Arch Gynecol Obstet DOI 10.1007/s00404-013-3121-4
GYNECOLOGIC ONCOLOGY
Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome Malgorzata Lanowska • Verena Brink-Spalink • Mandy Mangler • Ulrike Grittner • Elisabeth von Tucher Achim Schneider • Christhardt Ko¨hler
•
Received: 8 October 2013 / Accepted: 3 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls. Methods One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs. Results In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P \ 0.001). Bladder function resumed sooner (P \ 0.001), and patients were discharged earlier after VALRH (P \ 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year
M. Lanowska (&) V. Brink-Spalink M. Mangler E. von Tucher A. Schneider C. Ko¨hler Department of Gynecology, Charite´-University Medicine Berlin, Campus Mitte and Benjamin Franklin, Charite´platz 1, 10117 Berlin, Germany e-mail: [email protected] U. Grittner Department of Biostatistics and Clinical Epidemiology, Charite´University Medicine Berlin, Berlin, Germany
recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740). Conclusion VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach. Keywords Cervical cancer Laparoscopic-assisted radical vaginal hysterectomy Vaginal-assisted laparoscopic radical hysterectomy Urologic complications
Introduction Radical hysterectomy is the accepted treatment for the majority of patients with early stage cervical cancer and various techniques are demonstrated in the literature. These include abdominal radical hysterectomy (ARH) with and without nerve-sparing, total laparoscopic radical hysterectomy (TLRH), laparoscopic-assisted vaginal hysterectomy (LARVH) and robotic procedures. LARVH is a standardized procedure combining the modified Schauta operation [1, 2] with the laparoscopic approach. LARVH has a good oncological outcome as demonstrated by numerous studies, comprising more than 800 patients, but at the expense of considerable urologic complication rate compared to ARH and TLRH [3–7]. A reason for this is the complicated vaginal part of the surgery. However, in procedures that do not utilize the vaginal approach, such as ARH or TLRH, the resection of an adequate part of the vagina can be technically challenging
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with the added concern of the possible spread of tumour cells when using a manipulator. With the objective to overcome these concerns and improve the technique, the vaginal-assisted radical laparoscopic hysterectomy (VALRH) was developed. It combines the advantages of the laparoscopic radical hysterectomy with the simplified vaginal approach in order to develop a tumour-adapted vaginal cuff [8]. In this study, the surgical results and the oncologic outcome of patients who underwent VALRH and patients who underwent LARVH are compared.
vesicovaginal septum is carried out by laparoscopy, whereas the major part of the surgical procedure is done by vaginal route according to the original description of Schauta and Stoeckel (LARVH type II) [1, 2] and LatzkoMeigs Mackenroth (type III) [14]. During VALRH, the hysterectomy is carried out laparoscopically with only the vaginal cuff, the removal of the uterus and closure of the vagina being performed vaginally [8]. The VARLVH was developed as a modification of LARVH in order to simplify the procedure and reduce the risk of intraoperative complications.
Materials and methods
Statistical analysis
Patient characteristics
The majority of patients were followed up in the institution that performed the surgery. If follow-up was performed outside the institution, responsible gynaecologist was contacted for the data collection. In terms of oncological outcome, we only analysed patients within the tumour stage Ib1 of both groups as the remaining data proved too heterogeneous for meaningful comparisons. Statistical analysis was performed using SPSS software (SPSS, 17.0, SPSS, Inc. Chicago, IL). Differences between frequencies were compared using Pearson’s Chi-square test, Fisher’s exact test, and McNemar test (for the matched-pair analysis); differences between continuous normally distributed data were compared using independent t test when analysing data from all patients and dependent t test when analysing matched pairs. Overall survival and disease-free survival rates were calculated according to Kaplan–Meier method and the log-rank test was used to test group differences between time-to-event data in all patients. A significance level of a = 0.05 was considered. No adjustment for multiple testing was applied.
Between January 2007 and December 2009, 109 patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb at the Department of Gynecology at Charite´ University Medicine Berlin, Germany, Campi Mitte and Benjamin Franklin were entered into a prospective database. The data for the LARVH group were also collected prospectively and contain information of 200 patients who underwent LARVH for early-stage cervical cancer at the University of Jena between August 1994 and April 2002, where two members of our division were based. Institutional Review Board approval was obtained for both groups. In addition to the statistical analysis of all patients, we used 1:1 individual pair-matching as a technique for controlling confounders in our patient groups. From 309 patients 50 pairs could be found according to the parameters of age (±1 year of age), BMI (±2), and the same TNM-stage of the tumour. In an explorative analysis, we analysed differences in age, BMI, operating time, blood loss, node counts, periand post-operative complications, time to spontaneous voiding of urine, and length of hospital stay between all patients in the two groups as well as the matched pairs. Additionally, the recurrence-free survival rates and overall survival rates were analysed in all patients. Surgical technique Both approaches began with the laparoscopic evaluation of the abdominal cavity followed by laparoscopic lymphadenectomy, which was performed equally in both groups and has been previously described in detail [9–11]. Laparoscopy and lymphadenectomy were performed as a staging procedure to exclude patients with abdominal spread of disease and positive lymph nodes. Both surgical methods of performing hysterectomy were previously described in the literature [8, 12, 13]. During LARVH, only the dissection of vesicocervical and
