Laparoscopic radical hysterectomy with enclosed colpotomy without the use of uterine manipulator for early-stage cervical cancer.

BACKGROUND: We report the application of transuterine suspension sutures (TUSSs) for manipulation and vaginal closure before colpotomy in laparoscopic radical hysterectomy for early-stage cervical cancer.
METHODOLOGY: Eight patients with clinical stage IB1 cervical squamous cell cancer were treated with laparoscopic radical hysterectomy between October 2019 and May 2020. The procedure was performed without a traditional uterine manipulator, and the vaginal cuff was closed with a stapler before colpotomy to prevent tumour spillage.
RESULTS: All patients successfully underwent the surgery, with a median hospitalisation of 8 days (range 6-14). All drains and urethral catheters were removed after a median of 7 days (range 5-11) and 16 days (range 12-21), respectively. A median of 26 (range 20-32) pelvic lymph nodes were resected and no lymph-related complications were encountered post-operatively. With an enclosed colpotomy, no visible tumour tissues were exposed to the pelvic cavity, and all vaginal stumps healed well without complications. All pathological examinations of the vaginal margin were negative, and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease.
CONCLUSION: We found that laparoscopic radical hysterectomy with TUSS and vaginal closure before colpotomy is a useful and effective procedure to prevent tumour spillage for the treatment of cervical cancer.

INTRODUCTION

A recent prospective randomised trial conducted by Ramirez et al. reported that laparoscopic radical hysterectomy was associated with lower rates of disease-free survival and poor overall survival than open abdominal approach among early-stage cervical cancer patients.[1] The usage of traditional uterine manipulators and exposed colpotomy may being the two main potential factors for the poor prognostic outcomes in the minimally invasive surgery group.[23]

In this study, we aimed to improve the laparoscopic radical hysterectomy procedure with the applications of relative tumour-free surgical techniques. The therapeutic effects are reported as follows.

MATERIALS AND METHODS

A total of eight patients with cervical cancer from October 2019 to May 2020 at Zhongda Hospital of Southeast University, Nanjing, China, were chosen for this study. The medical ethics issues were assessed and approved by our institutional review board. The demographic and clinico-pathological characteristics of the patients are summarised in Table 1.

Table 1

Demographic and clinico-pathological characteristics of the study population

Characteristic	Value
Age (years)	53 (41-64)
BMI (kg/m2)	26 (19.1-31.2)
Number of comorbid medical disease	2 (25)
ECOG score	0-1
Histotype
Squamous	5 (62.5)
Adenocarcinoma	3 (37.5)
FIGO stagea
IB1	8 (100)
Tumour diameter (mm)	11 (4-18)
Tumour differentiation
G1	0
G2	5 (62.5)
G3	3 (37.5)

aAccording to FIGO 2009 staging system of cervical cancer. Values are presented as median (range) or n (%). BMI: Body mass index, ECOG: Eastern Cooperative Oncology Group, FIGO: International Federation of Gynecology and Obstetrics

All of the patients underwent extensive laparoscopic hysterectomy with pelvic lymph node dissection, with or without bilateral adnexectomy. During the surgery, a total of four ports were used: (1) a 10-mm camera port in the umbilicus, (2) a 5-mm port at McBurney’s point on the right side, (3) a 12-mm working port in the mirror images on the left side, and (4) a 5-mm port para-rectally in the left mid-clavicular line at level of umbilicus.

A suture with a needle pierced through the abdominal wall from McBurney’s point, through the fundus of uterus twice to ensure adequate suspension strength, and finally exited out from the mirror image of McBurney’s point. This fixed suture eased with the abdominal manipulation of the uterus [Figure 1]. The standard laparoscopic radical hysterectomy technique was then conducted under transuterine suspension sutures (TUSSs). Pulling on the unilateral suture to the left or to the right facilitated further lateral pelvic dissection. Traction on both sides of the suture with pulling on the uterus forward or backward provided additional space for dissection of uterovesical space and the pouch of Douglas.

