comparison of survival outcomes between laparoscopic and
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Comparison of survival outcomes between laparoscopicand abdominal radical hysterectomy for early-stage
cervical cancer: A French multicentric studyFrançois Zaccarini, Anna Santy, yohann Dabi, Vincent Lavoue, Xavier
Carcopino, Sofiane Bendifallah, Amélie Benbara, Pierre Collinet, GeoffroyCanlorbe, Emilie Raimond, et al.
To cite this version:François Zaccarini, Anna Santy, yohann Dabi, Vincent Lavoue, Xavier Carcopino, et al.. Comparisonof survival outcomes between laparoscopic and abdominal radical hysterectomy for early-stage cervicalcancer: A French multicentric study. Journal of Gynecology Obstetrics and Human Reproduction,Elsevier, 2021, 50 (2), pp.102046. �10.1016/j.jogoh.2020.102046�. �hal-03122609�
Comparison of survival outcomes between laparoscopic and abdominal radical hysterectomy for
early-stage cervical cancer: a French multicentric study
Zaccarini François1, Santy Anna2, Dabi Yohann3, Lavoue Vincent4, Carcopino Xavier5, Bendifallah Sofiane1,
Benbara Amelie6, Collinet Pierre7, Canlorbe Geoffroy8, Raimond Emilie9, Graesslin Olivier9, Ouldamer Lobna10,
Darai Emile1, Huchon Cyrille11, Golfier François2, Touboul Cyril1, Bolze Pierre Adrien2.
1. Department of Gynaecology and Obstetrics, Tenon University Hospital (AP-HP), Sorbonne
University, Institut Universitaire de Cancérologie (IUC), France
2. Lyon 1 University; Department of Gynecological and Oncological Surgery, Obstetrics, University
Hospital Lyon Sud, 69495 Pierre Bénite, France
3. Department of Obstetrics and Gynecology, Centre Hospitalier Intercommunal, Créteil, France.
Faculté de médecine de Créteil UPEC – Paris XII.
4. Department of gynecologic surgery, CHU de Rennes, Université de Rennes 1, France
5. Department of Obstetrics and Gynecology, Hopital Nord, APHM, Marseilles
6. Department of Obstetrics and Gynecology, Jean-Verdier University Hospital, Assistance Publique
des Hôpitaux de Paris (AP-HP), France
7. Department of Obstetrics and Gynecology, Centre Hospitalier Régional Universitaire, Lille, France
8. Department of Gynaecology and Obstetrics, Pitié Salpetrière University Hospital, Assistance
Publique des Hôpitaux de Paris (AP-HP), University Pierre and Marie Curie, Paris 6, Institut
Universitaire de Cancérologie (IUC), France
9. Department of Obstetrics and Gynaecology, Institute Alix de Champagne University Hospital,
Reims, France
10. Department of Obstetrics and Gynaecology, Centre hospitalier régional universitaire de Tours,
hôpital Bretonneau, Tours, France
11. Department of Gynaecology and Obstetrics, Intercommunal Hospital Centre of Poissy-Saint-
Germain-en-Laye, 78103, Poissy, France
ORCID ID of All Authors
- ZACCARINI François 0000-0002-6476-4590
- SANTY Anna 0000-0003-0828-1962
- DABI Yohann 0000-0002-9353-6036
- LAVOUE Vincent 0000-0002-4682-2806
- CARCOPINO Xavier 0000-0002-9533-3558
- BENDIFALLAH Sofiane 0000-0002-0310-1152
- BENBARA Amelie
- COLLINET Pierre 0000-0002-3824-572X
- CANLORBE Geoffroy 0000-0003-2653-4097
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- RAIMOND Emilie 0000-0003-2860-5450
- GRAESSLIN Olivier
- OULDAMER Lobna 0000-0001-9465-0335
- DARAI Emile 0000-0003-2083-7097
- HUCHON Cyrille 0000-0001-5334-6345
- GOLFIER François 0000-0002-6063-2291
- TOUBOUL Cyril 0000-0002-9149-1663
- BOLZE Pierre Adrien 0000-0002-4988-9723
*Corresponding author: Prof. Cyril Touboul, M.D. Ph.D, Service de Gynécologie Obstétrique, Hôpital Tenon
Assistance Publique des Hôpitaux de Paris, 8 rue de la Chine, 75020 Paris, France.