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Results Patient characteristics The median age of patients was 44 (range 25–79) years in the VALRH group and 44 (range 17–78) years in the LARVH group. The median weight was 66 (48–150) kg with BMI of 24 (17–46) in the VALRH group and 65 (44–108) kg with BMI of 24 (15–38) in the LARVH group. Stage of disease (TNM) was distributed as follows to the groups: VALRH group: stage Ia1 L1 (n = 10; 9.2 %), Ia2 (n = 5; 4.6 %), Ib1 (n = 83; 76.1 %), yIb1 (n = 2; 1.8 %), Ib2 (n = 2; 1.8 %), IIa (n = 1; 0.9 %), IIb (n = 6; 5.6 %), and LARVH group: stage Ia1 L1 (n = 6; 3.0 %), Ia2 (n = 21; 10.5 %), Ib1 (n = 89; 44.5 %), Ib2 (n = 26; 13.0 %), IIa (n = 11; 5.5 %), IIb (n = 45; 22.5 %), IIIa (n = 1; 0.5 %), IV (n = 1; 0.5 %). Squamous cell
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carcinoma was diagnosed in 67 (61.5 %) patients in the VALRH group and 150 (75.0 %) of the patients in the LARVH group, adenocarcinoma in 40 (36.7 %) and 47 (23.5 %), and neuroendocrine carcinoma in 2 (1.8 %) and 3 (1.5 %), respectively. In the VALRH group, lymphovascular space involvement was found in 25 (22.9 %), angiovascular space involvement in 7 (6.4 %), and in the in the LARVH group 31 (15.5 %) and 41 (20.5 %) of the patients, respectively. Grading was distributed as follows to the groups: VALRH: G1: 14 (12.8 %); G2: 68 (62.4 %); G3: 27 (24.8 %); and LARVH: G1: 16 (8.0 %); G2: 108 (54.0 %); G3: 76 (38.0 %). Patient characteristics of both groups are represented in Table 1. The median age of the patients in the matched pairs group was 42 years and the median BMI was 24. The following tumour stages were present in the matched pairs: stage Ia2: 3 (6.0 %) patient-pairs; Ib1: 41 (82.0) patientpairs; Ib2: one (2.0 %) patient-pair; IIb: 5 (10.0 %) patientpair. In the matched-pair analysis, 28 (56.0 %) patients from the VALRH group had a squamous cell carcinoma and 22 (44.0 %) adenocarcinoma, in the LARVH group, there were 37 (74.0 %) and 13 (23.0 %), respectively. Lymph vascular space involvement was found in 12 Table 1 Patient characteristics
n (patients) a
VALRH
LARVH
109
200 44 years (17–78)
Age (median; range)
44 years (25–79)
Weight (median; range)
66 kg (48–150)
65 kg (44–108)
BMIa (median; range)
24 (17–46)
24 (15–38)
IA1 L1
10 (9.2 %)
6 (3.0 %)
IA2
5 (4.6 %)
21 (10.5 %)
IB1
83 (76.1 %)
89 (44.5 %)
yIB1
2 (1.8 %)
IB2
2 (1.8 %)
26 (13.0 %)
IIA
1 (0.9 %)
11 (5.5 %)
IIB IIIA
6 (5.6 %)
45 (22.5 %) 1 (0.5 %)
FIGO stagea
IV
1 (0.5 %)
Histologic type Squamous cell carcinoma
67 (61.5 %)
150 (75.0 %)
Adenocarcinoma
40 (36.7 %)
47 (23.5 %)
2 (1.8 %)
3 (1.5 %)
LVSI
Neuroendocrine carcinoma
25 (22.9 %)
31 (15.5 %)
VSI
7 (6.4 %)
41 (20.5 %)
G1
14 (12.8 %)
16 (8.0 %)
G2
68 (62.4 %)
108 (54.0 %)
G3
27 (24.8 %)
76 (38.0 %)
Grading
a
Matching criterion
(24.0 %) matched patients in the VALRH group, and 8 (16.0 %) in the LARVH group; blood vascular space involvement in 2 (4.0 %) and 6 (12.0 %), respectively. Operative data In the VALRH group, type II surgery was performed in 86 (78.9 %) and the type III surgery in 23 (21.1 %) cases; LARVH type II was performed in 102 (51.0 %) patients, LARVH type III was performed in 98 (49.0 %) of the patients. The mean duration of the surgery in the VALRH group was 298 min (range 145–665 min) and was significantly shorter than in the LARVH group with a mean of 333 min (range 151–556 min) (P \ 0.001). In the VALRH group, paraaortic lymph nodes were removed in 74 (85 %) patients with a mean count of 16 (range 2–36) removed lymph nodes, in the LARVH group paraaortic lymph nodes were removed in 170 (85 %) of patients with a mean of 8 (range 1–27) lymph nodes removed. This significant difference in the paraaortic lymph nodes count (P \ 0.001) is due to the learning curve of the surgeons. The lymphadenectomy was performed in both groups by the same surgeons; however, the VALRH procedures were performed subsequent to the LARVH and by that stage the surgeons were more familiar with the procedure. Pelvic lymphadenectomy was performed in all patients of both groups, the mean count of the removed nodes was 21 (range 4–43) in the VALRH group, and 22 (range 3–57) in the LARVH group with no significant difference between the groups (P = 0.684). In the VALRH group, 5 (4.6 %) patients had positive pelvic and one (0.5 %) patient positive paraaortic nodes; in the LARVH group, there were 25 (12.5 %) patients with positive pelvic and 1 (0.5 %) patient positive paraaortic nodes. Sentinel lymph node detection prior to the complete lymphadenectomy was performed in 32 (29.4 %) patients in the VALRH group and 60 (30.0 %) patients in the LARVH group. Neither group converted to laparotomy due to intraoperative complications. After VALRH the mean blood loss, measured by the haemoglobin drop after surgery in g per dl, was significantly lower than after LARVH (1.9 vs. 3.2 g/dl; P \ 0.001). However, data of 48 patients in the VALRH and 29 in the LARVH group were unobtainable. Prevalence of blood transfusion due to surgery was significantly lower in the VALRH group (2 vs. 39; P \ 0.001). Bladder function was restored significantly earlier after VALRH with a mean of 8 postoperative days (range 2–40) than after LARVH with a mean of 11 (range 1–50) days (P \ 0.001). Patients were discharged significantly earlier after VALRH with a mean of 10 (range 5–31) than after LARVH with a mean of 14 (range 5–32) (P \ 0.001). Operative data are shown in Table 2. In the analysis of the matched pairs, a mean of 22 pelvic lymph nodes was removed in the patients who underwent
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Arch Gynecol Obstet Table 2 Operative data of the study cohorts
Table 3 Matched-pair analysis of operative data
VALRH
LARVH
n (patients)
109
200
n (matched pairs) = 50
Radical hysterectomy type II
86 (78.9 %)
102 (51 %)
median age = 42 years
Radical hysterectomy type III
23 (21.1 %)
98 (49 %)
median BMI = 24
Operation time (min; min–max)
298 (145–665)
333 (151–556)
Tumour stage: Ia2: 3 (6 %); Ib1: 41 (82 %); Ib2: 1 (2 %); IIb: 5 (10 %).
