In recent years, with the continuous development and improvement of laparoscopic technology, laparoscopy has been able to perform more difficult surgeries such as pelvic and para-aortic lymph node dissection and radical hysterectomy, and its application in the diagnosis and treatment of gynecological malignancies has become more and more widespread and has shown certain superiority. It has laid the technical foundation for the surgical pathological staging and minimally invasive treatment of cervical cancer, and has an important role in the assessment of the disease before cervical cancer treatment, treatment choice and organ and function preservation. The author reviews the indications, feasibility, safety, complications and impact on prognosis of laparoscopic diagnosis and treatment of cervical cancer. Wang Yongjun, Department of Gynecology, Peking University International Hospital
1. Indications of laparoscopic surgery for cervical cancer
From the beginning of this century to the present, there have been successive reports in China that have affirmed the effectiveness and safety of laparoscopic surgery for the treatment of early-stage uterine malignancies [1]. After years of practice, a relatively consistent view has been reached on the use of laparoscopy for the diagnosis and treatment of cervical cancer. The indications for surgery include: (i) extensive hysterectomy and pelvic lymph node dissection for patients with stage Ia to IIb cervical cancer; (ii) laparoscopic pelvic lymph node dissection plus extensive cervical dissection for young patients with stage Ib cervical cancer who need to preserve their fertility[2]; and (iii) advanced cervical cancer patients can undergo staging surgery before initial radiotherapy or chemotherapy to obtain accurate information on tumor spread and guide individualized treatment[3] . . The inclusion criteria for patients with cervical cancer to undergo laparoscopic extensive hysterectomy include (i) tumor diameter ≤3 cm; (ii) assessment of obesity with a Quetelet index ≤40; (iii) no significant pelvic adhesions; and (iv) general physical condition consistent with anesthesia requirements [4]. The key steps of the procedure are pelvic and para-aortic lymph node dissection and laparoscopic extensive hysterectomy or laparoscopic-assisted cathartic extensive hysterectomy.
2. Laparoscopic use for disease assessment and surgical staging of cervical cancer
Clinical staging of cervical cancer cannot accurately assess the presence of tumor infiltration and metastasis in the parametrium and pelvic lymph nodes, and thus there is inevitably the problem of under- or over-staging. It is estimated that about 31.4% of FIGO stage I-II patients have pelvic lymph node metastasis and 19% have para-aortic lymph node metastasis, of which about 19.8% of stage Ib patients have pelvic lymph node metastasis and 6% have para-aortic lymph node metastasis. Using surgical pathological staging as the gold standard, the noncompliance rate of clinical stage I to II is about 25%, while stage IIIb is as high as 65% to 90%; 20% to 30% of patients with clinical stage IIb may be understaged, while 64% of patients with stage IIIb may be overstaged, and the resulting treatment plan is prone to problems of over- and under-treatment [5]. In the last decade, the increasing maturity of laparoscopic pelvic lymph node dissection has provided an accurate and reliable minimally invasive surgical method for the assessment of cervical cancer, surgical pathological staging, and individualized treatment.
Laparoscopic pelvic lymph node dissection is performed using methods familiar to gynecologic oncologists, and its success rate can reach 95%-100%. Regarding the number of lymph nodes removed laparoscopically, the results of a study by Liang Zhiqing [6] were that the average number of lymph nodes removed for early-stage cervical cancer in LTPL was between 16 and 23. The number of pelvic lymph nodes removed in most open surgeries was around 20. Nijman et al [7] reported that in 594 pelvic lymph node resections, the number of lymph nodes obtained in the laparoscopic surgery group even exceeded that of the open surgery group. To verify the effectiveness and completeness of laparoscopic retroperitoneal lymph node dissection, a number of scholars have performed laparoscopic pelvic and para-aortic lymph node dissection followed by open retroperitoneal lymph node dissection, and the results showed that nearly 60% to 100% of retroperitoneal lymph nodes could be dissected by laparoscopic surgery. Although some lymph nodes can still be removed by open surgery, they are benign lymph nodes without tumor metastasis [8]. This shows that laparoscopic surgery can achieve the required number of lymph nodes removed by open surgery.