Phone : +33.1. 56.01.70.00
E-mail : [email protected]
ABSTRACT
Objectives: A recent randomized controlled trial has reconsidered the use of laparoscopy for treating patients
with early-stage cervical cancer with radical hysterectomy (RH). We aimed to evaluate if surgical approach had
an impact on surgical and oncological outcomes in these patients in a French setting.
Methods: Data of 1706 patients with cervical cancer treated between 1996 and 2017 were extracted from
maintained databases of 9 French University hospitals. Patients, with FIGO stage IA2 to IIB tumors, treated by
radical hysterectomy were selected for further analysis. A propensity score matching was used with a ratio of 2:1
in favor of laparoscopic approach was used. The Kaplan Meier method was used to estimate the survival
distribution.
Results: 34 patients treated with laparotomy were matched with 61 patients treated by minimally invasive
surgery (MIS). There was no difference regarding overall survival (91% vs 81%, p>0.05) or disease-free survival
(82% vs 78%, p>0.05). There was no difference regarding surgical outcomes with no excess of postoperative
complication in patients with MIS. Hospital stay was significantly longer in patients operated on laparotomy.
Conclusion: In our study, there was no evidence of a difference in survival between minimally invasive surgery
and laparotomy in patients treated with radical hysterectomy for early-stage cervical cancer.
KEYWORDS: cervical cancer, radical hysterectomy, laparoscopy, open surgery, survival outcomes
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INTRODUCTION
Despite prevention screening campaigns for cervical cancer and the widespread of HPV-vaccination
among several countries, cervical cancer still remains the fourth most common cancer in women worldwide[1].
International Federation of Gynecology and Obstetrics (FIGO) stage determines the most appropriate treatment
and radical hysterectomy is currently the standard treatment for patients at early stage (2018 FIGO IA2 to IB2
and FIGO IIA1)[2].
Historically, radical hysterectomy was performed by laparotomy. Along with many studies demonstrating
fewer postoperative complications and shorter hospital stays, minimally invasive technics were increasingly used
in the last decades [3–5]. However, unlike other types of cancer such as colorectal or endometrial cancer,
equivalence in terms of cancer treatment has not been formally demonstrated[6–8]. This hypothesis has recently
been challenged by the outstanding results of the LACC trial[9]. In this randomized controlled trial, the patients
undergoing laparoscopic surgery had a significantly higher relapse rate and significantly lower rates of disease-
free survival and overall survival than the patients undergoing open surgery. However, some comments have
been reported on stages, number of laparoscopic procedures by centers as well as experience of surgeon and
modalities of neoadjuvant and adjuvant therapies. Such results were unexpected by the scientific community and
while the trial is well designed, it is legitimate to question the generalization of such results in European setting.
Indeed, French surgeons have a long history and high experience of laparoscopy approach.
The main objective of this study was therefore to evaluate if surgical approach had an impact on surgical
and oncological outcomes in patients with early-stage cervical cancer treated with radical hysterectomy in a
French University Hospital setting.
MATERIAL AND METHODS
Patients and selection criteria
We conducted a retrospective study using maintained database from 9 French institutions (Creteil
University Hospital, Tenon University Hospital, Pitié-Salpétrière University Hospital, Poissy University
Hospital, Lille University Hospital, Tours University Hospital, Bondy University Hospital, Rennes University
Hospital, and Marseille Public Hospital North, Lyon Sud Hospitals, Reims University Hospitals). These
databases registered all patients diagnosed with cervical cancer at any stage between January 1996 and
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December 2017. The research protocol was approved by the Institutional Review Board (IRB) of the French
College of Obstetrics and Gynecology (CEROG 2016-GYN-0502).
The following data were extracted from the medical charts: age, BMI, medical and surgical history,
surgical procedure, FIGO stage, final pathological analysis, treatment received, recurrence and survival.
Patients were included whenever they were treated by radical hysterectomy. Early-stage cervical cancer
are known as FIGO stage IA2 to IB2 and FIGO stage IIA1 (FIGO 2018). FIGO stages were determined on pre-
operative MRI. Few patients with FIGO IIB stages were included. Indeed, we noticed that a very few numbers of
patients with FIGO IIB stages determined on MRI had radical hysterectomies. We chose not to eliminate them
since they had radical hysterectomies and we performed a propensity score matching. The aim of a radical
hysterectomy is to remove the uterus with a resection of at least 10 mm of vagina and a portion of parametrium.
