.[11–15] Despite the advantages of nerve-sparing surgery, there remains significant debate regarding duration of urinary catheter in patients who undergo radical hysterectomy, and practice patterns vary widely among gynecologic oncologists.[16] Recent evidence suggests that early catheter removal may be appropriate in patients undergoing radical hysterectomy,[16–21] however the interpretation of these studies in contemporary practice is limited by small numbers of patients undergoing open surgery on Enhanced Recovery After Surgery (ERAS) pathways.[22]
Early catheter removal may offer patients a faster time to recovery and functional recovery after surgery, but further evidence is needed. Therefore, our study used a large cohort of patients with early cervical cancer who underwent radical hysterectomy to evaluate whether the timing of urinary catheter removal was associated with voiding dysfunction.
MATERIALS AND METHODS
We performed a single-institution retrospective cohort study of patients who underwent Piver type II-III radical hysterectomy for primary early-stage cervical cancer (FIGO 2009 stage IA1 with lymphovascular space invasion to stage IIA) between January 2006 and December 2019 and had a urinary catheter postoperatively. We excluded patients with recurrent cervical cancer and those who had previous radiotherapy and/or chemotherapy, preoperative neurologic and/or urinary dysfunction, and those who required postoperative intensive care unit admission. Of the remaining patients, we excluded those who had an intraoperative genitourinary injury, lack of postoperative documentation, or discharge without a voiding trial due to suprapubic catheter use or self-catheterization (Figure 1). For statistical reasons, we also excluded patients who had void trials past 15 days postoperatively.
Figure 1.
Flowchart of patient selection
The timing of void trials after radical hysterectomy was done by surgeon discretion and could occur prior to postoperative hospital discharge or after hospital discharge at an outpatient appointment. Void trials could be completed either via urinary catheter removal and a 6-hour trial to await spontaneous voiding; or via a retrograde trial, wherein normal saline solution was injected into the indwelling urinary catheter, the catheter was removed, and voiding was attempted. In both cases, after spontaneous voiding occurred, a post-void residual (PVR) test was performed with straight catheterization. If the PVR was found to be <100mL, the void trial was considered successful. If the patient was not able to spontaneously void or if the PVR volume was >100mL, the void trial was considered a failure and the patient either had an indwelling urinary catheter reinserted or was taught to perform intermittent self-catheterization. If the catheter was reinserted, a void trial was reattempted every 7 days until a successful void trial was achieved.
Clinical and demographic data for all patients were collected from review of the electronic medical record and managed using institutional Research Electronic Data Capture (REDCap) tools.[23] Data collected included age, body mass index (BMI), American Society of Anesthesiologists (ASA) physical status, 2009 FIGO cancer stage,[24] tumor size, surgical approach (open or minimally invasive), type of Piver hysterectomy,[1] and whether surgery was done in the pre-ERAS (prior to November 2014) or ERAS (November 2014 or later) timeframe. Our institutional ERAS program for gynecologic surgery has previously been described;[25] key components include preoperative carbohydrate intake up to two hours before induction of anesthesia, avoidance of bowel preparation, use of opioid-sparing multimodal perioperative analgesia, intraoperative goal-directed fluid therapy, avoidance of nasogastric tubes and drains, and early postoperative ambulation and feeding. Operative data collected included duration of surgery, intraoperative estimated blood loss, and intraoperative complications.
The primary outcome was voiding dysfunction, defined as the inability to spontaneously void with a PVR <100 mL after urinary catheter removal. Secondary outcomes included time in days to urinary functional recovery (defined as the time from surgery to spontaneous voiding), urinary tract infection (UTI) within 30 and 60 days, hospital length of stay, and hospital readmission within 30 and 60 days due primarily to a genitourinary issue (acute kidney injury, UTI, urinary retention, urinary leak, or urinoma). UTI was defined as a positive urine culture in the presence of clinical symptoms of urinary infection (at least 1 of: polyuria, dysuria, urgency, hematuria, suprapubic pain) or as the administration of antibiotics for a presumed UTI, even in the absence of a positive urine culture.
