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PERSPECTIVE ARTICLE
Year : 2023 | Volume
: 12
| Issue : 1 | Page : 1-3
From radical hysterectomy to radical surgery for deep endometriosis
Chyi- Long Lee1, Boom Ping Khoo2, Kuan- Gen Huang1
1 Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital At Linkou; Taiwan Chang Gung University College of Medicine, Taoyuan City, Taiwan
2 Department of Obstetrics and Gynecology, Hospital Raja Permaisuri Bainun, Ipoh, Malaysia
Correspondence Address:
Dr. Kuan- Gen Huang
Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital At Linkou, Taoyuan City; Taiwan Chang Gung University College of Medicine, Kwei-Shan, Taoyuan City
Taiwan
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/gmit.gmit_140_22
Pelvic surgery is a study and art of the basic human anatomy; besides removing pathological organs and parts, it allows the study of pelvic anatomy through careful dissection of its structures. Radical pelvic surgery started about 120 years ago; it has progressively improved and evolved techniques to provide the best outcome for gynecological cancers. It started initially with a laparotomy approach of radical and debulking surgeries with complete systematic pelvic lymph node dissection, para-aortic lymph node dissection, and omentectomy. Since the 1990s with the introduction of minimally invasive surgery for gynecology diseases, the management of gynecological cancer has evolved into individualized treatment. It has made Minimally Invasive Surgery (MIS) the gold standard treatment for endometrial cancer.[1],[2],[3],[4],[5] Many doctors and researchers worldwide have a positive opinion regarding the MIS approach in treating cervical cancer;[6] it benefits fertility preservation, lower morbidity, and quicker recovery compared to open surgery.[7],[8],[9],[10] The current trend for gynecological cancer is shifting toward the MIS approach; in developed countries, MIS for endometrial cancers has increased from 10% to more than 80%.[11]
Radical surgeries have an important role in treating deep infiltrating endometriosis (DIE), besides treating cervical cancer. Especially relevant when it involves bowel and ureters adhesions and partial or complete obliteration of the Cul-De-Sac. Although the concepts of radicality for cervical cancer surgery mandated complete resection of cancer with clear margins, which is not necessary for endometriosis surgery, both types of surgeries showed similar resemblances in dissection and resection for endometriotic tissue. In certain cases of DIE, the extent of adhesions to the bowel and other adjacent structures is sometimes much more difficult than those of cervical cancer. The principles for DIE surgery are first to inspect the extent of endometriosis involvement and adhesiolysis of involved structures to restore the anatomy to proceed with subsequent procedures.
MIS was gaining popularity over the years for gynecologists as it provides an enlarged vision of surgical view with the help of a high-definition camera displayed on a TV monitor. Small structures visible on the laparotomy approach are enlarged at least 4–7 times with a laparoscopic camera, enabling more detailed dissection of tissues. Not until 2018, when the Laparoscopic Approach to Cervical Cancer (LACC) study was published, the result showed a lower rate of disease-free survival and overall survivor for cervical cancer treated with a minimally invasive approach versus radical abdominal hysterectomy (survival rate over 4.5 years for MIS vs. open = 86% vs. 96.5%). Higher rate of locoregional recurrence for minimally invasive surgery arm.[12] This landmark trial has negatively impacted MIS's use to treat cervical cancer. The National Comprehensive Cancer Network (NCCN) has revised its guidelines on managing cervical cancer, stating that “the standard and historical approach for radical hysterectomy is an open abdominal approach.” Based on several key reports, the guideline questioned the presumed therapeutic equivalency of open versus MIS approaches.[13] NCCN, in its guidelines for patients, has also been revised to an open abdominal approach, which led to an open abdominal approach as the standard of care for cervical cancer surgery. Following the revision of the treatment recommendation, physicians switched from the MIS approach back to the open abdominal approach. Thus, raising the question, should we stop performing laparoscopic radical hysterectomy (LRH) for cervical cancer? A European perspective on surgical approach in early cervical cancer after the LACC trial showed a marked negative impact on European practices, a threefold reduction in laparoscopy as the primary surgical approach from 48.9% to 18.2% in 2020, an increase of open abdominal approach from 29.8% to 63.0%.[14]
On the contrary, our hospital data, Lee–Huang team's published article “standardization and experience may influence the survival of LRH for cervical cancer” showed a 100% from 5-year survival of patients with cervical cancer operated with MIS approach from 2009 to 2014.[15] Extrapolate from our data, with standardization of surgical techniques and surgeons' experience, should improve treatment outcomes [Figure 1].