The extent of the parametrium resected defines different types of radical hysterectomy. A partial resection of the
uterosacral and vesicouterine ligaments were performed. The ureter was dissected and protected laterally,
permitting transection of the paracervix at the level of the ureteral tunnel. Surgery could be accomplished either
by laparotomy, or by a minimally invasive approach including laparoscopy or robot-assisted surgery. All patients
included benefited at the same time of pelvic lymphadenectomy. Patients who had initial laparoscopy and were
operated by open surgery were considered in the open surgery group.
Exclusion criteria included non-radical procedures or surgeries not performed within one of the included centers.
Were also excluded patients that benefited of a fertility-sparing surgery because the risk of relapse is higher is
this population.
Pre-operative imaging work up included pelvic magnetic resonance imaging (MRI) to determine tumor
size, local extension, lymph nodes involvement and FIGO stages. All stages were reassigned using the 2009
International Federation of Gynecology and Obstetrics (FIGO) since patients were registered before the
publication of the new FIGO classification in 2018. Patients with cervical – limited large sized tumors (≥ 2 cm)
could benefit of preoperative vaginal brachytherapy as it is sometimes performed in France.
Postoperative complications were registered and classified in four categories: urinary, vascular, digestive and
other.
Initial surgical management as well as adjuvant therapies were validated in multidisciplinary committees.
Adjuvant chemotherapy or radiotherapy was proposed as recommended in patients with lymph nodes
involvement, positive margins or in some cases of lymphovascular space invasion[2,11].
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Follow up was performed as recommended[11] by clinical examination every 4 month during 2 years then every
6 month during 3 years then annually. Imaging exams were performed only in cases of suspicion of recurrence
clinically.
Date of surgery was used to calculate overall survival (OS) and disease-free survival (DFS).
Statistical analysis
Databases were managed using Excel (Microsoft Corporation, Redmond, WA, USA) and statistical
analyses were performed using R software and packages MatchIt and Rms (3.3.1 version, available online).
Descriptive statistics were based on the Student’s t test for continuous variable and the χ2 test or Fisher’s exact
test for categorical variables. The Kaplan–Meier method was used to estimate the survival distribution.
Comparisons of survival were made using the log rank test. Values of p < 0.05 were considered to denote
significant differences.
Before Propensity Score Matching (PSM), two groups were constituted: patients operated by laparotomy
and those operated by minimally invasive surgery (laparoscopy or robotic surgery). PSM is a statistical matching
technique that attempts to estimate the effect of a certain treatment by accounting for covariates that predict
receiving such treatment[12] . A propensity score was calculated using a logistic regression model, as described
by Rosenbaum and Rubin and used by Sjölander in 2009[13]. To adjust and optimize the matching procedure,
the variables having a potential impact on the prognosis were included in the model: age at diagnosis, body mass
index, histological type, FIGO stage on the preoperative MRI, tumor size defined by MRI.
Patients with missing data for the variables used in the propensity matched score were excluded as there were
not many (< 5% of the cohort). Only patients with complete data for the main prognostic variables were
included.
As the number of patients in our MIS group was way higher than in the laparotomy group, we decided that
women would be matched (a 2:1) using the PS by an “exact” matching algorithm. To find matched women from
the two groups, we adopted a caliper matching approach that can avoid bad matches (i.e., too much of a
difference in PS). Once a control was matched, it was not considered again as a match for any other case (i.e.,
matching without replacement).
RESULTS
Characteristics of the population
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A total of 1706 patients with a cervical cancer were treated within one of the 9 university hospitals involved
between 1996 and 2017. Among them, 417 patients (24.4%) underwent surgery (non-radical and radical
surgeries, conservative treatments). Radical hysterectomy was performed in 264 patients: 223 underwent
minimally invasive surgery (MIS) and 41 underwent open surgery. There was a difference in BMI and FIGO
stages between the two groups (Table 1).
After using a propensity score matching, the minimally invasive surgery group counted 61 patients (laparoscopy
and robot-assisted surgery) and the laparotomy group 32 patients. The 2 groups were comparable for the main
prognostic factors of cervical cancer (Table 2).
Pre-operative brachytherapy was performed on 8 patients among which 5 had tumors ≥ 20mm., 1 patient had a
19 mm tumor (2 missing data).