Pelvic lymph nodes (mean, range)
21 (4–43)
22 (3–57)
Operation time (min)
302
322
Paraaortic lymph nodes (mean, range)
16 (2–36)
8 (1–27)
Pelvic lymph nodes (mean)
22
23
Paraaortic lymph nodes (mean) VALRH n = 38 (76 %) patients
16
8
Sentinel lymphadenectomy
22
10
Blood loss (haemoglobin drop in g/dl) n = 30 matched pairs
2.1
2.4
39 (19.5.0 %)
Blood transfusion
0
11
Bladder function restored (days)
7
12
8 (2–40)
11 (1–50)
Hospital stay (days)
10
14
10 (5–31)
14 (5–32)
VALRH n = 74 (85 %) patients LARVH n = 170 (85 %) patients Sentinel lymphadenectomy
32 (29.4 %)
60 (30.0 %)
Blood loss (haemoglobin drop in g/dl)
1.9
3.2
VALRH n = 61 (56.0 %) patients LARVH n = 171 (85.5 %) patients Blood transfusion Bladder function restored (days, median, range) Hospital stay (days, median, range)
2 (1.8 %)
VALRH and 23 after LARVH, with no significant difference between the groups (P = 0.792). Paraaortic lymphadenectomy was performed in 38 (76.0 %) matched patients in the VALRH group with a mean of 16 lymph nodes, and in 42 (84.0 %) patients in the LARVH group with a mean of 8 lymph nodes (P \ 0.001). In 11 (22.0 %) patients in the VALRH group and 10 (20.0 %) in the LARVH group sentinel lymph nodes were removed prior to complete lymphadenectomy. In the matched patients, the duration of the surgery was 302 min for VALRH and 322 for LARVH which was not significant (P = 0.155), but demonstrated a trend for shorter procedure length in the VALRH group. In matched patients, the blood loss, measured by the haemoglobin drop after surgery in g per dl, was comparable after VALRH and LARVH (2.1 vs. 2.4 g/ dl; P = 0.509) with a trend in favour of VALRH. However, data of only 30 pairs could be evaluated. Prevalence of blood transfusion rate due to surgery was significantly lower in the matched patients after VALRH than after LARVH (0 vs. 11; P \ 0.001). In the VALRH group, the time to the restoration of the bladder function was 7 days on median in the matched patients and was significantly shorter than in the LARVH group (12 days) (P \ 0.001). After VALRH, the matched patients were discharged after a median of 10 days that was significantly earlier than after the LARVH with a median hospital stay of 14 days (P \ 0.001). Operative data of the matched pairs are shown in Table 3. In the VALRH group, no intraoperative injuries of bladder, ureter, blood vessel or bowel occurred. In the
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VALRH
LARVH
LARVH n = 42 (84 %) patients
LARVH group, the most frequent intraoperative injuries occurred to the bladder while opening the cervico-vesical space in 14 (7.0 %) patients. Further intraoperative complications in the LARVH group were injury of the ureter in 7 cases (3.5 %), of a blood vessel in 4 (2.0 %) cases and of the bowel in 1 (0.5 %) of the cases. All intraoperative complications were recognized and managed during the surgery. Thus, in the VALRH group, there were significantly less complications during the surgery (P \ 0.001). In the analysis of the matched pairs, no intraoperative complications were found in the VALRH group, and there was one (2 %) bladder injury, one (2 %) ureter injury and two (4 %) vessel injuries in the LARVH group. Postoperative complications Postoperative revisions were performed in 4 (3.7 %) patients in the VALRH group, all laparoscopically (2 for abdominal pain due to adhesions, one for lost drainage and one for chylascos). In the LARVH group, revisions occurred in 7 (3.5 %) cases; in 5 patients laparoscopic revision was performed (3 for diffuse bleeding, 1 for bleeding from the medial rectal artery and cardinal ligament, 1 for bladder bleeding from a dislocated suprapubic catheter), one patient underwent open surgery for diffuse bleeding, and one patient had a transvaginal revision due to a serocele. In the VALRH group the following postoperative complications occurred: ureterovaginal fistula (n = 3; 2.7 %), asymptomatic embolism of the lung artery (n = 2; 1.8 %), dehiscence of the vagina (n = 1; 1 %), postoperative fever (n = 3; 2.7 %), lymphocele (n = 1;
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1 %), and stress-induced cardiomyopathy (n = 1; 1 %). In the VALRH group, all three patients with ureterovaginal fistula were successfully treated with ureteral stents. In the LARVH group, ureterostenosis occurred in 7 cases (3.5 %), uretero/bladder fistula in 2 cases (1 %), and postoperative fever in 14 cases (7 %). In two patients, bowel obstruction occurred, treated by laparotomy in one case and conservatively in the other. In the LARVH group, ureterostenosis was treated with nephrostomy in four patients and with ureteral stents in three patients. The difference between the groups and the matched pairs among the groups concerning the rate of postoperative complications failed significance (P = 0.502, Fisher’s exact test and P = 0.508, McNemar test, respectively); only a trend in favour of VALRH is demonstrated. In total there were 30 intra- and postoperative complications concerning the urologic tract in the LARVH group, whereas only 3 complications occurred in the VALRH group. Thus, the complication rate for urologic complications was significantly lower after VALRH (P \ 0.001, Fisher’s exact test). Postoperative complications are shown in Table 4. Adjuvant therapy In the VALRH group, adjuvant therapy was recommended for 22 patients and 2 patients declined. Twenty patients underwent adjuvant therapy: two patients with neuroendocrine tumours underwent chemotherapy with carboplatin/taxol/etoposide and radiochemotherapy, 15 patients underwent chemo-radiation, and 2 patients were treated with brachytherapy. One patient underwent platine-based
Table 4 Perioperative complications VALRH (%) Bladder injury Ureter injury
– –
LARVH (%) 14 (7) 7 (3.5)
Bowel injury
–
1 (0.5)
Major haemorrhage
–
4 (2)
Revision
4 (3.7)
7 (3.5)
Fistula (bladder/ureter/vagina)
3 (2.7)
2 (1)
Ureterostenosis
–
Pulmonary embolism
2 (1.8)
Vaginal dehiscence
1 (1)
Fever
3 (2.7)
Ileus
–
7 (3.5 – – 14 (7) 2 (1)
Lymphocele
1 (1)
–
Stress-induced cardiomyopathy
1 (1)
–
Fistula (bladder/ureter/vagina)
chemotherapy due to ovarian metastasis. One patient in tumour stage Ib2 was received neoadjuvant chemotherapy and postoperative chemo-radiation. In the LARVH group, neoadjuvant chemotherapy (19 cisplatin/ifosfamide, 39 carboplatin/taxol/etoposide) had been given to four patients (2 %). Adjuvant chemotherapy (39 cisplatin/ifosfamide, 19 navelbine/5FU, 19 carboplatin/taxol, 79 carboplatin/taxol/etoposide, 19 vepeside/ haloxane/carboplatin) was given to 13 patients (6.5 %). Radiotherapy was performed in 71 patients (35.5 %): brachytherapy in 27 cases, teletherapy in 11 patients, and combined radiation in 33 patients. Follow-up The median follow-up was 60 months [Interquartile range (IQR) 47–100 months]. In the VALRH group, eight recurrences (7.3 %) occurred, and 4 patients (3.7 %) died following recurrence. In the LARVH group, 40 recurrences (20 %) occurred, and 31 patients (15.5 %) died following recurrence. In our study, both groups consisted of patients of different tumour stages and more patients with early stage cervical cancer in the VALRH group. Therefore, we only compared the recurrence-free survival rates and overall survival rates of patients with FIGO stage Ib1 cervical cancer. For FIGO stage Ib1 cervical cancer, the 5-year recurrence-free survival rate in the VALRH group was 92.8 % [95 % confidence interval (95 % CI) 87.3–98.3 %] and in the LARVH group was 88.2 % (95 % CI 81.3–95.1 %), (Fig. 1). Comparing the 5-year recurrence-free survival of patients with FIGO stage Ib1 in both groups, we found no significant difference in the survival rate (log rank, P = 0.589). The overall survival in patients with tumour stage Ib1 was 95.2 % (95 % CI 90.7–99.7 %) in the VALRH group and 90.5 % (95 % CI 84.2–96.8 %) in the LARVH group, (Fig. 2). There was no difference in the overall survival of patients in tumour stage Ib1 in both groups (log rank, P = 0.740).
