mis

1. Minimally invasive surgery -
current status in cervical
cancer
Dr Ancy T Jacob
Professor in Obstetrics and Gynaecology
Consultant Gynaec endoscopic surgeon
Travancore Medicity Kollam

2. ● Radical hysterectomy + Bilateral pelvic lymphadenectomy - Treatment of
choice for early stage cervical cancer, FIGO stage 1B - IIA
● En bloc resection of the uterus, cervix and surrounding parametria,
uterosacral ligaments and upper third of the vagina.
● By laparotomy or minimally invasive approach - laparoscopy or robotic
assisted technique
● Radical trachelectomy - Removal of cervix, upper vagina and parametrium
Fertility sparing surgery for smaller lesions < 2 cm

3. Radical hysterectomy by laparotomy
● Excellent tumour control
● Overall survival 50 - 90%
● Post op complications - formation of uretero vaginal and vesico
vaginal fistulas
○ Ureteral injury and devascularization
○ Lymphedema
○ Prolonged bladder dysfunction
○ Sexual dysfunction

4. MIS
Why minimally invasive surgery?
Advantages
- Fewer perioperative and postoperative complications
- Minimal blood loss
- Shorter hospital stay
- Fast recovery
Disadvantages
- Longer operating time
- Surgical expertise

5. Robotic approach
Advantages
● 3D visual access
● Better instrument articulation
● Improved dexterity
● Filtration of tremors
● Precise
Disadvantages
● Lack of tensile feedback
● Increased cost
● Complexity of the system

6. MIS in cervical cancer
● First laparoscopic radical hysterectomy with pelvic lymphadenectomy in
1990s - Nezhat et al and Canis et al.
● First robotic assisted radical hysterectomy in 2006 - Sert and Abler
● Retrospective studies in 2000s - favoring MIRH with comparable outcomes
with open method

7. LACC trial
“Laparoscopic Approach to Carcinoma of the Cervix” (LACC) trial - a prospective
phase III RCT(2018)
-statistically significant poorer overall survival
- lower disease free survival (DFS)
- higher recurrence rate
Compared to laparotomy for early stage cervical cancer

8. Why poorer oncological outcome in LACC trial?
Potential causes
- Type of MIS ( Laparoscopy vs Robotic surgery)
- Size of the lesion ( <2 cm vs > 2cm
- Impact of CO2 pneumoperitoneum
- Prior conization
- Use of a uterine manipulator
- Use of protective measures (vaginal closure before colpotomy)
- Surgical expertise/learning curve

9. Fusegi et al. - narrative review (Jan 2023)
- Analysed potential poorer prognostic factors of MIRH in LACC trial
- Analysed the importance of avoidance of cancer cell spillage as a prognostic
factor
MIRH using surgical technique to prevent cancer cell spillage - favourable
outcome similar to open surgery
Analysed 6 meta analyses

11. 2 factors to be analysed
- Learning curve
- Surgical procedural effect - measures to avoid cancer spillage

12. MIRH and the learning curve effect
● The learning curve effect including the surgical quality has affected the
prognosis in LACC trial resulted in poorer outcome
● The learning curve effect was not evaluated in LACC trial
● MIRH quality control was performed by evaluating an unedited surgical video
(not available), hence evaluation process unclear
● LACC trial started in 2008, when MIRH just commenced in US, surgeons
involved were under the learning curve effect, affected the prognosis

13. MIRH and surgical procedural effect
In LACC trial - loco-regional recurrence rate higher in MIRH
Cancer cell spillage in MIRH - a concern
Risks:
● Exposure of the tumour
● Use of a uterine manipulator
● Direct handling of the uterine cervix

14. ● Tumour exposure to CO2 pneumoperitoneum
○ Colpotomy under CO2 pneumoperitoneum - risk for local recurrence.
○ Still controversial, precautions to be taken
● Use of a uterine manipulator
○ May introduce dysplastic cells in to fallopian tube - triggers peritoneal
dissemination
○ Local recurrence with uterine manipulator ( retrospective studies)
Use of uterine manipulator should be discouraged

15. ● Direct handling of the cervix
○ Applying excessive force to the cancerous tissue can result in cancer cell dissemination
Kong et al - oncological outcome with Intracorporeal vs vaginal colpotomy - poorer
outcome with intra corporeal
Minimizing cervical tumour compression during surgery is necessary

16. MIRH with avoidance of cancer spillage
Fusegi et al.
Included MIRH which avoided cancer cell spillage including vaginal cuff creation
before laparoscopy
10 retrospective analyses included
Oncological outcomes were equivalent between MIRH and open radical
hysterectomy

18. SUCCOR study - a large observational cohort study- Disease free survival in the
no manipulator group similar to open group
Strength of the study - large sample size with multiple centres

19. LRH using no look - no touch technique ( Kanoa et al. and Fusegi et al.)
● Creation of vaginal cuff before laparoscopy
● Uterine manipulation without the use of a manipulator
● Avoidance of direct handling of the cervix by creating surgical spaces -
paravesical and pararectal spaces
● Using an endobag while removing the specimen

20. DFS was not significantly different between MIRH and open groups
Strengths :
- Quality control of the surgery was ensured ( by a single surgeon in the same
manner)
- Large sample size

21. LRH excluding robotic assisted vs open RH
Meta analysis ( Marchand et al., January 2023 ) of studies comparing LRH vs
open method excluding robotic assisted for early stage cervical cancer
Primary outcomes :
Operative time, estimated blood loss, intra op and post op complications
Secondary outcomes :
Recurrence rate, 5 year survival rate, disease free survival rate

22. Results:
LRH - lower incidence of estimated blood loss, post operative complications
shorter hospital stay
No significant difference between both groups - 5 year overall survival
disease free survival and intra and post operative mortality

23. What is the future?
High quality prospective studies confirming surgeon’ skills needed
Ongoing clinical trials
- A non randomized controlled LRH trial in Japan, aims to prevent cancer
spillage
- SOLUTION - a phase 2 non inferiority trial - using endoscopic stapler as a
tool to prevent cancer spillage
- Ohio clinical trial comparing MIRH including robotic surgery with open
methods after adopting tumour containment methods

24. To Conclude
MIS - not inferior to open surgery
- when appropriate tumour containment methods are utilized
- uterine manipulators are avoided

25. Thank You