Survival outcomes
There was no significant difference in overall survival: 91% in the minimally invasive surgery group and 81% in
the open-surgery group (p = 0.14, CI95% 0.66 – 11.9). The rate of disease-free survival at 5 years was 82% in
the minimally invasive surgery group and 78% in the open surgery group (p = 0.78, CI95% 0.38 – 3.6) (Figure
2).
In the minimally invasive group, there were 8 (13.1%) recurrences and 3 deaths (4.9%). The median follow-up
was 39.6 months. The recurrences were mainly loco-regional (n=6). One patient had peritoneal carcinosis and 1
recurrence was at a distant site.
In the laparotomy group, there were 5 (15.6%) recurrences (15.6%) and 5 deaths (15.6%). The median follow-
up was 57.4 months. We counted 2 loco-regional recurrences and 1 peritoneal carcinosis (the data was missing
for the 2 other patients).
Intra and post-operative complications
Minimally invasive surgery was associated with a significantly shorter hospital stay than open surgery: 5.9 vs 9.0
days (p <0.01). Operating time was shorter in minimally invasive surgery without reaching a statistical
significance: 228 vs 278 minutes (p = 0.17). There was no significant difference in intra and postoperative
complications between the groups (Table 3).
Histopathological results
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There was no difference between the groups regarding the size of the vaginal cuff length that was around 14mm
(Table 4). Negative margins were obtained in more than 80% of cases in both groups. There was a vaginal
invasion in 6% of cases in both groups. There was no difference in parametrial involvement and lymph node
involvement: 8.3% in the MIS group versus 15.6% in the open surgery group (Table 4).
There were two surgical revisions for intestinal obstruction in the open surgery group and none in the minimally
invasive surgery group. Three reoperations for disunion of the vaginal suture were recorded in the minimally
invasive surgery group and none in the open surgery group.
Regarding patients who had a preoperative brachytherapy, 6 patients had no residual tumors, 1 had a 5 mm
residual tumor and 1 patient had a 20 mm residual tumor (starting from a 31 mm tumor)
DISCUSSION
In this multicentric study, using a propensity score matching, no difference in overall survival and in
disease-free survival was found among patients undergoing minimally invasive or abdominal radical
hysterectomy for cervical cancer at early stage. The rate of overall survival at 5 years was 91% with minimally
invasive surgery and 81% with open surgery. The rate of disease-free survival at 5 years was 82% with
laparoscopy and 78% with open surgery. No difference in operative complication rate was noted. Hospital stay
was shorter in the minimally invasive surgery group confirming its relevance from the medico-economic part.
Before November 2018, the literature was solely constituted with retrospective data and showed no
difference in survival outcomes depending on the operative approach, combined with lower morbidity with
minimally invasive techniques. In 2007, Frumovitz et al.[5] compared 54 patients operated on laparotomy and
35 patients operated on laparoscopy (IA1 to IB3, FIGO 2018) for cervical cancer at an early stage. Despite a
longer operative time, laparoscopy was associated with a reduction of blood loss, a decrease in the number of
infectious complications and in hospital stay. Another retrospective study published in 2011[14] about 263
patients operated on laparoscopy and 263 operated on laparotomy for tumors stage IA2 to IIA (FIGO 2018) , did
not show any difference in 5-years recurrence free survival (92.8% and 94.4% respectively). There was a
significant decrease of blood loss, hospital stay and postoperative complications. The same results were found on
two meta-analysis[15,16] but they lack of long-term data oncological outcomes.
The unexpected results of the LACC trial[9] were largely commented and criticized. In this randomized
trial, minimally invasive radical hysterectomy was associated with lower rates of disease-free and overall
survival compared to open surgery. The authors hypothesized that the use of the uterine manipulator could
increase the tumor cells spreading. However, uterine cannulation is also used during surgery for endometrial
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cancer without compromising the patient's oncological prognosis as proven by a meta-analysis evaluating the
impact of uterine manipulator[17]. Another hypothesis is the proliferative effect of carbon dioxide on cancer
cells. However, the difference of size of the vaginal cuff length depending on the surgical approach was not
presented in this article.
