|Year : 2015 | Volume
| Issue : 8 | Page : 258-264
Comparison of conventional laparoscopy and robotic radical hysterectomy for early-stage cervical cancer: A meta-analysis
Hao Xianhua, Han Shuzhai, Wang Yunfei
Department of Gynaecology, Jining Medical College Affiliated Hospital, Jining Medical University, Jining, Shandong 272029, PR, China
|Date of Web Publication||26-Nov-2015|
Jining Medical College Affiliated Hospital, 79, Guhuai Road, Jining, Shandong 272029
Source of Support: None, Conflict of Interest: None
Background: Cervical cancer continues to be a global burden for women, with >500,000 cases and 275,000 deaths reported annually. Resources-rich countries have seen a dramatic reduction in the prevalence of invasive cervical cancer due to widely accessed radical hysterectomy (RH). We aimed to compare initial surgical outcomes and complication rates of conventional laparoscopic RH (LRH) and robotic RH (RRH) for treating cervical cancer through a systematic meta-analysis.
Methods: PubMed, EMBASE, and the Cochrane Library databases were systematically searched for all relevant studies. Data were abstracted independently. A meta-analysis was performed to compare intra- and post-operative outcomes for the two techniques.
Results: A total of 12 clinical trials were identified. Meta-analysis showed that although LRH and RRH were similar in terms of operating time, the length of hospital stay, and a number of pelvic lymph nodes resected, RRH presented less blood loss and overwhelming advantage against LRH with the respect of complications.
Conclusion: RRH may be a reliable technique for treating early cervical cancer. Available evidence suggests that it is better than LRH for postoperative recovery, while the two techniques involve similar surgical outcomes and share the same limits in clinical practice.
Keywords: Cervical cancer, laparoscopy, meta-analysis, robotic radical hysterectomy, surgical outcomes
|How to cite this article:|
Xianhua H, Shuzhai H, Yunfei W. Comparison of conventional laparoscopy and robotic radical hysterectomy for early-stage cervical cancer: A meta-analysis. J Can Res Ther 2015;11, Suppl S4:258-64
|How to cite this URL:|
Xianhua H, Shuzhai H, Yunfei W. Comparison of conventional laparoscopy and robotic radical hysterectomy for early-stage cervical cancer: A meta-analysis. J Can Res Ther [serial online] 2015 [cited 2020 Jan 24];11:258-64. Available from: http://www.cancerjournal.net/text.asp?2015/11/8/258/170533
| > Introduction|| |
Cervical cancer continues to be a global burden for women, with >500,000 cases and 275,000 deaths reported annually. Resource-rich countries have seen a dramatic reduction in the prevalence of invasive cervical cancer due to widely accessed screening program and mature application of radical hysterectomy (RH) in early-stage cervical cancer patients.,,,
As we all know that conventional surgical management of early-stage cervical carcinoma is RH,, which is associated with postoperative morbidities such as bladder dysfunction, sexual dysfunction, and colorectal motility disorders. Accidental damage to the pelvic autonomic nerves during surgery is thought to be a major cause of these morbidities. Improving surgical treatment as well as the postoperative quality of life is increasingly important challenges given that more than 54% of women diagnosed with cervical cancer are younger than 50 years. As a result of advances in minimally invasive surgery, laparoscopic RH (LRH),, is now performed routinely around the world. While this technique is less invasive than RH, it can still lead to substantial rates of postoperative morbidity. In an effort to reduce postoperative morbidity, many gynecologists have focused on such surgical approach that is known as robotic RH (RRH),,, was invented by Japanese gynecologists. RRH has been adopted and developed over the last 20 years by surgical schools around the world. Many clinicians believe that the robotic approach is associated with lower postoperative morbidity than conventional RH, with similar clinical efficacy and safety. We decided to test this belief rigorously by conducting a meta-analysis of pooled studies.,
| > Methods|| |
All relevant studies published in English and Chinese ranged from 2007 to 2015 were identified through systematic searches in PubMed, EMBASE, and the Cochrane Library database. The search terms used were RRH, RH, conventional laparoscopy, LRH, and all these terms in combination with cervix carcinoma or cervical cancer. Reference lists in all relevant articles were also manually searched.
A study was included in the meta-analysis if it involved patients with proven cervical cancer, regardless of age, ethnicity or location, a pair-matched or non-pair-matched controlled design, or a case–control design; laparotomy or laparoscopy; comparison of surgical outcomes of LRH with RRH; and evaluation of at least one outcome from among following: Operating time, intraoperative blood loss, hospital stay, pelvic lymph nodes, complications, and recovery time.