Patient demographics and clinical characteristics were summarized using frequencies and percentages for categorical variables; continuous variables were presented as means with standard deviations (SD) or medians with interquartile ranges (IQR),[7] according to the distribution of the data which was measured by the Kolmogorov-Smirnov test10. For analytic purposes, patients were categorized based on timing of urinary catheter removal in days after radical hysterectomy: 1-5 days (Group 1), 6-10 days (Group 2), and 11-15 days (Group 3). We estimated the quartile distribution of the timing of catheter removal, which allowed us to include only those patients within the 90th percentile, which was 15 days.
Univariate analyses compared clinical and sociodemographic characteristics and outcomes between the three time-to-catheter removal groups. We conducted a multivariate analysis coming postoperative outcomes by timing of catheter removal and a multiple logistic regression analysis of voiding dysfunction by clinical and surgical characteristics and catheter removal group controlled for patient age, ASA score, and surgical approach. Each variable was tested for significance using chi-squared (χ2) test or Fisher test for categorical variables and ANOVA or t-Student for quantitative variables.
Comparisons were considered statistically significant using two-sided alpha level at 0.05. All analyses were performed using Stata 14.0 (College Station, TX). The study was approved by the institution’s Institutional Review Board. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines were used in the preparation of this manuscript.
RESULTS
A total of 312 patients underwent radical hysterectomy who met our study criteria. Of these, 66 patients were ineligible for study analysis due to use of a suprapubic catheter (n=3), intraoperative genitourinary injury (n=8), or missing data (n=55), and 12 patients were excluded due to a void trial more than 15 days postoperatively (n=9) or use of self-catheterization without a voiding trial (n=3) (Figure 1). The remaining 234 patients were included in analysis, with patient and clinical characteristics provided in Table 1. The mean age at radical hysterectomy was 42 years (SD 10.5 years) and most patients were overweight or obese (61.5%). The majority of patients had stage IA1 - IB1 disease (224 patients; 95.7%) with a median tumor size of 22 mm (IQR 13-30mm). Of our study cohort, 86 patients (36.8%) underwent open radical hysterectomy and 112 patients (47.9%) had surgeries during the ERAS time period.
Table 1.
Baseline patient and clinical characteristics by timing of catheter removal group
| Variable | Overall (n=234) | Postoperative day of urinary catheter removal | |||
|---|---|---|---|---|---|
| Group 1: 1-5 days (n=29) | Group 2: 6-10 days (n=141) | Group 3: 11-15 days (n=64) | P value | ||
| Age in years, mean ± SD | 42.4 ± 10.5 | 44.3 ± 10.5 | 43.9 ± 11.1 | 42.7 ± 10.5 | 0.69 |
| Body mass index, n (column %) | 0.25 | ||||
| Underweight <18.5 | 5 (2.1) | 2 (6.9) | 3 (2.1) | 0 (0) | |
| Normal 18.5–24.9 | 85 (36.3) | 12 (41.4) | 49 (34.8) | 24 (37.5) | |
| Overweight 25-29.9 | 63 (26.9) | 5 (17.2) | 42 (29.8) | 16 (25.0) | |