In our study, the vaginal cuff was the same size for both groups, around 14 mm. However, it seems more
difficult to assess the size of the vaginal cuff during laparoscopy than open surgery since it has been described a
difference depending on the surgical approach in the literature. In a randomized trial published in 2009[18], the
vaginal cuff was significantly smaller in case of laparoscopy than open surgery: 1.26 vs 2.16 cm (p=0.014). A
2016 publication[19] showed in a population of 108 patients operated on laparoscopy and 20 patients operated
on robot, that performing colpotomy by laparoscopy compared to a vaginal colpotomy, was a prognostic factor
for recurrence with more intraperitoneal recurrences. The intraperitoneal way of recurrence could be explained
by the use of CO2 during laparoscopy, even if the size of the “laparoscopic colpotomy” was significantly smaller:
2.2 vs 1.5 cm. There is currently no recommendation for the length of the vaginal cuff. Piver[20] described in
1974, 5 different types of hysterectomy, associated with a vaginal resection ranging from 1/3 to 3/4 of the
vagina. The Querleu classification only takes into account the width of the parametrial resection. The literature is
also not very rich on the subject. In a study published in 2018[21], a vaginal cuff smaller than 2 cm was
associated with a lower relapse-free survival and overall 5-year survival and a higher local recurrence rate,
compared to a vaginal cuff higher than 2 cm. The length of the vaginal cuff was an independent poor prognosis
factor with FIGO stage and lymph node involvement. Another study highlighted a similar relationship: narrow
cervical margins were associated with higher recurrence rates[22]. However, Kim et al.[23] did not find any link
between the length of the vaginal cuff and the loco-regional recurrence rate. Many patients received adjuvant
radiotherapy that could balance the lack of radical surgery.
Another study published in October 2018 using data from the National Cancer Registry in the United
States included 2,461 patients with stage IA2 to IB1[24] cervical cancer. After using a propensity matching
score, this study highlighted a higher risk of mortality at 4 years with a rate of 9.1% in patients operated on
minimally invasive versus 5.3% in patients operated on laparotomy. Overall survival was also lower in case of
minimally invasive surgery. Likewise, this study has found a decline in cervical cancer survival since the
introduction of laparoscopy. The same type of study was carried out in endometrial cancer and it did not show
this negative effect of laparoscopy[25]. This would be in favor of a specific effect in cervical cancer. A recent
Korean study published in 2019[26], comparing 435 patients operated on laparotomy and 158 patients operated
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on minimally invasive surgery for stage IB1 to IIA2 cervical cancer, showed a higher risk of relapse in the
minimally invasive surgery group without any difference in overall survival. In the multivariate analysis
conducting on patients treated for IB1 stage, the minimally invasive technique was a poor prognostic factor for
disease-free survival, which was not found in the context of tumors less than 2 cm. However, laparoscopy has
only been practiced significantly in their center since 2012, which is far from other European practices.
In our study, among FIGO IB patients, there was the same number of patients with tumors <2cm and
tumors ≥2cm but we could not perform sub-groups survival analyses. The number of patients was too low. A
recent Chinese multicentric [27] retrospective study showed that robot assisted radical hysterectomy was
associated with a worse 3-year oncologic outcomes than abdominal radical hysterectomy. However, the
oncological outcomes were similar among patients with stage IB1 and tumor size < 2cm. In a recent
retrospective study from Uppal et al.[28], a worse recurrence-free survival but a similar overall survival were
noted in patients undergoing minimally invasive radical hysterectomy compared with open surgery. A higher
recurrence rate was also noted in patients with tumor size ≤2cm on final pathology in the minimally invasive
approach. However, the size of the tumor was determined clinically. The results of an European cohort
observational study (SUCCOR) comparing minimally invasive surgery versus open abdominal radical
hysterectomy in patients with stage IB1 cervical cancer operated in 2013-2014 were recently presented[29].
Radical hysterectomy by minimally invasive surgery showed a significantly higher risk of relapse and death.
However, the survival was similar in the subgroups of patients with tumors <2cm on final pathology. They also
could demonstrate that the use of a uterine manipulator impacted the disease-free survival negatively. Patients
that underwent radical hysterectomy by minimally invasive surgery without using a manipulator showed the
same outcome that patients operated by open surgery. The information regarding the use of uterine manipulator
was not available in our database.
Eventually, it is important to emphasize that assessing surgical competence and inter-operator variability
is complex (especially in laparoscopy) and could largely influence prognostic as well as complications rates.
This has been studied in a recent article by Nezhat et al.[30]. Indeed, in the LACC trial[9], there was no
adjustment on surgical experience or stratification according to centers or surgeons case volume, while the trial
was conducted in 33 centers across 13 different countries over 9 years.