It can be seen that, as far as the technique itself is concerned, LTPL is safe and feasible to obtain a sufficient number of lymph nodes to accurately understand the presence or absence of metastasis and the site of metastasis in retroperitoneal lymph nodes. At the same time, it can remove lymph nodes with existing tumor metastases and know whether there are tumor metastases in the pelvic and abdominal organs, which is an important guideline for formulating the first treatment plan for cervical cancer and guiding postoperative radiotherapy and chemotherapy. Laparoscopic pelvic and para-aortic lymph node dissection has been included as one of the important tools for early cervical cancer disease assessment and treatment in the guidelines for gynecologic malignancy staging and clinical practice published after the FIGO meeting in November 2003 and an important component of treatment [9]. It is recommended that laparoscopic pelvic and para-aortic lymph node biopsy or systematic resection should be performed first for all clinical stages of cervical cancer, and if intraoperative frozen pathological examination indicates that the lymph nodes have metastases, they can be directly transferred to radiotherapy or radiotherapy or chemotherapy, or radiotherapy or radiotherapy can be performed after laparoscopic resection of enlarged lymph nodes or systematic resection of pelvic and para-aortic lymph nodes. If intraoperative pathological examination indicates that there is no tumor metastasis in retroperitoneal lymph nodes, radical hysterectomy can be performed through laparoscopy, laparoscopy-assisted negative, negative or small abdominal incision to complete surgical treatment of cervical cancer, and further treatment measures will be decided according to pathological results after surgery.
3.Laparoscopy for radical surgical treatment of cervical cancer
3.1 Laparoscopic-assisted extensive total hysterectomy In the early stage of laparoscopic surgical intervention in the field of gynecologic malignancies, the main purpose was to remove pelvic and para-aortic lymph nodes under the microscope, while upper vaginal resection, ureteral freeing, separation of uterosacral ligaments and suturing of vaginal stumps were still done through negative surgery. It has developed to the point that laparoscopic opening of the bladder reflex peritoneum, separation of the rectal fossa and lateral rectal fossa, severance of the sagittal portion of the sacral ligament, and even the cervical space of the bladder and ureteral tunnel can be accomplished, while resection of the superior vaginal segment, paravaginal, main ligament, and descending sacral ligament is done from the vagina, greatly simplifying the difficulty of radical hysterectomy in the cathartic fashion while removing enough of the vagina and ligaments [10]. A comprehensive literature reported that laparoscopic-assisted radical femoral hysterectomy was superior to the abdominal radical hysterectomy group in terms of intraoperative bleeding and postoperative length of stay. Schiender’s group in Germany published their LARVH study of a large sample of 200 cases of cervical cancer with a mean operative time of 333 min and a mean hospital stay of 14 days, with major intraoperative and postoperative complications including bladder perforation, ureteral injury, vascular injury, bowel injury, abscess, hematoma, and transfusion rate [11]. With the continuous improvement of surgical techniques and the improvement of laparoscopic surgical instruments, this procedure will become increasingly safe and fast.
3.2 Complete laparoscopic extensive total hysterectomy Since Nezhat et al. first reported a case of laparoscopic extensive total hysterectomy with pelvic and para-aortic lymphatic dissection in a patient with stage Ia2 cervical cancer in 1992 [12], many gynecologic oncologists have begun to explore the feasibility of laparoscopic radical hysterectomy for cervical cancer as a standard procedure, and more than 1,000 cases have been reported to date. The entire operation is performed laparoscopically and only the resected uterine specimen is removed from the vagina. The operation is summarized in seven steps: (i) pelvic and para-aortic lymph node dissection; (ii) separation of the lateral fossa of the bladder and rectum; (iii) freeing the ureter; (iv) freeing and ligating the uterine artery; (v) pushing down the bladder and rectum; (vi) cutting off the parametrial tissue; and (vii) excision of the superior vaginal segment. zakashansky et al [13] observed that laparoscopic radical hysterectomy with pelvic lymph node dissection increased the operative time compared to open surgery. The mean operative time was 315 min, similar to other reports.Pomel et al [14] reported the follow-up data of a group of laparoscopic radical hysterectomy for cervical cancer, 41 patients with stage Ia2 to Ib cervical cancer underwent laparoscopic surgery and were followed up for 4 to 76 months without any recurrence. From the case data reported so far, the rate of intermediate open abdomen was 3% to 4%, the rate of bladder perforation was 2% to 3%, the rate of ureteral injury was 2% to 3%, and the rate of blood transfusion was 1% to 2%. In terms of postoperative survival and vaginal stump recurrence rates, the extent of resection performed by this procedure is able to meet the requirements of open surgery [15].