Discussion Radical hysterectomy represents the standard surgical treatment for women with early stage cervical cancer. Multiple approaches such as open abdominal [15, 16], total laparoscopic [17–19], laparoscopic-assisted vaginal [4, 20, 21], and robotic [22, 23] have been described in the literature. The published studies comparing open with laparoscopic or laparoscopic-combined (or laparoscopic–roboticcombined) procedures for treatment of early-stage cervical cancer favour laparoscopy with respect to perioperative
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Fig. 1 Recurrence-free survival for 83 patients in tumour stage Ib1 in the VALRH group and 89 in the LARVH group. There is no significant difference between the groups
Fig. 2 Overall survival for 83 patients in tumour stage Ib1 in the VALRH group and 89 in the LARVH group. There is no significant difference between the groups
data such as blood loss, hospital stay, recovery, and cosmetic results and show comparable oncologic results [4, 5, 24–31]. However, large randomized studies directly comparing the different approaches are not in evidence [20, 32]. As such studies would give more precise information
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on the direct comparison of different methods of radical hysterectomy, they set a challenge for the future. Several requirements are to be considered when modifying an established method: same or better oncologic outcome, equal or lower complication rate, good recovery of the patient, high quality of life postoperatively including low morbidity of the procedure when combined with adjuvant therapy, good cosmetic results, economic aspects concerning the hospital stay, the use of instruments and the operating time, and a favourable learning curve for the surgeon. In our institution, radical hysterectomies were traditionally performed as LARVH following laparoscopic staging. With regard to the aspects mentioned above, we aimed to make the procedure easier to learn and to reduce the complications, especially the urologic ones, by modifying it to VALRH which combines the advantages of both the vaginal and the laparoscopic approach. In this study, we compared the oncologic and surgical outcome of matched patients treated by the new method to their pairs treated by LARVH when it was performed as the standard procedure for early-stage cervical cancer by the members of our department. Regarding the operative data, a positive trend in favour of VALRH is demonstrated in several areas. We focus on the matched-pair analysis, as comparing the surgical procedures of patients of the same age, with the same BMI and in the same tumour stage increases reliability. Blood transfusions were significantly lower than in the VALRH cohort. When compared to the literature, the blood loss of the new technique was in the lower range of the TLRH and RRH and lower than ARH [33–35]. The recovery of the patients (expressed by the restoration of the bladder function and duration of the hospital stay) was significantly improved in the VALRH group. This trend was clearly seen among the matched pairs and indeed the entire cohort. When compared to the literature both procedures, as well as the RRH, are superior to the open procedure in these points [20, 36]. Regarding the operation time a trend in favour of a shorter operating time for VALRH compared to LARVH. The reported mean operation time for ARH, TLRH and RRH are shorter [16, 27, 37]; however, paraaortic lymphadenectomy was performed in the majority of our procedures which is missing in most reported procedures in the literature Comparable lymph node counts in the pelvic region and higher counts in the paraaortic region could be harvested in the VALRH group compared to the LARVH patients. However, this is likely due to the learning curve of the surgeons who were more experienced operators when the new technique was introduced. The rate of intraoperative and postoperative complications is crucial in evaluating a new surgical technique. The reported data for intraoperative complications vary for differing procedures (ARH: 4–12.5 % [20]; TLRH:
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1–11.8 % [22]; LARVH: 5.9–13.2 % [4]; RRH: 0–14 % [29]). No intraoperative complications were demonstrated in our study, which is a significant advance, considering the relatively high rate of urologic complications in LARVH which are due to the complicated vaginal part of this procedure. The rate of postoperative complications can also be reduced by the new procedure [17, 20]—and in particular an improved outcome can be achieved regarding the urologic complications. As the oncologic data could not be compared directly in both cohorts, we compared the survival of patients in tumour stage Ib1—who are ideal candidates for radical hysterectomy—in both groups. No difference could be demonstrated in the survival of patients after VALRH as the projected 5-year recurrence-free survival rate was 92.8 % and the 5-year overall survival rate 95.2 % with a 95 % CI overlapping those in the LARVH cohort. When compared to other approaches, such as ARH, TLRH, RRH, the new technique is oncologically safe and feasible [5, 38, 39]. We conclude that with the VALRH procedure, the same radicality and the same oncologic outcome can be achieved in patients with early-stage cervical cancer. We believe that VALRH is a feasible and oncologically safe method for surgical treatment of patients with earlystage cervical cancer. It combines two standard techniques and can be easily learned by the surgeon. In particular, the low rate of intra- and postoperative complications is promising. However, large randomized studies are still required for directly comparing the different approaches of radical hysterectomy for early stage cervical cancer. This would aid in defining the most suitable procedure for our patient groups.
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Acknowledgments We thank Hermann Hertel, M.D. for disposing the LARVH database. The authors would like to thank Dr Lindsay Damkat-Thomas for assistance with the preparation of the manuscript. 16. Conflict of interest
There is no conflict of interest.