| Obese ≥30 | 81 (34.6) | 10 (34.5) | 47 (33.3) | 24 (37.5) | |
| Tumor size mm, median (IQR) | 22 (13-30) | 16.5 (7.5-24) | 23 (15-30) | 23 (17-30) | 0.10 |
| Type of Piver hysterectomy, n (column %) | 0.65 | ||||
| II | 8 (3.4) | 1 (3.4) | 6 (4.3) | 1 (1.6) | |
| III | 226 (96.6) | 28 (96.6) | 135 (95.7) | 63 (98.4) | |
| Cancer stage, n (column %) | 0.21 | ||||
| IA1 | 15 (6.4) | 0 (0) | 14 (9.9) | 1 (1.6) | |
| IA2 | 42 (17.9) | 4 (13.8) | 22 (15.6) | 16 (25.0) | |
| IB1 | 167 (71.4) | 25 (86.2) | 98 (69.5) | 44 (68.8) | |
| IB2 | 8 (3.4) | 0 (0) | 6 (4.3) | 2 (3.1) | |
| IIA | 2 (0.9) | 0 (0) | 1 (0.7) | 1 (1.6) | |
| Surgical approach, n (column %) | 0.028 | ||||
| Open | 86 (36.8) | 16 (55.2) | 54 (38.3) | 16 (25.0) | |
| Minimally invasive | 148 (63.2) | 13 (44.8) | 87 (61.7) | 48 (75.0) | |
| ERAS era, n (column %) | < 0.01 | ||||
| Pre-ERAS | 122 (52.1) | 9 (31.0) | 69 (48.9) | 44 (68.8) | |
| ERAS | 112 (47.9) | 20 (69.0) | 72 (51.1) | 20 (31.3) | |
| Duration of surgery in minutes, mean ± SD | 289 ± 69 | 256 ± 63 | 283 ± 67 | 318 ± 73 | < 0.01 |
| Estimated blood loss in mL, median (IQR) | 150 (75 – 300) | 225 (50-400) | 150 (89-290) | 150 (100-350) | 0.49 |
Significant p-values bolded
SD: Standard deviation; IQR, interquartile range; ERAS, Enhanced Recovery After Surgery; mL, milliliters.
Of the total cohort, 29 patients (12.4%) had their urinary catheter removed between 1-5 days (Group 1), 141 patients (60.3%) between 6-10 days (Group 2) and 64 patients (27.4%) between 11-15 days (Group 3) (Table 1). Of the 29 patients in Group 1, 5 patients had their catheter removed within 48 hours of surgery (17.2%) and 10 patients had their catheter removed within 72 hours of surgery (34.5%). There was no significant difference between groups in age, BMI, tumor size, type of hysterectomy, cancer stage, or intraoperative estimated blood loss. There were significant differences between groups for surgical approach (p=0.028) with more open compared to minimally invasive surgery in Group 1 (55.2%) compared to Group 2 (38.3%) or Group 3 (25.0%). In addition, more patients in Group 1 (69.0%) underwent surgery in the ERAS vs the pre-ERAS time period compared to Group 2 (51.1%) or Group 3 (31.3%) (p<0.01). Median operative time differed significantly by group (p<0.01) and was shortest in Group 1 (256 min) and longest in Group 3 (318 min).
Overall, 27 patients (11.5%) failed their initial voiding trial, with no difference in voiding dysfunction based on timing of catheter removal (Group 1: 17.2% vs Group 2: 11.3% vs Group 3: 9.4%, p=0.54) (Table 2). The median days to urinary functional recovery among all patients was 9 days (IQR 7-12), and Group 1 had a significantly shorter median time to urinary functional recovery (4 days, IQR 3-5 days) compared to Group 2 (8 days, IQR 7-10 days) and Group 3 (13 days, IQR 11-15 days) (p<0.01). Overall, 17.1% of the cohort developed a UTI within 30 days and an additional 4.3% developed a UTI within 60 days, with no differences based on time to catheter removal group. Likewise, there was no difference by group in hospital length of stay, 30-day, or 60-day readmission due to a genitourinary complication.
Table 2.