4. Laparoscopic and preserved functional surgical treatment of cervical cancer
4.1 Radical hysterectomy In 1994, Dargent first reported a case of successful conception and delivery in a patient after laparoscopic pelvic and para-aortic lymph node dissection and radical hysterectomy, which attracted widespread academic attention and controversy. As of August 2004, more than 200 suitable patients have been reported in the literature to have undergone this surgical treatment and more than 30 live births have been achieved after surgery. The main procedure is laparoscopic transabdominopelvic lymph node dissection, intraoperative frozen pathology to determine the absence of lymph node metastasis before RVT, and frozen pathology of the resected specimen to determine whether there is tumor residue at the incision margin. The overall recurrence rate after RVT is about 3.3%, which is not significantly different from that of radical hysterectomy. The overall recurrence rate after RVT was about 3.3%, which was not significantly different from that of radical hysterectomy. The diameter of the lesion and the presence or absence of choroidal infiltration were important factors affecting postoperative recurrence. 28% of cases with lesion diameter ≥2 cm showed extra-uterine tumor metastasis, while only 13% of stage Ib cases with lesion diameter <2 cm and none of stage Ia cases showed extra-uterine metastasis. Most patients were able to conceive spontaneously within 1 year after RVT. Because of the high rate of miscarriage and preterm delivery, cervical cerclage is recommended at about 14 weeks of gestation to prevent miscarriage and preterm delivery, and it is also recommended once pregnancy is established. Termination by cesarean section is preferred for full-term pregnancies or for preterm and late abortions where fetal survival is estimated. The current findings show that laparoscopic pelvic and para-aortic lymph node dissection and radical hysterectomy is a safe and feasible procedure that preserves the patient's reproductive function, with no higher probability of surgical complications or recurrence of disease after surgery than radical hysterectomy, and most patients are able to conceive and deliver after surgery, either spontaneously or with the aid of assisted reproductive techniques [16].
4.2 Laparoscopic ovarian transposition Transposition of the ovary outside the radiation field prior to radiotherapy is an important method to prevent radioactive ovarian debulking. The recovery time after open ovarian transposition is long and may interfere with the timely delivery of subsequent radiotherapy. Laparoscopic ovarian transposition is less invasive, has a faster postoperative recovery, does not delay subsequent radiotherapy, and allows for a comprehensive understanding of the pelvic and abdominal cavity for tumor metastases and, if necessary, biopsy of the ovary to ensure that completely normal ovarian tissue is left. It is recommended that laparoscopic ovarian transposition be performed at the same time as laparoscopic pelvic and para-aortic lymph node dissection or biopsy to free the ovarian vessels to ensure that the ovarian arteries and veins are left intact and to move the ovaries to a location as far away from the radiation field as possible, such as the paracolon sulcus.