A strength of our study lies in its multicentric nature as well as in cross-checking data from patients
treated in centers accustomed to the treatment of cervical cancer. The propensity score matching replicates
virtually the conditions of a randomized trial and is powerful to evaluate the potential impact of surgical
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approach in this context. This matching was performed on preoperative characteristics to get closer to “real life”
conditions. That is the reason why we did not consider the size of tumor on histological findings on our inclusion
criteria. Consequently, some patients were upstaged with the histologic findings and needed adjuvant therapies.
Our study suffers other limitations. Missing data, such as vaginal preparation or the use of uterine manipulator,
due to its retrospective nature could have influenced our results. Obviously, the limited number of patients that
benefited from open surgery limits the extent of our conclusions. Besides, the longer follow up of these patients
reflects that most patients treated with open surgery were operated in the first decade of inclusion which could
also constitutes a bias. French surgeons are long used to laparoscopy and this could explain both why most
patients of our cohort underwent minimally invasive approach and why we did not find any difference regarding
survival in our study. Few patients with FIGO IIB stages had radical hysterectomy which we could not explain.
We decided to keep those patients since they underwent radical hysterectomies, and they were matched with the
propensity score matching. The aim of this study was not to discuss the validity of the conclusions of the LACC
trial but simply to investigate the survival in a french cohort based on surgical approach.
The LACC trial has certainly changed our practices. Does-it mean minimally invasive surgery should not
be performed anymore? Some data suggest that this is not so simple. It is important to find a way to select
properly patients that could benefit from laparoscopy. A recent study [31] showed that disease free survival
among patients undergoing laparoscopic surgery for tumor ≤ 20 mm was similar to patients undergoing open
surgery. The case of patients at low risk of parametrial invasion (tumors less than 2cm, negative sentinel lymph
node, depth of invasion less than 10 mm and no LVSI in the event of an available conization) seems less
complicated. Indeed, this population could benefit from laparoscopy without worsening their oncological
outcomes. Current thinking is even to offer them an extra-fascial total hysterectomy. The SHAPE trial currently
underway will answer this question[32]. This trial is the results of 20 years of surgical aggressiveness de-
escalation wondering how to select patients with low risk of parametrial involvement.[33,34]
Patients with a 2 to 4 cm tumor are a more complex situation. In France, these patients can benefit from
primary vaginal brachytherapy before radical hysterectomy to improve local control and reduce the use of
adjuvant radiotherapy but also to reduce the extension of the parametrectomy during surgery. The management
of FIGO IB patients should differ with tumor size and the 2018 FIGO classification highlighted this principle. A
publication[35] shown the effectiveness of such a strategy (brachytherapy followed within 6 to 8 weeks by a
radical hysterectomy type B in the Querleu classification) with a recurrence-free survival rate of 93.6% in 182
IB1-IIA1 stage patients with few complications, especially urinary. Another older French study[36] showed
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some equivalent results. In our study, only 8 patients underwent a preoperative brachytherapy among which 5
tumors were ≥ 2cm on MRI. It seems that there is a place for MIS without the use of the uterine manipulator
after pre-operative brachytherapy. Another strategy to improve the technique of laparoscopic radical
hysterectomy was proposed by Kohler et al.. The creation of a vaginal cuff enclosing the tumor and the
avoidance of use of a uterine manipulator are the main characteristics of the technique[37]. They reported a
similar survival than the laparotomy group of the LACC trial.[38]. Complete vaginal radical hysterectomy
known as Schauta operation with laparoscopic lymphadenectomy or extraperitoneal pelvic lymphadenectomy
was described [39,40]. However, this technique has been almost abandoned and is not taught in most of
University hospitals since the appearance of laparoscopic or robotic techniques.
CONCLUSION
We found no difference in survival depending on the surgical approach (minimally invasive surgery or
laparotomy) for radical hysterectomy in the context of cervical cancer at an early stage. Vaginal approach for
radical hysterectomy has been slowly disappearing of our practices. It might be of interest to combine good peri-
operative outcomes without compromising oncological results.
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FIGURES
Figure 1: Flow-charts
1706 patients treated for cervical
cancer
1289 with advanced stage disease
417 patients surgically treated
264 patients operated with
radical hysterectomy
223 patients treated by
minimally invasive
surgery (MIS)
41 patients operated
by open surgery (OS)
153 patients excluded: non-radical
procedures, trachelectomy, operated
elsewhere
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Tableau 1: Baseline characterics of the patients before the propensity score matching.