Postoperative outcomes by timing of catheter removal group
| Variables | Overall (n=234) | Postoperative day of urinary catheter removal | P value | ||
|---|---|---|---|---|---|
| Group 1: 1-5 days (n=29) | Group 2: 6-10 days (n=141) | Group 3: 11-15 days (n=64) | |||
| Voiding dysfunction, n (%) | 27 (11.5) | 5 (17.2) | 16 (11.3) | 6 (9.4) | 0.54 |
| Day to urinary function recovery, median (IQR) | 9 (7 – 12) | 4 (3-5) | 8 (7-10) | 13 (11-15) | < 0.01 |
| Hospital length of stay in days, median (IQR) | 2 (1 – 3) | 2 (1-4) | 2 (1-3) | 2 (1-3) | 0.94 |
| UTI within 30 days, n (%) | 40 (17.1) | 6 (20.7) | 26 (18.4) | 8 (12.5) | 0.55 |
| UTI within 60 days, n (%) | 50 (21.4) | 9 (31.0) | 29 (20.6) | 12 (18.8) | 0.61 |
| Readmission due to genitourinary complication within 30 days, n (%) | 36 (15.4) | 5 (17.2) | 23 (16.3) | 8 (12.5) | 0.80 |
| Readmission due to genitourinary complication within 60 days, n (%) | 44 (18.8) | 7 (24.1) | 27 (19.1) | 10 (15.6) | 0.43 |
Significant p-values bolded
IQR, interquartile range; UTI, urinary tract infection
When we compared patients who did and did not pass their void trial, there was no difference in voiding dysfunction based on tumor size, type of radical hysterectomy, or cancer stage (Table 3). The odds of voiding dysfunction did not differ between patients who underwent open compared to minimally invasive surgery (OR 1.00, 95% CI 0.47-2.17) or who underwent surgery in the pre-ERAS compared to ERAS study period (OR 0.66, 95% CI 0.19-2.21). Compared to Group 1, there was no difference in the odds of voiding dysfunction for Group 2 (OR 0.61, 95% CI 0.21-1.84, p=0.38) or Group 3 (OR 0.49, 95% CI 0.14-1.78, p=0.28).
Table 3.
Analysis of voiding dysfunction by clinical characteristics and timing of catheter removal group
| Voiding dysfunction | ||||
|---|---|---|---|---|
| Variable | Yes (n=27) | No (n=207) | Odds ratio (95% CI) | P-value |
| Tumor size mm, median (IQR) | 22 (15 – 30) | 22 (12 – 30) | N/A | 0.99 |
| Type of hysterectomy, n (%) | N/A | 0.57 | ||
| II | 1 (3.7) | 6 (2.9) | ||
| III | 25 (92.6) | 201 (97.1) | ||
| Stage, n (%) | N/A | |||
| IA1 | 0 (0.0) | 15 (7.2) | 0.23 | |
| IA2 | 5 (18.5) | 37 (17.9) | 0.94 | |
| IB1 | 21 (77.8) | 145 (70.0) | 0.41 | |
| IB2 | 0 (0.0) | 8 (3.9) | 0.60 | |
| IIA | 1 (3.7) | 2 (1.0) | 0.31 | |
| Surgical approach, n (%) | ||||
| Open | 10 (37.0) | 78 (37.7) | REF | |
| Minimally invasive | 17 (62.9) | 129 (62.3) | 1.00 (0.47-2.17) | 0.99 |
| ERAS era, n (%) | ||||
| Pre-ERAS | 19 (70.4) | 123 (59.4) | REF | |
| ERAS | 8 (29.6) | 84 (40.6) | 0.66 (0.19-2.21) | 0.50 |
| Timing of catheter removal group, n (%) | ||||
| 1 (1-5 days) | 5 (18.5) | 24 (11.6) | REF | |
| 2 (6-10 days) | 16 (59.3) | 125 (60.4) | 0.61 (0.21-1.84) | 0.38 |
| 3 (11-15 days) | 6 (22.2) | 58 (28.9) | 0.49 (0.14-1.78) | 0.28 |
DISCUSSION
Summary of Main Results
There was no difference in voiding dysfunction, UTI development, hospital length of stay, or hospital readmission due to genitourinary complications based on timing of urinary catheter removal after radical hysterectomy in this retrospective cohort institutional study. Our results support an early void trial attempt after radical hysterectomy for early cervical cancer, as the worst-case scenario for all groups in our analysis appears to be catheter reinsertion without differences in postoperative genitourinary complications.