A study was excluded from the study if it failed to report the principal demographic and clinicopathological findings of patients, including age, body mass index, International Federation of Gynecology and Obstetrics stage, histological findings, and tumor size.,
We carried out literature searches and identified eligible articles based on the inclusion and exclusion criteria. Then we extracted data from each study independently, including the first author, publication year, country, study design, patient characteristics, and data on the outcomes in the inclusion criteria. Discrepancies in extracted data were resolved by consensus.
Assessment of study quality
We assessed the quality of included studies using the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. The assessment tool contained six core items: Sequence generation, allocation concealment, blinding, incomplete outcome data (e.g. about follow-up/withdrawals), selective outcome reporting, and other potential sources of bias (e.g., comparability of groups). Each study was classified as having a low, moderate, or high risk of bias.
Data management and statistical analysis
Data for dichotomous variables were analyzed using relative risk while data for continuous variables with the same measurement unit were analyzed using the weighted mean difference; in all cases, the binomial 95% confidence interval (95% CI) was also calculated. All statistical tests were performed using RevMan 5.2 software (Cochrane Collaboration). Possible heterogeneity among studies was evaluated using Chi-squared-based Q-test or Chi-square test. Heterogeneity was also estimated using the I2 index, which describes the percentage of total variation across studies that is due to heterogeneity rather than chance. A fixed-effects model was used if no statistical heterogeneity existed (P > 0.1, I2 ≤ 50%); otherwise, a random-effects model was used, and sensitivity analysis was performed.
We planned to perform subgroup analysis in the event that we were able to identify the source of clinical heterogeneity or in the event that the included studies encompassed a range of study designs. We also planned to provide a descriptive analysis of data from different studies if they could not be combined into a meta-analysis. We planned to assess publication bias by visual inspection of Begg's funnel plots if we could include a sufficient number of studies in the analysis.
| > Results|| |
We identified a total of 28 relevant studies in our database searches. After eliminated the reviews and those concerning patients transferred to receive laparotomy or robot-assisted operation, 19 were remained to read in detail. Since three of them lack extractable data or focus only on one of the two techniques, 12 were remained as final references [Figure 1]. Of these, one published in 2011, which was conducted by Sert et al. to compare surgical outcomes and postoperative complications of conventional laparoscopic hysterectomy with that of robot-assisted LRH, was also included in this meta-analysis. We limited all the whole literature mining within early-stage cervical cancer so that we could ensure the similar health issues in patients involved in this study. The scientific objectivity of conclusions drawn from this meta-analysis was based on some main characteristics of all these included studies [Table 1]. Since patients' physical conditions influence the outcome of treatment, patients' ages and BMIs potentially accounted for our inclusive criteria as samples in these 12 studies framed in the same scale. Besides, we also noticed that different terms were used to refer laparoscopic radical hysterectomy among these studies, for example, laparoscopic radical hysterectomy in the study of Chong et al. was referred to as TLRH (total laparoscopic radical hysterectomy) while the counterpart in that of Estape et al. simply was LRT. The expressional differences were not taken into account in our study.
While 7 of 12 studies reported operating time,,,,,,,,,, presenting as means ± standard deviations, we took them into account. Operating time did not differ significantly between the RRH (n = 304) and LRH (n = 322) groups (95% CI [− 19.46, 1.88], P = − 8.79), since slight heterogeneity existed (heterogeneity: χ2 = 10.10, df = 6 [P = 0.12]; I2 = 41%, [Figure 2]).
Estimated blood loss
Six RH studies reported data on intraoperative blood loss. Heterogeneity (heterogeneity: χ2 = 22.95, df = 5 [P = 0.0003]; I2 = 78%) was calculated, as we know that I2 = 78%, much greater than the standard level 50%, so a random-effects model was applied. However, it had little effect on heterogeneity, for which the source of heterogeneity was attributed to other reasons. The RRH group (n = 270, mean value = 112.87 ml) showed much less blood loss when comparing with LRH group (n = 291, mean value = 188.32 ml, [Figure 3]).
Length of hospital stay
Seven studies reported data on a hospital stay. The authors reported slightly shorter length of hospital stay, with a mean difference (95% CI [− 0.22, 0.8], P = 0.29) in the RRH group (5.14 d; n = 302) than in the LRH group (6.06 d; n = 308). Heterogeneity was detected (heterogeneity: χ2 = 20.42, df = 6 (P = 0.002);
I2 = 71%), and after applying a random-effects model to neutralize such heterogeneity, no valuable results were produced [Figure 4].