**RT-CHT: radiation therapy and chemotherapy
**Intensity-modulated radiation therapy (IMRT)
MIS
n =223
Open
n=41
Age (mean) 48.3 +/- 11.7 51.0 +/- 15.4 p = 0.18
Body Mass Index (mean) 24.6 +/- 4.7 27.2 +/-6.0 p=0.008
Histologic type p=0.47
Squamous cell
carcinoma
148 (66.4) 26 (63.4)
Adenocarcinoma 60 (26.9) 10 (24.4)
Others 15 (6.7) 5 (12.2)
FIGO IRM stage p= 0.045
IA 21 (9.4) 5 (12.2)
IB 164 (73.5) 32 (78)
IIA 12 (5.4) 0
IIB 9 (4.0) 3 (7.3)
IIIA 2 (0.9) 1 (2.4)
Tumor size (mm) 12.8 +/-12.56 17.6 +/-15.0 p=0.05
LVSI 54 (24.2) 12 (29.3) p= 0.57
Preoperative
brachytherapy
14 (6.3) 3 (7.3)
Adjuvant therapy p=0.47
None 118 (52.9) 19 (46.3)
Brachyterapy 50 (22.4) 8 (19.5)
RT-CHT* 48 (21.5) 14 (34.1)
IMRT** 6 (2.7) 0
Chemotherapy 1 (0.45) 0
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Tableau 2: Characteristics of the patients after using the propensity score matching.
*RT-CHT: radiation therapy and chemotherapy
MIS
n= 61
Open
n=32
p-value
Age (mean) 50.8 51.8 0.74
Body mass index (mean) 26.1 26.4 0.39
Histologic type 0.66
Squamous cell carcinoma 43 (70.5) 23 (71.9) 1
Adenocarcinoma 13 (21.3) 6 (18.6) 1
Others 5 (8.2) 3 (9.4) 1
FIGO IRM stage (2009) 0.13
IA 5 (8.2) 4 (12.5) 0.48
IB 49 (80.3) 25 (78.1) 0.79
< 2 cm
≥2 cm - <4cm
≥4 cm
NA
23
19
1
6
11
10
0
4
IIA 6 (9.8) 0 /
IIB 1 (1.6) 3 (9.4) 0.11
Tumor size (mm) 15.8 16.4 0.6
LVSI 18 (29.5) 10 (31.3) 1
Preoperative brachytherapy 5 (8.2) 3 (9.4) NA
Adjuvant therapy 0.75
None 27 (44.3) 17 (53.1) 0.5
Brachytherapy 25 (41) 9 (28.1) 0.26
RT-CHT 14 (23) 10 (31.2) 0.59
Robot asssited surgery 13 (12.7) - NA
Laparoconversion - 4 NA
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Figure 2: Survival outcomes of minimally invasive surgery and open surgery. Red curve: open surgery. Blue
curve: minimally invasive surgery.
A: Overall survival, p = 0.77
B: Disease-free survival, p=0.14
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Table 3 : Surgical parameters
MIS
n= 61
Open
n=32
p-value
Mean length of surgery (min) 228 278 0.17
Intraoperative complications 6 (8.3) 5 (15.6) 0.5
Urinary
- Bladder injury
- Ureteral injury with
reimplantation
2 (3.3)
1
1
3 (9.4)
1
2
Vascular 1 (6.6) 0
Digestive 1 (6.6) 1 (3.1)
Other 2 (3.3) 1 (3.1)
Postoperative complications
Dysuria/Urinary retention
Uretero-vaginal fistula
Lymphocele
Pelvic abscesses/peritonitis
Hemorrhagic complication
Autres
Reoperation (among previous
complication)
12 (19.7)
5
0
1
1
0
7
2
9 (28.1)
1
1
1
1
1
7
5
0.43
Mean length of hospital stay (days) 5.9 9.0 < 0.01
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Table 4 : Histopathologic characteristics
MIS
n= 61
Open
N=32
p-value
Negative margins 54 (88.5) 27 (84.4) 0.74
Length of the vaginal cuff (mm) 14.05 14.50 0.88
Parametrial invasion 6 (8.3) 5 (15.6) 0.5
Vaginal invasion 4 (6.6) 2 (6.3) 1
Lymph nodes invasion 6 (8.3) 5 (15.6) 0.5
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