Figure 1

Abdominal uterine manipulation with fixing sutures on the uterus

After completion of the radical hysterectomy procedures, an Ethicon Powered plus articulating endoscopic endocutter (Ethicon endocutter) was placed into the abdominal cavity through a 12-mm trocar [Figure 2]. The uterus was elevated with fixed sutures on the uterus. Then, the stapler was placed. Before the surgical stapler was fired to close the vagina, it was ensured that no other unintended structure was included in the jaws of the stapler. After firing, the stapler places 2 triple-staggered rows of titanium staples and simultaneously knife blade cuts between them. Once the vagina had been divided, the stapler was released. The upper part of the vaginal cuff was excised and checked by pathology for a clear surgical margin, and the uterus was removed through the vagina. Finally, the vaginal cuff was closed with absorbable barbed sutures.

Figure 2

Ethicon Powered plus articulating endoscopic endocutter was used in vaginal closure

RESULTS

Peri-operative outcomes are listed in Table 2. All eight cases successfully underwent the surgery, with no complications occurring during and after the operation to date. The median duration of surgery was 152 min (range 131–205). The estimated blood loss was 218 ml (range 200–350), and only one patient required a transfusion due to pre-operative anaemia. The patients all recovered well, with a median hospital stay of 8 days (range 6–14). All drains and urethral catheters were removed after a median of 7 days (range 5–11) and 16 days (range 12–21), respectively. The median number of pelvic lymph nodes removed was 26 (range 20–32), and histopathological positivity was found in only one patient. No tumour tissue was exposed to the pelvic cavity after closure, and all vaginal stumps healed well. No lymph-related complications were encountered post-operatively, all pathological examination of vaginal margin was negative and there were no residual lesions. At a median follow-up of 6 months, all patients were alive with no recurrence of disease.

Table 2

Peri-operative outcomes of the study population

Characteristic	Value
Surgical time (min)	152 (131-205)
Estimated blood loss (ml)	218 (200-350)
Transfusion requirement	1 (12.5)
Duration of drain (days)	7 (5-11)
Time of urethral catheter removal	16 (12-21)
Hospital stay (days)	8 (6-14)
Number of nodes removed for pelvic lymph nodes	26 (20-32)
Number of patients for positive pelvic lymph nodes	1 (12.5)
Post-operative complications
Tumour tissue exposed to pelvic cavity after closure	0
Poor healing of vaginal stumpa	0
Lymphatic complicationsb	0
Positive pathological examination of vaginal margin	0
Follow-up (months)	6 (3-9)
Recurrence (case)	0
Death (case)	0

aPoor healing of vaginal stump include infection, dehiscence and poor healing of vaginal suture stump, bLymphatic complications include lymphatic cysts, lymphatic fluid secretion and lymphoedema. Values are presented as median (range) or n (%)

DISCUSSION

During minimally invasive surgery of cervical cancer, the uterine manipulator and myoma screw are usually used for mobilisation of the uterus. However, despite the widespread use of the instruments, the uterine manipulator is linked to direct squeezing and extrusion of the tumour, and the myoma screw may lead to spillage of malignant cells into the peritoneal cavity.[3] In this study, we found that TUSSs have some specific advantages over uterine manipulator, which could not only fully manipulate the uterus and expose operative field during the surgery but also avoid the risks brought by uterine manipulator. Moreover, the technique did not significantly increase the operation time, which was easy, effective and economical.

Intra-corporeal open colpotomy is the last step of laparoscopic radical hysterectomy, which was also reported increasing the risk of tumour spillage.[24] Yuan et al. reported a method of vaginal closure by ligating the upper vagina before colpotomy to prevent tumour spillage.[5] In the study, we found that vaginal closure with surgical stapler was another straightforward and simple way to prevent tumour spillage in laparoscopic radical hysterectomy. Based on our experience, the vaginal closure device had the following advantages although it might be relatively expensive: First, just as in laparotomy, intra-operative resection was easy and simple and could provide the same guarantees of sufficient resection of the vagina and sacral ligaments to ensure the safety of the incision margin. Second, the closure of the upper vagina indicated that the lesion of the cervix was in an enclosed space, which might avoid intra-peritoneal tumour spillage. Third, the lower part of the vaginal cuff was excised and a secondary pathological examination could be carried out to avoid residual carcinoma and early cancer recurrence.

There were several limitations of the study that should be addressed. First, patient number was too small in the study. Second, follow-up duration after surgery was too short, and data of long-time prognosis remained relatively scarce.

CONCLUSION

In conclusion, uterine manipulation with TUSS and enclosed colpotomy technique are both effective and feasible and guarantee a relatively tumour-free principle for minimally invasive radical hysterectomy. Further larger prospective studies are needed to confirm the hypothesis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.