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GYNECOLOGIC ONCOLOGY
Vaginal-assisted laparoscopic radical hysterectomy (VALRH) versus laparoscopic-assisted radical vaginal hysterectomy (LARVH) in the treatment of cervical cancer: surgical results and oncologic outcome Malgorzata Lanowska • Verena Brink-Spalink • Mandy Mangler • Ulrike Grittner • Elisabeth von Tucher Achim Schneider • Christhardt Ko¨hler
•
Received: 8 October 2013 / Accepted: 3 December 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Abstract Purpose The aim of this study was to compare the morbidity and survival rates of patients with early-stage cervical cancer treated by vaginal-assisted laparoscopic radical hysterectomy (VALRH) with pair-matched laparoscopic-assisted vaginal radical hysterectomy (LARVH) controls. Methods One hundred nine patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb between 2007 and 2009 and 200 patients who underwent LARVH between 1994 and 2002 were analysed in their entirety and in a group of matched pairs. Results In both groups, there was no conversion to laparotomy due to an intraoperative complication. Prevalence of blood transfusions was significantly lower in the VALRH group (2 vs. 39 patients; P \ 0.001). Bladder function resumed sooner (P \ 0.001), and patients were discharged earlier after VALRH (P \ 0.001). There were no intraoperative injuries in the VALRH group. In the LARVH group, the most common intraoperative injury occurred to the bladder (7.0 %). Postoperatively, the most common complication in the VALRH group was ureterovaginal fistula (2.7 %) and fever (2.7 %) and in the LARVH ureterostenosis (3.5 %), uretero/bladder fistula (1 %), and fever (7 %). For patients with tumour stage Ib1 the 5-year
M. Lanowska (&) V. Brink-Spalink M. Mangler E. von Tucher A. Schneider C. Ko¨hler Department of Gynecology, Charite´-University Medicine Berlin, Campus Mitte and Benjamin Franklin, Charite´platz 1, 10117 Berlin, Germany e-mail: [email protected] U. Grittner Department of Biostatistics and Clinical Epidemiology, Charite´University Medicine Berlin, Berlin, Germany
recurrence-free survival was 92.8 % and 5-year overall survival 95.2 % following VALRH and 88.2 and 90.5 %, respectively, following LARVH. No significant difference in the survival rate was found (log rank, P = 0.740). Conclusion VALRH is a feasible and oncologically safe surgical option for patients with early-stage cervical cancer. We believe the complication rate is lowered in VALRH by the combination of the laparoscopic and vaginal approach. Keywords Cervical cancer Laparoscopic-assisted radical vaginal hysterectomy Vaginal-assisted laparoscopic radical hysterectomy Urologic complications
Introduction Radical hysterectomy is the accepted treatment for the majority of patients with early stage cervical cancer and various techniques are demonstrated in the literature. These include abdominal radical hysterectomy (ARH) with and without nerve-sparing, total laparoscopic radical hysterectomy (TLRH), laparoscopic-assisted vaginal hysterectomy (LARVH) and robotic procedures. LARVH is a standardized procedure combining the modified Schauta operation [1, 2] with the laparoscopic approach. LARVH has a good oncological outcome as demonstrated by numerous studies, comprising more than 800 patients, but at the expense of considerable urologic complication rate compared to ARH and TLRH [3–7]. A reason for this is the complicated vaginal part of the surgery. However, in procedures that do not utilize the vaginal approach, such as ARH or TLRH, the resection of an adequate part of the vagina can be technically challenging
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with the added concern of the possible spread of tumour cells when using a manipulator. With the objective to overcome these concerns and improve the technique, the vaginal-assisted radical laparoscopic hysterectomy (VALRH) was developed. It combines the advantages of the laparoscopic radical hysterectomy with the simplified vaginal approach in order to develop a tumour-adapted vaginal cuff [8]. In this study, the surgical results and the oncologic outcome of patients who underwent VALRH and patients who underwent LARVH are compared.
vesicovaginal septum is carried out by laparoscopy, whereas the major part of the surgical procedure is done by vaginal route according to the original description of Schauta and Stoeckel (LARVH type II) [1, 2] and LatzkoMeigs Mackenroth (type III) [14]. During VALRH, the hysterectomy is carried out laparoscopically with only the vaginal cuff, the removal of the uterus and closure of the vagina being performed vaginally [8]. The VARLVH was developed as a modification of LARVH in order to simplify the procedure and reduce the risk of intraoperative complications.
Materials and methods
Statistical analysis
Patient characteristics
The majority of patients were followed up in the institution that performed the surgery. If follow-up was performed outside the institution, responsible gynaecologist was contacted for the data collection. In terms of oncological outcome, we only analysed patients within the tumour stage Ib1 of both groups as the remaining data proved too heterogeneous for meaningful comparisons. Statistical analysis was performed using SPSS software (SPSS, 17.0, SPSS, Inc. Chicago, IL). Differences between frequencies were compared using Pearson’s Chi-square test, Fisher’s exact test, and McNemar test (for the matched-pair analysis); differences between continuous normally distributed data were compared using independent t test when analysing data from all patients and dependent t test when analysing matched pairs. Overall survival and disease-free survival rates were calculated according to Kaplan–Meier method and the log-rank test was used to test group differences between time-to-event data in all patients. A significance level of a = 0.05 was considered. No adjustment for multiple testing was applied.
Between January 2007 and December 2009, 109 patients who underwent VALRH for cervical cancer stage FIGO Ia1, L1 to IIb at the Department of Gynecology at Charite´ University Medicine Berlin, Germany, Campi Mitte and Benjamin Franklin were entered into a prospective database. The data for the LARVH group were also collected prospectively and contain information of 200 patients who underwent LARVH for early-stage cervical cancer at the University of Jena between August 1994 and April 2002, where two members of our division were based. Institutional Review Board approval was obtained for both groups. In addition to the statistical analysis of all patients, we used 1:1 individual pair-matching as a technique for controlling confounders in our patient groups. From 309 patients 50 pairs could be found according to the parameters of age (±1 year of age), BMI (±2), and the same TNM-stage of the tumour. In an explorative analysis, we analysed differences in age, BMI, operating time, blood loss, node counts, periand post-operative complications, time to spontaneous voiding of urine, and length of hospital stay between all patients in the two groups as well as the matched pairs. Additionally, the recurrence-free survival rates and overall survival rates were analysed in all patients. Surgical technique Both approaches began with the laparoscopic evaluation of the abdominal cavity followed by laparoscopic lymphadenectomy, which was performed equally in both groups and has been previously described in detail [9–11]. Laparoscopy and lymphadenectomy were performed as a staging procedure to exclude patients with abdominal spread of disease and positive lymph nodes. Both surgical methods of performing hysterectomy were previously described in the literature [8, 12, 13]. During LARVH, only the dissection of vesicocervical and