Results in the Context of Published Literature
Our results are consistent with previous retrospective studies demonstrating the overall safety of early catheter removal after radical hysterectomy.[16–21] Despite using various definitions of early urinary catheter removal and voiding dysfunction, these studies have overall demonstrated that urinary catheter removal <72 hours postoperatively results in voiding dysfunction rates between 17-44%.[16–18, 20] In our study, the rate of voiding dysfunction was 11.5% overall and 17.2% in the earliest catheter removal group. Voiding dysfunction rates may have been higher in our analysis if we restricted the earliest catheter removal group to <72 hours after surgery, however we were unable to analyze this due to low patient numbers. While we did not examine long-term genitourinary outcomes, our analysis did not find any differences in readmissions due to genitourinary complications between groups at 30 or 60 days based on timing of catheter removal.
Our analysis is distinct from previous studies in that we included a large, carefully defined cohort of patients undergoing radical hysterectomy for early-stage cervical cancer treated with radical hysterectomy and included a high number of open surgeries, with no difference in voiding dysfunction found based on open vs minimally invasive surgical approach. Previous studies include three which were done exclusively after laparoscopic radical hysterectomy,[18, 19, 26] one which included non-cervical cancer patients,[16] and two which included radical trachelectomy.[20, 21] In addition, our study included a large number of patients undergoing surgery on ERAS pathways, which is increasingly the standard of care practice for gynecologic oncologic surgery, with no difference in voiding dysfunction in pre-ERAS compared to ERAS patients.
Strengths and Weaknesses
Our study is one of the largest examining the impact of urinary catheter removal timing on voiding dysfunction after radical hysterectomy and includes a large number of patients who underwent open surgery. Because we included both pre-ERAS and ERAS patients, our results are likely broadly generalizable to institutions. Although our void trials included both standard and retrograde techniques, we used a consistent and quantitative definition of voiding dysfunction as measured by PVR. We examined outcomes out to 60 days postoperatively, which encompasses most or all of the time of postoperative recovery trajectory back to normal preoperative functioning[27, 28] and can be used to educate patients on postoperative expectations.
Limitations of our study include the single-institution and retrospective, non-randomized design. We did not have a standardized method of void trial (standard or retrograde). Timing of void trial was at the surgeon’s discretion and may have been influenced by unmeasured clinical or surgical factors. Due to the non-standard timing of catheter removal according to surgeon discretion, we had an uneven distribution of patients in each of the groups, which may have impacted our statistical conclusions. In addition, we did not require a positive urine culture in our definition of a UTI, which may have affected our outcome results. Because we defined our hysterectomy type by the Piver classification,[1] our results may not be directly transferrable to a three-dimensional model of radical hysterectomy.[29] The outcomes we measured in this study are limited to the postoperative period and do not evaluate for long-term voiding dysfunction. Finally, our endpoints are clinically derived rather than patient reported, an important distinction when examining the morbidity of cancer treatment.
There was no difference in voiding dysfunction based on timing of catheter removal, tumor size, type of Piver hysterectomy, or cancer stage in our analysis. Of note, our study used 2009 FIGO staging for cervical cancer and 4.7% of patients in our analysis had tumors >4 cm in dimension (although all of these patients had their catheters removed at 6 or more days postoperatively). Our study results should be interpreted carefully in the setting of updated FIGO staging and current recommendations for management of early-stage cervical cancer.[2] A previous retrospective study demonstrated that tumor size >4 cm was significantly associated with postoperative voiding dysfunction on multivariate analysis,[30] thus early urinary catheter removal should be studied more carefully in this group of patients and may be most appropriate for patients with smaller tumors.