5. Prognostic effect and limitation of laparoscopy for surgical treatment of cervical cancer
5.1 Prognostic effect of surgery The determination of the treatment method and scope of surgery for cervical cancer is based on a long-term summary of clinical data on the rate of lymph node metastasis at various clinical stages of cervical cancer, the incidence of postoperative complications and the survival rate of patients at 2-5 years after treatment.Hertel et al[17] reported the efficacy of LTPL and LARVH in treating 200 cases of cervical cancer, including 6 cases at stage Ia1, 21 cases at stage Ia2, 89 cases at stage Ib1 and 89 cases at stage Ib1. b1 stage 89 cases, Ib2 stage 26 cases, IIa stage 11 cases, IIb stage 45 cases, IIIa stage 1 case, and IV stage 1 case, of which 76.5% were squamous carcinoma and 23.5% were adenocarcinoma. LTPL and LARVH were performed in all cases, and 170 cases underwent simultaneous resection of paraaortic lymph nodes. The median follow-up time was 40 months, with an overall 5-year survival rate of 83% and a recurrence rate of 18.5%. Of these, 35% were extra-pelvic recurrences and 11% died of recurrence.Nam et al [18] reported 84 patients with stage Ia1 to IIb1 cervical cancer who underwent LTPI and LAVRH, 47 with concomitant para-aortic lymph node sampling, and 142 in the laparotomy group. There was no significant difference in the operation time, complication rate and the number of resected lymph nodes between the two groups, and the hospital stay was significantly shorter in the laparoscopic group than in the laparotomy group. 4 of 47 cases of LAVRH and 2 of 96 cases of ARH had recurrence; the recurrence rate of those with tumor volume ≥4.2 cm3 in LAVRH was 42.9%, which was significantly higher than that of those with tumor volume <4.2 cm3, and the 3-year progression-free survival rates of the two groups were 97.1% and 98.9%, respectively.Steed et al [3] compared LARVH and ARH with 71 cases in the laparoscopic group and 205 cases in the abdominal group, both with stage Ia/Ib cervical cancer. Intraoperative bleeding was 300 ml and 500 ml, operative time was 3.5 h and 2.5 h, intraoperative complication rate was 13% and 14%, and postoperative hospital stay was 1 day and 5 days, respectively. The median follow-up time was 17 and 21 months. 4 cases of recurrence in the LARVH group and 13 cases of recurrence in the RAH group were found, and the 2-year survival rate was 94%. The above data indicate that laparoscopic surgery is safe and effective in the treatment of early cervical cancer, and the surgical complications and recent outcomes are not inferior to those of traditional open surgery.
5.2 Limitations of surgery Laparoscopic extensive hysterectomy and pelvic lymph node dissection requires not only excellent equipment, instruments and instruments, but also skilled and experienced gynecologic oncologists. Therefore, to perform laparoscopic surgery, physicians should not only have rich clinical experience in open surgery, but also have skillful laparoscopic operation skills, and they should accumulate experience and improve their skills in clinical practice. Laparoscopic radical cervical cancer surgery is limited to some senior physicians who are familiar with the anatomy of the retroperitoneum of the pelvis. Laparoscopic surgery cannot directly palpate the retroperitoneal lymph nodes, and it is difficult to perform laparoscopic surgery if the pelvic organs are heavily adhered or if the uterus is larger than 4 months of gestation. In addition, patients undergoing laparoscopic surgery should have a certain degree of affordability.
6. concluding remarks
Laparoscopic surgery has developed rapidly in the last decade and is now recognized as a very effective and indispensable invasive examination tool. Its indications for surgical treatment of gynecologic malignancies are still being explored, but the general trend is that the indications for laparoscopic surgery are expanding, and those previously considered as contraindications are now gradually included as relative contraindications or even indications. The role and superiority of laparoscopy in the assessment of cervical cancer, surgical staging, treatment choice, minimally invasive treatment, and preservation of fertility and ovarian function have been confirmed by numerous clinical studies. Laparoscopic pelvic and para-aortic lymph node dissection should be routinely performed before the first treatment of all cervical cancers when available, and individualized treatment should be performed after accurate knowledge of the actual extent of the tumor to ensure that all cervical cancer patients enjoy a good quality of life while receiving effective treatment. The long-term efficacy of laparoscopic surgery for cervical cancer remains to be confirmed in multicenter prospective randomized controlled trials, and the improvement of the fertility status of patients after radical hysterectomy also needs to be studied in depth.
Laparoscopic lymph node dissection may have the following advantages
(1) The laparoscopic anatomy is clear and can be magnified 5 to 7 times. Therefore, the accuracy of diagnosis can be improved compared with traditional surgery.
(2) Laparoscopic evaluation of lymph node condition in conjunction with pathological examination can guide clinical treatment.
(3) Laparoscopic lymph node dissection reduces postoperative pelvic and abdominal adhesions and avoids radiological complications arising from inappropriate radiotherapy.
(4) After laparoscopic removal of positive lymph nodes is applied first, the tumor load is reduced, which leads to improved effectiveness of radiotherapy or chemotherapy and can improve the prognosis.