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Results Patient characteristics The median age of patients was 44 (range 25–79) years in the VALRH group and 44 (range 17–78) years in the LARVH group. The median weight was 66 (48–150) kg with BMI of 24 (17–46) in the VALRH group and 65 (44–108) kg with BMI of 24 (15–38) in the LARVH group. Stage of disease (TNM) was distributed as follows to the groups: VALRH group: stage Ia1 L1 (n = 10; 9.2 %), Ia2 (n = 5; 4.6 %), Ib1 (n = 83; 76.1 %), yIb1 (n = 2; 1.8 %), Ib2 (n = 2; 1.8 %), IIa (n = 1; 0.9 %), IIb (n = 6; 5.6 %), and LARVH group: stage Ia1 L1 (n = 6; 3.0 %), Ia2 (n = 21; 10.5 %), Ib1 (n = 89; 44.5 %), Ib2 (n = 26; 13.0 %), IIa (n = 11; 5.5 %), IIb (n = 45; 22.5 %), IIIa (n = 1; 0.5 %), IV (n = 1; 0.5 %). Squamous cell
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carcinoma was diagnosed in 67 (61.5 %) patients in the VALRH group and 150 (75.0 %) of the patients in the LARVH group, adenocarcinoma in 40 (36.7 %) and 47 (23.5 %), and neuroendocrine carcinoma in 2 (1.8 %) and 3 (1.5 %), respectively. In the VALRH group, lymphovascular space involvement was found in 25 (22.9 %), angiovascular space involvement in 7 (6.4 %), and in the in the LARVH group 31 (15.5 %) and 41 (20.5 %) of the patients, respectively. Grading was distributed as follows to the groups: VALRH: G1: 14 (12.8 %); G2: 68 (62.4 %); G3: 27 (24.8 %); and LARVH: G1: 16 (8.0 %); G2: 108 (54.0 %); G3: 76 (38.0 %). Patient characteristics of both groups are represented in Table 1. The median age of the patients in the matched pairs group was 42 years and the median BMI was 24. The following tumour stages were present in the matched pairs: stage Ia2: 3 (6.0 %) patient-pairs; Ib1: 41 (82.0) patientpairs; Ib2: one (2.0 %) patient-pair; IIb: 5 (10.0 %) patientpair. In the matched-pair analysis, 28 (56.0 %) patients from the VALRH group had a squamous cell carcinoma and 22 (44.0 %) adenocarcinoma, in the LARVH group, there were 37 (74.0 %) and 13 (23.0 %), respectively. Lymph vascular space involvement was found in 12 Table 1 Patient characteristics
n (patients) a
VALRH
LARVH
109
200 44 years (17–78)
Age (median; range)
44 years (25–79)
Weight (median; range)
66 kg (48–150)
65 kg (44–108)
BMIa (median; range)
24 (17–46)
24 (15–38)
IA1 L1
10 (9.2 %)
6 (3.0 %)
IA2
5 (4.6 %)
21 (10.5 %)
IB1
83 (76.1 %)
89 (44.5 %)
yIB1
2 (1.8 %)
IB2
2 (1.8 %)
26 (13.0 %)
IIA
1 (0.9 %)
11 (5.5 %)
IIB IIIA
6 (5.6 %)
45 (22.5 %) 1 (0.5 %)
FIGO stagea
IV
1 (0.5 %)
Histologic type Squamous cell carcinoma
67 (61.5 %)
150 (75.0 %)
Adenocarcinoma
40 (36.7 %)
47 (23.5 %)
2 (1.8 %)
3 (1.5 %)
LVSI
Neuroendocrine carcinoma
25 (22.9 %)
31 (15.5 %)
VSI
7 (6.4 %)
41 (20.5 %)
G1
14 (12.8 %)
16 (8.0 %)
G2
68 (62.4 %)
108 (54.0 %)
G3
27 (24.8 %)
76 (38.0 %)
Grading
a
Matching criterion
(24.0 %) matched patients in the VALRH group, and 8 (16.0 %) in the LARVH group; blood vascular space involvement in 2 (4.0 %) and 6 (12.0 %), respectively. Operative data In the VALRH group, type II surgery was performed in 86 (78.9 %) and the type III surgery in 23 (21.1 %) cases; LARVH type II was performed in 102 (51.0 %) patients, LARVH type III was performed in 98 (49.0 %) of the patients. The mean duration of the surgery in the VALRH group was 298 min (range 145–665 min) and was significantly shorter than in the LARVH group with a mean of 333 min (range 151–556 min) (P \ 0.001). In the VALRH group, paraaortic lymph nodes were removed in 74 (85 %) patients with a mean count of 16 (range 2–36) removed lymph nodes, in the LARVH group paraaortic lymph nodes were removed in 170 (85 %) of patients with a mean of 8 (range 1–27) lymph nodes removed. This significant difference in the paraaortic lymph nodes count (P \ 0.001) is due to the learning curve of the surgeons. The lymphadenectomy was performed in both groups by the same surgeons; however, the VALRH procedures were performed subsequent to the LARVH and by that stage the surgeons were more familiar with the procedure. Pelvic lymphadenectomy was performed in all patients of both groups, the mean count of the removed nodes was 21 (range 4–43) in the VALRH group, and 22 (range 3–57) in the LARVH group with no significant difference between the groups (P = 0.684). In the VALRH group, 5 (4.6 %) patients had positive pelvic and one (0.5 %) patient positive paraaortic nodes; in the LARVH group, there were 25 (12.5 %) patients with positive pelvic and 1 (0.5 %) patient positive paraaortic nodes. Sentinel lymph node detection prior to the complete lymphadenectomy was performed in 32 (29.4 %) patients in the VALRH group and 60 (30.0 %) patients in the LARVH group. Neither group converted to laparotomy due to intraoperative complications. After VALRH the mean blood loss, measured by the haemoglobin drop after surgery in g per dl, was significantly lower than after LARVH (1.9 vs. 3.2 g/dl; P \ 0.001). However, data of 48 patients in the VALRH and 29 in the LARVH group were unobtainable. Prevalence of blood transfusion due to surgery was significantly lower in the VALRH group (2 vs. 39; P \ 0.001). Bladder function was restored significantly earlier after VALRH with a mean of 8 postoperative days (range 2–40) than after LARVH with a mean of 11 (range 1–50) days (P \ 0.001). Patients were discharged significantly earlier after VALRH with a mean of 10 (range 5–31) than after LARVH with a mean of 14 (range 5–32) (P \ 0.001). Operative data are shown in Table 2. In the analysis of the matched pairs, a mean of 22 pelvic lymph nodes was removed in the patients who underwent
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Arch Gynecol Obstet Table 2 Operative data of the study cohorts
Table 3 Matched-pair analysis of operative data
VALRH
LARVH
n (patients)
109
200
n (matched pairs) = 50
Radical hysterectomy type II
86 (78.9 %)
102 (51 %)
median age = 42 years
Radical hysterectomy type III
23 (21.1 %)
98 (49 %)
median BMI = 24
Operation time (min; min–max)
298 (145–665)
333 (151–556)
Tumour stage: Ia2: 3 (6 %); Ib1: 41 (82 %); Ib2: 1 (2 %); IIb: 5 (10 %).