Pelvic lymph nodes
Seven randomized RH studies reported pelvic lymph nodes. Heterogeneity was detected (heterogeneity: χ2 = 7.19, df = 6 [P = 0.30]; I2 = 17%), concerning I2 = 17%, far below 50%, the application of a random-effects model would not be used in the further study. Pelvic lymph nodes were not significantly different in the RRH (n = 304) group and in the LRH (n = 322) group (95% CI = − 1.87–1.70, P = − 0.99; [Figure 5]).
Twelve randomized RH studies ,,,,,,,,, reported both intraoperative and postoperative complications.,,,,,,,,,,, Heterogeneity was detected (Heterogeneity: χ2 = 22.45, df = 11 [P = 0.02]; I2 = 51%), concerning I2 = 51%, slightly above 50%, the application of a random-effects model could be alternatively used. Since RRH group (n = 343 with 63 patients possessing complications) showed evident advantage over LRH group (n = 358 with 82 patients possessing complications), with a risk ratio of 1.31 (0.99, 1.74) [Figure 6]. Considering intraoperative/postoperative complication as a major bar to evaluate the clinical efficacy of the two techniques, we conducted further study under the dimensions of 5 intraoperative complication symptoms (vascular injury, pelvic bleeding, ureter-vaginal fistula, lymphorrhea, trocar hernia), and four postoperative items (urinary dysfunctions, bowel dysfunctions, vaginal cuff dehiscence, vaginal, and sex dysfunctions), within 6 of the 14 studies eligible., 17, ,,, In general, RRH was characterized with higher complication rate (8.2%) comparing with LRH (7.4%). Among all the relevant symptoms, listed in [Table 2], vaginal cuff dehiscence was the most major contributor to complications in patients receiving RRH while pelvic bleeding was the most common complication in those undergone LRH. Based on the same size of population pool, overwhelming numbers of complication-possessed patients were observed in LRH group.
| > Discussion|| |
LRH and RRH have become increasingly common in clinical practice,, in large part because the procedure is thought minimally invasive surgery and thereby reducing postoperative morbidity compared to laparotomy., To examine whether RRH possesses an overwhelming advantage over LRH in surgical outcomes and intraoperative/postoperative complications, we performed a systematic meta-analysis of the literature comparing the clinical efficacy and complications of RRH and LRH based on laparotomy., Our findings support the results of individual studies indicating that RRH leads to less blood loss during the surgery and economical operating-room time. We also found RRH to be associated with lower risk of intraoperative/postoperative complications. These conclusions are consistent with at least two studies that we were unable to include in the meta-analysis because they focused only on RRH without LRH., In addition, the two approaches were generally similar with the respect of the length of hospital stay, with a mean difference 0.29 (− 0.22, 0.80) and the number of pelvic lymph nodes resected, with a mean difference − 0.09 (− 1.87, 1.70).
RRH is thought to be associated with better recovery and faster back to normal function, yet we found little relevant data in the studies included in this analysis. Sert and Abeler reported a 3-year follow-up in 2011, from which we could deduced indirectly that patients undergone RRH might demonstrate better cause-free survival. Unfortunately, we could not meta-analyze the data because there were three trials concerning 3 years follow-up of patients either undergone RRH or LRH, but reporting results in the form of divers recurrence patterns.
The results of our meta-analysis suggest that RRH characterized by fewer complications and potentially better postoperative life quality, especially in certain functional outcomes, than is LRH. We also attempted to figure out which surgical technique cherished larger extent of resection. After compared parametrical width and vaginal cuff length, proposed in one study published in 2007 by Sert and Abeler we found that there was no significant difference of feasibility between these two approaches. Meanwhile, laparotomy showed the much larger extent of resection in practice even with a lot of disadvantages at the same time. However, the belief that RRH involves less extensive resection and, therefore, can lead to lower survival and a higher risk of recurrence proved to be irrational through a close look at three studies published by Soliman et al., Kim et al., and Sert and Abeler, respectively.,, The reason why we did not include these findings on survival and recurrence was that they should be interpreted with caution for they come from individual studies of relatively limited statistical power, which could not be combined because of differences in study design and outcomes reporting.,
| > Conclusion|| |
This meta-analysis provides evidence for the belief that RRH is associated with low intraoperative/postoperative complications and good clinical efficacy for treating patients with early-stage cervical cancer, which has helped make it an increasingly popular clinical option. It appears to be competitive over LRH in terms of intraoperative blood loss. Many of these findings are based on a relatively small number of trials. Therefore, they should be verified in larger, multi-center pools in the future.