Implications for Practice and Future Research
We believe that our study demonstrates the safety of early urinary catheter removal within the context of contemporary practice due to our inclusion of large numbers of patients undergoing open surgery and surgery incorporating ERAS pathways. In our study, the earliest catheter removal group had a higher rate of open surgery than other groups with no difference in voiding dysfunction, which is important as open abdominal surgery is now recommended over laparoscopic surgery for early-stage cervical cancer[2] based on studies demonstrating worse survival with a laparoscopic approach.[4, 5, 31] In addition, the earliest catheter removal group had a significantly higher rate of ERAS surgery than the other groups with no difference in postoperative voiding dysfunction or genitourinary complications in ERAS compared to pre-ERAS patients. An important component of ERAS practice is the early removal of urinary catheters after surgery, ideally within 24 hours.[22] ERAS patients generally have superior clinical outcomes compared to non-ERAS patients[25] and this may have influenced our results, although which components of ERAS may have contributed to successful early catheter removal is not clear. Regardless, the success of the earliest catheter removal group within an ERAS protocol is important because early urinary catheter removal has not routinely been incorporated for patients undergoing radical hysterectomy due to a presumed higher risk of postoperative voiding dysfunction compared to non-radical hysterectomy.[6, 7] With the advent of nerve sparing radical hysterectomy,[9, 10] and its association with less postoperative voiding dysfunction,[11–15] this practice should be reconsidered as a safe adjunct to current ERAS practice. In our institution, patients who undergo a radical hysterectomy under an ERAS pathway undergo urinary catheter removal within 48-72 hours after surgery, although it is possible that even earlier removal of urinary catheter could be appropriate in the context of contemporary surgical practice incorporating nerve-sparing techniques and perioperative ERAS care.
Because our study is retrospective in nature, future studies should be performed to prospectively evaluate the impact of early compared to delayed urinary catheter removal after radial hysterectomy and better define the ideal time period for catheter removal postoperatively, ideally in a randomized study design. In addition, studies should be conducted over a lengthier time frame to examine long-term rates of voiding dysfunction. For patients who are identified to be at risk of long-term voiding dysfunction after radical hysterectomy, studies should examine perioperative interventions that may prevent complications and improve bladder function to continue to optimize quality of life for these patients.
Conclusions
We found that urinary catheter removal within 5 days of radical hysterectomy was not associated with a higher rate of voiding dysfunction or genitourinary complications compared with longer times to catheter removal. Given the growing body of evidence from our study and others, early removal of urinary catheter should be considered after radical hysterectomy.
KEY MESSAGES.
What is already known on this topic:
Studies suggests that early catheter removal may be appropriate in patients undergoing radical hysterectomy. However, the interpretation of these studies in contemporary practice is limited by small numbers of patients undergoing open surgery and surgery on ERAS pathways.
What this study adds:
Within a study cohort which included patients undergoing open surgery and surgery on ERAS pathways, we found that urinary catheter removal within 5 days of radical hysterectomy for early-stage cervical cancer was not associated with a higher rate of voiding dysfunction or other genitourinary complications compared with longer periods of postoperative urinary catheter removal.
How this study might affect research, practice or policy:
Early removal of urinary catheter should be considered after radical hysterectomy for early stage cervical cancer.
Disclosure of funding:
This work was supported in part by the MD Anderson Cancer Center Support Grant from the National Cancer Institute of the National Institutes of Health (NIH/NCI P30 CA016672) and the T32 training grant (NIH/NCI CA101642). The funders played no role in the development, analysis, or presentation of the current study.
Author Disclosures:
SPH reports funding support for the present manuscript from the MD Anderson Cancer Center Support Grant from the National Cancer Institute of the National Institutes of Health (NIH/NCI P30 CA016672) and the T32 training grant (NIH/NCI CA101642). LAM reports consulting fees from Bristol Meyers Squibb, advisory board participation for GlaxoSmithKline, and stocks in Crisper, Invitae, and Bristol-Myers Squibb. MF is a consultant/speaker for Stryker, a consultant for Stryker, Astrellas, and Seagen, and receives research funding from Astra Zeneca and GlaxoSmithKline. PTR reports payments as Editor-in-Chief of the International Journal of Gynecological Cancer. The remaining authors report no conflicts of interest.
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