Figure 1: Surgical outcomes in Lee–Huang team's 5-year survival of cervical cancer patients treated with laparoscopic radical hysterectomy. SD: Standard deviation, LN: Lymph nodeWe have studied and found some bias in the LACC trial. There was no standardization in oncology and reproductive procedures among participating surgeons. Based on these biases, the Asia-Pacific Association of Gynecologic Endoscopy (APAGE) declared our different opinions on the results of the LACC trial.[6] We think the clinical trial should be more rigorous. Surgeons' capability is a critical factor in the success of surgical cases.
Despite the negative impact on Western practices, LRH is still being practiced in many Asian countries, thanks to the statement made by APAGE on the LACC trial. Lee–Huang's team had designed a strategy toward successful LRH for cervical cancer; these include (1) early detection of cervical cancer – Screening and early detection of early stages of cervical cancer, which qualify for a laparoscopic approach, (2) standardization, of “Radicality technique” – Techniques like the open abdominal approach must be standardized, (3) “Tumour-Free” concept – Zero residual tumors with a maximum clearance margin, (4) advanced instrumentation – Newer energy devices such as Ligasure, PK knife, and harmonics scalpel, (5) adjuvant therapy in a timely and appropriate manner – Faster recovery from surgery without delay to commence on adjuvant chemotherapy or radiotherapy, and (6) qualified surgeons in minimally invasive surgery centers – Training and certification of surgeons with standardized laparoscopic techniques. Considering the facts, APAGE proposed a new clinical trial: minimally invasive therapy versus open radical hysterectomy. With this new trial, someday, we might be able to undo the nightmare that resulted from the LACC trial.
DIE surgery shares the same concepts with LRH for cervical cancer; opening pelvic spaces enables complete resection of involved tissue. It is found in 10% of women in their reproductive age; about 176 million women worldwide have endometriosis. Two percent–eleven percent of women with endometriosis were asymptomatic; 5%–50% of them were infertile, whereas 5%–21% were hospitalized for pelvic pain. DIE accounted for 1% of women in their reproductive age;[16] it is defined as a solid endometriosis mass situated more than 5 mm deep in the peritoneum. It may involve the vagina, uterosacral ligaments, bowel, bladder, and ureter. For bowel involvement, the rectum (13%–53%), sigmoid colon (18%–47%), ileum or other small bowels (2%–5%), and appendix (3%–18%).[17],[18],[19] Indications for surgery include severe pelvic pain, unresponsiveness to medical treatment, obstructive uropathy, symptomatic bowel stenosis, adnexal mass of a doubtful nature, and reproductive desire.
Our team has created seven strategies for the surgical management of DIE, (1) restore pelvic anatomy, (2) identify U-S ligament, (3) identify ureter, (4) create pararectal space, (5) create prerectal space, (6) excise the DIE, and (7) adhesion prevention. With the understanding of pelvic anatomy, space adaptation of these strategies and technique in radical hysterectomy in cervical cancer, DIE can be completely resected without causing complications.
Some might think LRH for cervical cancer is not an important surgery, but laparoscopic resection of DIE shares similarities with LRH. Through the laparoscopic approach, the pelvic spaces and structures could be clearly identified and demarcated thanks to the anatomical concepts brought by LRH for cervical cancer. Therefore, laparoscopic cervical cancer surgery lays the foundation for training junior resident doctors for endometriosis surgery. Moreover, cervical cancer surgeries had good outcomes in our country, hence, the patient's right to this treatment modality cannot be denied. This is also an important training opportunity for junior resident doctors to learn about pelvic anatomy and spaces. We shall preserve laparoscopic cervical cancer surgery to our coming generations to learn and flourish in laparoscopic resection of endometriosis.
Financial support and sponsorship
Nil.
Conflicts of interest
Prof. Chyi-Long Lee and Prof. Kuan-Gen Huang, editorial board members at Gynecology and Minimally Invasive Therapy, had no roles in the peer review process of or decision to publish this article. The other author declared no conflicts of interest in writing this paper.
References
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