This work was supported by The "Nursery" program of Jining Medical College Affiliated Hospital (NO. MP-2014-001), Jining science and technology development plan and Wu Jieping Medical Foundation (NO. 320.6750.14079).
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| > References|| |
Dizon DS, Mackay HJ, Thomas GM, Werner TL, Kohn EC, Hess D, et al.
State of the science in cervical cancer: Where we are today and where we need to go. Cancer 2014;120:2282-8.
Frumovitz M, Querleu D, Gil-Moreno A, Morice P, Jhingran A, Munsell MF, et al.
Lymphadenectomy in locally advanced cervical cancer study (LiLACS): Phase III clinical trial comparing surgical with radiologic staging in patients with stages IB2-IVA cervical cancer. J Minim Invasive Gynecol 2014;21:3-8.
Polistena A, Monacelli M, Lucchini R, Triola R, Conti C, Avenia S, et al.
Surgical morbidity of cervical lymphadenectomy for thyroid cancer: A retrospective cohort study over 25 years. Int J Surg 2015;21:128-34.
Pfaendler KS, Tewari KS. Changing paradigms in the systemic treatment of advanced cervical cancer. Am J Obstet Gynecol 2015. pii: S0002-937800772-3.
Shrivastava SR, Shrivastava PS, Ramasamy J. Negating the impact of radiation in development of cancers. Asian Pac J Oncol Nurs 2015;2:52.
Pilka R, Marek R, Dzvincuk P, Kudela M, Neubert D. "Learning curve" robotic radical hysterectomy compared to standardized laparoscopy assisted radical vaginal and open radical hysterectomy. Ceska Gynekol 2013;78:20-7.
Mettler L, Meinhold-Heerlein I. The value of laparoscopic surgery to stage gynecological cancers: Present and future. Minerva Ginecol 2009;61:319-37.
Koehler C, Gottschalk E, Chiantera V, Marnitz S, Hasenbein K, Schneider A. From laparoscopic assisted radical vaginal hysterectomy to vaginal assisted laparoscopic radical hysterectomy. BJOG 2012;119:254-62.
Lowe MP, Chamberlain DH, Kamelle SA, Johnson PR, Tillmanns TD. A multi-institutional experience with robotic-assisted radical hysterectomy for early stage cervical cancer. Gynecol Oncol 2009;113:191-4.
Tinelli R, Malzoni M, Cosentino F, Perone C, Fusco A, Cicinelli E, et al.
Robotics versus laparoscopic radical hysterectomy with lymphadenectomy in patients with early cervical cancer: A multicenter study. Ann Surg Oncol 2011;18:2622-8.
Obermair A, Gebski V, Frumovitz M, Soliman PT, Schmeler KM, Levenback C, et al.
A phase III randomized clinical trial comparing laparoscopic or robotic radical hysterectomy with abdominal radical hysterectomy in patients with early stage cervical cancer. J Minim Invasive Gynecol 2008;15:584-8.
Kruijdenberg CB, van den Einden LC, Hendriks JC, Zusterzeel PL, Bekkers RL. Robot-assisted versus total laparoscopic radical hysterectomy in early cervical cancer, a review. Gynecol Oncol 2011;120:334-9.
Sert MB. Comparison between robot-assisted laparoscopic radical hysterectomy (RRH) and abdominal radical hysterectomy (ARH): A case control study from EIO/Milan. Gynecol Oncol 2010;117:389.
Zhang B, Zhu F, Ma X, Tian Y, Cao D, Luo S, et al.
Matched-pair comparisons of stereotactic body radiotherapy (SBRT) versus surgery for the treatment of early stage non-small cell lung cancer: A systematic review and meta-analysis. Radiother Oncol 2014;112:250-5.
Bertolaccini L, Terzi A, Ricchetti F, Alongi F. Surgery or stereotactic ablative radiation therapy: How will be treated operable patients with early stage not small cell lung cancer in the next future? Ann Transl Med 2015;3:25.
Chang JY, Senan S, Paul MA, Mehran RJ, Louie AV, Balter P, et al.
Stereotactic ablative radiotherapy versus lobectomy for operable stage I non-small-cell lung cancer: A pooled analysis of two randomised trials. Lancet Oncol 2015;16:630-7.
Vizza E, Corrado G, Mancini E, Vici P, Sergi D, Baiocco E, et al.
Laparoscopic versus robotic radical hysterectomy after neoadjuvant chemotherapy in locally advanced cervical cancer: A case control study. Eur J Surg Oncol 2015;41:142-7.