Pelvic lymph nodes (mean, range)
21 (4–43)
22 (3–57)
Operation time (min)
302
322
Paraaortic lymph nodes (mean, range)
16 (2–36)
8 (1–27)
Pelvic lymph nodes (mean)
22
23
Paraaortic lymph nodes (mean) VALRH n = 38 (76 %) patients
16
8
Sentinel lymphadenectomy
22
10
Blood loss (haemoglobin drop in g/dl) n = 30 matched pairs
2.1
2.4
39 (19.5.0 %)
Blood transfusion
0
11
Bladder function restored (days)
7
12
8 (2–40)
11 (1–50)
Hospital stay (days)
10
14
10 (5–31)
14 (5–32)
VALRH n = 74 (85 %) patients LARVH n = 170 (85 %) patients Sentinel lymphadenectomy
32 (29.4 %)
60 (30.0 %)
Blood loss (haemoglobin drop in g/dl)
1.9
3.2
VALRH n = 61 (56.0 %) patients LARVH n = 171 (85.5 %) patients Blood transfusion Bladder function restored (days, median, range) Hospital stay (days, median, range)
2 (1.8 %)
VALRH and 23 after LARVH, with no significant difference between the groups (P = 0.792). Paraaortic lymphadenectomy was performed in 38 (76.0 %) matched patients in the VALRH group with a mean of 16 lymph nodes, and in 42 (84.0 %) patients in the LARVH group with a mean of 8 lymph nodes (P \ 0.001). In 11 (22.0 %) patients in the VALRH group and 10 (20.0 %) in the LARVH group sentinel lymph nodes were removed prior to complete lymphadenectomy. In the matched patients, the duration of the surgery was 302 min for VALRH and 322 for LARVH which was not significant (P = 0.155), but demonstrated a trend for shorter procedure length in the VALRH group. In matched patients, the blood loss, measured by the haemoglobin drop after surgery in g per dl, was comparable after VALRH and LARVH (2.1 vs. 2.4 g/ dl; P = 0.509) with a trend in favour of VALRH. However, data of only 30 pairs could be evaluated. Prevalence of blood transfusion rate due to surgery was significantly lower in the matched patients after VALRH than after LARVH (0 vs. 11; P \ 0.001). In the VALRH group, the time to the restoration of the bladder function was 7 days on median in the matched patients and was significantly shorter than in the LARVH group (12 days) (P \ 0.001). After VALRH, the matched patients were discharged after a median of 10 days that was significantly earlier than after the LARVH with a median hospital stay of 14 days (P \ 0.001). Operative data of the matched pairs are shown in Table 3. In the VALRH group, no intraoperative injuries of bladder, ureter, blood vessel or bowel occurred. In the
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VALRH
LARVH
LARVH n = 42 (84 %) patients
LARVH group, the most frequent intraoperative injuries occurred to the bladder while opening the cervico-vesical space in 14 (7.0 %) patients. Further intraoperative complications in the LARVH group were injury of the ureter in 7 cases (3.5 %), of a blood vessel in 4 (2.0 %) cases and of the bowel in 1 (0.5 %) of the cases. All intraoperative complications were recognized and managed during the surgery. Thus, in the VALRH group, there were significantly less complications during the surgery (P \ 0.001). In the analysis of the matched pairs, no intraoperative complications were found in the VALRH group, and there was one (2 %) bladder injury, one (2 %) ureter injury and two (4 %) vessel injuries in the LARVH group. Postoperative complications Postoperative revisions were performed in 4 (3.7 %) patients in the VALRH group, all laparoscopically (2 for abdominal pain due to adhesions, one for lost drainage and one for chylascos). In the LARVH group, revisions occurred in 7 (3.5 %) cases; in 5 patients laparoscopic revision was performed (3 for diffuse bleeding, 1 for bleeding from the medial rectal artery and cardinal ligament, 1 for bladder bleeding from a dislocated suprapubic catheter), one patient underwent open surgery for diffuse bleeding, and one patient had a transvaginal revision due to a serocele. In the VALRH group the following postoperative complications occurred: ureterovaginal fistula (n = 3; 2.7 %), asymptomatic embolism of the lung artery (n = 2; 1.8 %), dehiscence of the vagina (n = 1; 1 %), postoperative fever (n = 3; 2.7 %), lymphocele (n = 1;
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1 %), and stress-induced cardiomyopathy (n = 1; 1 %). In the VALRH group, all three patients with ureterovaginal fistula were successfully treated with ureteral stents. In the LARVH group, ureterostenosis occurred in 7 cases (3.5 %), uretero/bladder fistula in 2 cases (1 %), and postoperative fever in 14 cases (7 %). In two patients, bowel obstruction occurred, treated by laparotomy in one case and conservatively in the other. In the LARVH group, ureterostenosis was treated with nephrostomy in four patients and with ureteral stents in three patients. The difference between the groups and the matched pairs among the groups concerning the rate of postoperative complications failed significance (P = 0.502, Fisher’s exact test and P = 0.508, McNemar test, respectively); only a trend in favour of VALRH is demonstrated. In total there were 30 intra- and postoperative complications concerning the urologic tract in the LARVH group, whereas only 3 complications occurred in the VALRH group. Thus, the complication rate for urologic complications was significantly lower after VALRH (P \ 0.001, Fisher’s exact test). Postoperative complications are shown in Table 4. Adjuvant therapy In the VALRH group, adjuvant therapy was recommended for 22 patients and 2 patients declined. Twenty patients underwent adjuvant therapy: two patients with neuroendocrine tumours underwent chemotherapy with carboplatin/taxol/etoposide and radiochemotherapy, 15 patients underwent chemo-radiation, and 2 patients were treated with brachytherapy. One patient underwent platine-based
Table 4 Perioperative complications VALRH (%) Bladder injury Ureter injury
– –
LARVH (%) 14 (7) 7 (3.5)
Bowel injury
–
1 (0.5)
Major haemorrhage
–
4 (2)
Revision
4 (3.7)
7 (3.5)
Fistula (bladder/ureter/vagina)
3 (2.7)
2 (1)
Ureterostenosis
–
Pulmonary embolism
2 (1.8)
Vaginal dehiscence
1 (1)
Fever
3 (2.7)
Ileus
–
7 (3.5 – – 14 (7) 2 (1)
Lymphocele
1 (1)
–
Stress-induced cardiomyopathy
1 (1)
–
Fistula (bladder/ureter/vagina)
chemotherapy due to ovarian metastasis. One patient in tumour stage Ib2 was received neoadjuvant chemotherapy and postoperative chemo-radiation. In the LARVH group, neoadjuvant chemotherapy (19 cisplatin/ifosfamide, 39 carboplatin/taxol/etoposide) had been given to four patients (2 %). Adjuvant chemotherapy (39 cisplatin/ifosfamide, 19 navelbine/5FU, 19 carboplatin/taxol, 79 carboplatin/taxol/etoposide, 19 vepeside/ haloxane/carboplatin) was given to 13 patients (6.5 %). Radiotherapy was performed in 71 patients (35.5 %): brachytherapy in 27 cases, teletherapy in 11 patients, and combined radiation in 33 patients. Follow-up The median follow-up was 60 months [Interquartile range (IQR) 47–100 months]. In the VALRH group, eight recurrences (7.3 %) occurred, and 4 patients (3.7 %) died following recurrence. In the LARVH group, 40 recurrences (20 %) occurred, and 31 patients (15.5 %) died following recurrence. In our study, both groups consisted of patients of different tumour stages and more patients with early stage cervical cancer in the VALRH group. Therefore, we only compared the recurrence-free survival rates and overall survival rates of patients with FIGO stage Ib1 cervical cancer. For FIGO stage Ib1 cervical cancer, the 5-year recurrence-free survival rate in the VALRH group was 92.8 % [95 % confidence interval (95 % CI) 87.3–98.3 %] and in the LARVH group was 88.2 % (95 % CI 81.3–95.1 %), (Fig. 1). Comparing the 5-year recurrence-free survival of patients with FIGO stage Ib1 in both groups, we found no significant difference in the survival rate (log rank, P = 0.589). The overall survival in patients with tumour stage Ib1 was 95.2 % (95 % CI 90.7–99.7 %) in the VALRH group and 90.5 % (95 % CI 84.2–96.8 %) in the LARVH group, (Fig. 2). There was no difference in the overall survival of patients in tumour stage Ib1 in both groups (log rank, P = 0.740).
