Uterine cervix is the lowermost part of uterus (womb). This is the portion which has highest risk of cancer. Cervical cancer is one of the most common cancers in the world (more so in the developing world). This cancer is easily preventable due to the availability of a vaccine that reduces the risk as well the presence of easy way to detect early cancers (simple tests). Treatment is also simple when detected early (refer to table).
What Is Uterine Cervix ?
Table of Cervical Cancer Staging & Suggested Treatment Based on FIGO Staging:
|Stage 0||Confined to surface layer (epithelium)||Simple loop excision orHysterectomy (Laparoscopic or open)|
|Stage 1A||Early Cancer||Laparoscopic or open Radical Hysterectomy|
|Stage 1B1||<4cm size|
|Stage 1B2 to 4A||Bulky & locally advanced disease||Laparoscopic or extraperitoneal lymphnode dissection (when present) |
Radiation with Chemotherapy
|Stage 4B||Spread to distant organs||Chemotherapy or palliation|
|Recurrent or residual disease||Following radiation &/or chemotherapy||Completion laparoscopic hysterectomy or exenteration (when possible)|
|Recurrent disease||Following surgery||Radiation with Chemotherapy when possible|
Concept Of Surgery For Cervical Cancer
Laparoscopic Radical Hysterectomy: Radical hysterectomy is the surgical treatment for cervical cancer. This involves the removal of uterus, cervix, tissue besides the uterus (parametrial tissues) and adequate upper vagina. It is usually combined with pelvic lymphadenectomy. The extent of parametrial tissue (tissue besides the uterus) removed depends on the stage of the disease. Radical hysterectomy is a more complex procedure than a simple hysterectomy and is undertaken by appropriately trained surgeons.
Completion Laparoscopic Hysterectomy: The combined treatment of radical surgery and postoperative radiotherapy increases overall morbidity compared to either alone. To minimise post-surgical morbidity, before doing an radical hysterectomy the size of primary tumour should be accurately assessed radiologically using MRI or CT scan and efforts should be made to ensure that there is no lymphadenopathy. For tumours measuring more than 4 cm the incidence of lymph node metastases is high. Presence of nodal metastasis is an indication for using adjuvant chemoradiotherapy or radiotherapy which increases the morbidity due to radiation to bowel. The evidence suggests that there is no difference in survival of these patients when treated by either radical hysterectomy or chemoradiotherapy. So, today the preferred treatment for these cases is chemoradiotherapy. When there is residual disease after chemoradiation a laparoscopic completion hysterectomy is advisable. Open technique is not recommended due to its morbidity.
Laparoscopic Lymphadenectomy in Advanced Cancers: When there is evidence of lymphnodal metastasis on CT or MRI scanning in patients with locally advanced disease, it is preferable to remove these nodes laparoscopically & then give chemoradiation to the cervical disease. Open surgery is not recommended due to its morbidity. This way the therapy can be focused on primary tumor with fewer side effects.
Laparoscopic Exenteration: The patients are placed in followup to detect recurrences as early as possible. In most of the cases of recurrence, exenteration is indicated. This can be performed by open or laparoscopic technique.
First laproscopic assisted vaginal radical hysterectomy was performed in 1991. With the improvements in technology & skills, presently totally laparoscopic radical hysterectomy is possible. The safety and feasibility of laparoscopic radical hysterectomy has been studied & proven at many centers. Though the initial studies showed that the surgical time was longer for laparoscopy compared to open surgery, with experience and improvement in technology, the time taken has come down. The blood loss is generally less during laparoscopy.
Oncological safety of laparoscopic radical hysterectomy has been studied at many centers. Laparoscopy definitely offers better quality of vision when compared to open, due to anatomical restrictions of pelvis. Many have shown that laparoscopy yields a higher number of lymph nodes than laparotomy, and achieves adequate tissue margins. This indicates that laparoscopy could be better than open surgery for cervical cancer. However, there have been no randomized trials so far to prove this. There are no long term data available on laparoscopic radical hysterectomy at present. laparoscopic radical hysterectomy give the advantage of shorter hospital stay & rapid recovery.
Presently available evidence indicates that laparoscopic radical hysterectomy to be a safe procedure
- Landoni F, maneo A, Colombo A, et al. randomised study of radical surgery versus radiotherapy for stage Ib-IIa cervical cancer. lancet 997;350(9077):535-40.
- Nezhat CR, Burrell MO, Nezhat FR, et al., Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection, Am J Obstet Gynecol , 1992;166:864–5.
- Frumovitz M, does Reis R, Sun CC, et al., Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer, Obstet Gynecol , 2007;110:96–102.
- Spirtos NM, Eisenkop SM, Schlaerth JB, et al., Laparoscopic radical hysterectomy (type III) with aortic and pelvic lymphadenectomy in patients with stage I cervical cancer: Surgical morbidity and intermediate follow-up, Am J Obstet Gynecol , 2002;187:340–48.
- Chi DS, Curtin JP. Gynecologic cancer and laparoscopy. Obstet Gynecol Clin North Am. 1999;26:201-15
- Chen Y, Xu H, Li Y, et al., The outsome of laparoscopic radical hysterectomy and lymphadenectomy for cervical cancer: A prospective analysis of 295 patients, Ann Surg Oncol , 2008; 15:2847–55.
- Ramirez P, Slomovitz BM, Soliman PT, et al., Total laparoscopic radical hysterectomy and lymphadenectomy: the M. D. AndersonCancer Center experience, Gynecol Oncol , 2006;102:252–5.
- Pomel C, Atallah D, Le Bouedec G, et al., Laparoscopic radical hysterectomy for invasive cervical cancer: 8-year experience of a pilot study, Gynecol Oncol , 2003;91:534–9.
- Abu-Rustum NR, Gemignani ML, Moore K, et al., Total laparoscopic radical hysterectomy with pelvic lymphadenectomy using the argon-beam coagulator: pilot data and comparison to laparotomy, Gynecol Oncol , 2003;91:402–9.
- Li G, Yan X, Shang H, et al., A comparison of laparoscopic radical hysterectomy and pelvic lymphadenectomy and laparotomy in the treatment of Ib-IIa cervical cancer, Gynecol Oncol , 2007;105: 176–80