Soliman PT, Frumovitz M, Sun CC, Dos Reis R, Schmeler KM, Nick AM, et al.
Radical hysterectomy: A comparison of surgical approaches after adoption of robotic surgery in gynecologic oncology. Gynecol Oncol 2011;123:333-6.
Sert MB, Abeler V. Robot-assisted laparoscopic radical hysterectomy: Comparison with total laparoscopic hysterectomy and abdominal radical hysterectomy; one surgeon's experience at the Norwegian Radium Hospital. Gynecol Oncol 2011;121:600-4.
Sert B, Abeler V. Robotic radical hysterectomy in early-stage cervical carcinoma patients, comparing results with total laparoscopic radical hysterectomy cases. The future is now? Int J Med Robot 2007;3:224-8.
Nezhat FR, Datta MS, Liu C, Chuang L, Zakashansky K. Robotic radical hysterectomy versus total laparoscopic radical hysterectomy with pelvic lymphadenectomy for treatment of early cervical cancer. JSLS 2008;12:227-37.
Kim TH, Choi CH, Choi JK, Yoon A, Lee YY, Kim TJ, et al.
Robotic versus laparoscopic radical hysterectomy in cervical cancer patients: A matched-case comparative study. Int J Gynecol Cancer 2014;24:1466-73.
Estape R, Lambrou N, Diaz R, Estape E, Dunkin N, Rivera A. A case matched analysis of robotic radical hysterectomy with lymphadenectomy compared with laparoscopy and laparotomy. Gynecol Oncol 2009;113:357-61.
Corrado G, Fanfani F, Ghezzi F, Fagotti A, Uccella S, Mancini E, et al.
Mini-laparoscopic versus robotic radical hysterectomy plus systematic pelvic lymphadenectomy in early cervical cancer patients. A multi-institutional study. Eur J Surg Oncol 2015;41:136-41.
Chong GO, Lee YH, Hong DG, Cho YL, Park IS, Lee YS. Robot versus laparoscopic nerve-sparing radical hysterectomy for cervical cancer: A comparison of the intraoperative and perioperative results of a single surgeon's initial experience. Int J Gynecol Cancer 2013;23:1145-9.
Ramirez PT, Soliman PT, Schmeler KM, dos Reis R, Frumovitz M. Laparoscopic and robotic techniques for radical hysterectomy in patients with early-stage cervical cancer. Gynecol Oncol 2008;110 3 Suppl 2:S21-4.
Petricca G, Leppilampi M, Jiang G, Owen GR, Wiebe C, Tu Y, et al.
Localization and potential function of kindlin-1 in periodontal tissues. Eur J Oral Sci 2009;117:518-27.
Dogan NU, Garagozova N, Pfiffer T, Beier A, Köhler C, Favero G. Symptomatic lymphocele formation after sentinel lymph node biopsy for early-stage cervical cancer. J Minim Invasive Gynecol 2015. pii: S1553-465000606-8.
Zakashansky K, Bradley WH, Nezhat FR. New techniques in radical hysterectomy. Curr Opin Obstet Gynecol 2008;20:14-9.
Rabinovich A. Robotic surgery for ovarian cancers: Individualization of the surgical approach to select ovarian cancer patients. Int J Med Robot 2015;doi: 10.1002/rcs.1684. [Epub ahead of print].
Kim TJ, Yoon G, Lee YY, Choi CH, Lee JW, Bae DS, et al.
Robotic high para-aortic lymph node dissection with high port placement using same port for pelvic surgery in gynecologic cancer patients. J Gynecol Oncol 2015;26:222-6.
Bradbury M, Founta C, Taylor W, Kucukmetin A, Naik R, Ang C. Pathological risk factors and outcomes in women with stage IB2 cervical cancer treated with primary radical surgery versus chemoradiotherapy. Int J Gynecol Cancer 2015;25:1476-83.
Soliman PT, Langley G, Munsell MF, Vaniya HA, Frumovitz M, Ramirez PT. Analgesic and antiemetic requirements after minimally invasive surgery for early cervical cancer: A comparison between laparoscopy and robotic surgery. Ann Surg Oncol 2013;20:1355-9.
Yim GW, Kim SW, Nam EJ, Kim S, Kim HJ, Kim YT. Surgical outcomes of robotic radical hysterectomy using three robotic arms versus conventional multiport laparoscopy in patients with cervical cancer. Yonsei Med J 2014;55:1222-30.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
[Table 1], [Table 2]