Discussion Radical hysterectomy represents the standard surgical treatment for women with early stage cervical cancer. Multiple approaches such as open abdominal [15, 16], total laparoscopic [17–19], laparoscopic-assisted vaginal [4, 20, 21], and robotic [22, 23] have been described in the literature. The published studies comparing open with laparoscopic or laparoscopic-combined (or laparoscopic–roboticcombined) procedures for treatment of early-stage cervical cancer favour laparoscopy with respect to perioperative
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Fig. 1 Recurrence-free survival for 83 patients in tumour stage Ib1 in the VALRH group and 89 in the LARVH group. There is no significant difference between the groups
Fig. 2 Overall survival for 83 patients in tumour stage Ib1 in the VALRH group and 89 in the LARVH group. There is no significant difference between the groups
data such as blood loss, hospital stay, recovery, and cosmetic results and show comparable oncologic results [4, 5, 24–31]. However, large randomized studies directly comparing the different approaches are not in evidence [20, 32]. As such studies would give more precise information
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on the direct comparison of different methods of radical hysterectomy, they set a challenge for the future. Several requirements are to be considered when modifying an established method: same or better oncologic outcome, equal or lower complication rate, good recovery of the patient, high quality of life postoperatively including low morbidity of the procedure when combined with adjuvant therapy, good cosmetic results, economic aspects concerning the hospital stay, the use of instruments and the operating time, and a favourable learning curve for the surgeon. In our institution, radical hysterectomies were traditionally performed as LARVH following laparoscopic staging. With regard to the aspects mentioned above, we aimed to make the procedure easier to learn and to reduce the complications, especially the urologic ones, by modifying it to VALRH which combines the advantages of both the vaginal and the laparoscopic approach. In this study, we compared the oncologic and surgical outcome of matched patients treated by the new method to their pairs treated by LARVH when it was performed as the standard procedure for early-stage cervical cancer by the members of our department. Regarding the operative data, a positive trend in favour of VALRH is demonstrated in several areas. We focus on the matched-pair analysis, as comparing the surgical procedures of patients of the same age, with the same BMI and in the same tumour stage increases reliability. Blood transfusions were significantly lower than in the VALRH cohort. When compared to the literature, the blood loss of the new technique was in the lower range of the TLRH and RRH and lower than ARH [33–35]. The recovery of the patients (expressed by the restoration of the bladder function and duration of the hospital stay) was significantly improved in the VALRH group. This trend was clearly seen among the matched pairs and indeed the entire cohort. When compared to the literature both procedures, as well as the RRH, are superior to the open procedure in these points [20, 36]. Regarding the operation time a trend in favour of a shorter operating time for VALRH compared to LARVH. The reported mean operation time for ARH, TLRH and RRH are shorter [16, 27, 37]; however, paraaortic lymphadenectomy was performed in the majority of our procedures which is missing in most reported procedures in the literature Comparable lymph node counts in the pelvic region and higher counts in the paraaortic region could be harvested in the VALRH group compared to the LARVH patients. However, this is likely due to the learning curve of the surgeons who were more experienced operators when the new technique was introduced. The rate of intraoperative and postoperative complications is crucial in evaluating a new surgical technique. The reported data for intraoperative complications vary for differing procedures (ARH: 4–12.5 % [20]; TLRH:
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1–11.8 % [22]; LARVH: 5.9–13.2 % [4]; RRH: 0–14 % [29]). No intraoperative complications were demonstrated in our study, which is a significant advance, considering the relatively high rate of urologic complications in LARVH which are due to the complicated vaginal part of this procedure. The rate of postoperative complications can also be reduced by the new procedure [17, 20]—and in particular an improved outcome can be achieved regarding the urologic complications. As the oncologic data could not be compared directly in both cohorts, we compared the survival of patients in tumour stage Ib1—who are ideal candidates for radical hysterectomy—in both groups. No difference could be demonstrated in the survival of patients after VALRH as the projected 5-year recurrence-free survival rate was 92.8 % and the 5-year overall survival rate 95.2 % with a 95 % CI overlapping those in the LARVH cohort. When compared to other approaches, such as ARH, TLRH, RRH, the new technique is oncologically safe and feasible [5, 38, 39]. We conclude that with the VALRH procedure, the same radicality and the same oncologic outcome can be achieved in patients with early-stage cervical cancer. We believe that VALRH is a feasible and oncologically safe method for surgical treatment of patients with earlystage cervical cancer. It combines two standard techniques and can be easily learned by the surgeon. In particular, the low rate of intra- and postoperative complications is promising. However, large randomized studies are still required for directly comparing the different approaches of radical hysterectomy for early stage cervical cancer. This would aid in defining the most suitable procedure for our patient groups.
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Acknowledgments We thank Hermann Hertel, M.D. for disposing the LARVH database. The authors would like to thank Dr Lindsay Damkat-Thomas for assistance with the preparation of the manuscript. 16. Conflict of interest
There is no conflict of interest.
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