Radical Hysterectomy For Cervical Cancer:Abdominal Versus Laparoscopic

IntroductionCancer of the uterine cervix is the second most common cancer in women, accounting for9.8%of all new cancer cases worldwide. In2008, there were an estimated5,29,000new cases of cervical cancer, of which over85%occurred in developing countries; and around2,75,000women died of this cancer, about88%of who were from developing countries. The geographical distribution is uneven; in developing countries, it ranks2nd, with a relative frequency of15%of all cancers in women, whereas it is5th in developed countries, with a relative frequency of4.4%. A reduction in the incidence of cervical cancer has been documented over the past2decades in some countries in Europe and North America, which has been largely attributed to widespread screening and early treatment of pre-invasive lesions.While abdominal radical hysterectomy is an accepted treatment for early stage cervical cancer, it is highly invasive with visible scarring and associated morbidity. An alternative treatment is the same by laparoscopy. The first laparoscopic radical hysterectomy with pelvic and paraaortic lymphadenopathy was perfonned by Nezhat et al in1989. Since then, laparoscopic radical hysterectomy has gained acceptance as a feasible alternative to an abdominal radical hysterectomy. In studies comparing the surgical outcomes of the laparoscopic approach to hysterectomy with the abdominal approach, significantly lower intraoperative blood loss and shorter hospital stay have been constantly reported with no apparent compromise in the extent of surgical resection. Although the technical feasibility of laparoscopic radical hysterectomy in the management of early cervical cancer has been demonstrated, long term survival data on this technique are limited.ObjectivesTo evaluate and compare abdominal radical hysterectomy and laparoscopic radical hysterectomy in patients with cervical cancer, in terms of operative time, intraoperative blood loss, post operative recovery, the duration of hospital stay and cost effectiveness.To compare the changes in treatment modality and patient outcome in the prior two years (2008,2009) and the later two years (2010,2011) of the study.Materials and MethodsA retrospective study was performed on305patients who had undergone abdominal radical hysterectomy (ARH) or laparoscopic radical hysterectomy (LRH) for cervical cancer from January2008to December2011at The Third Affiliated Hospital of Zhengzhou University in Henan, China.Out of this99patients had undergone LRH and206patients had undergone ARH. The data collected included patient demographics of age, weight, stage of cervical cancer, histological characteristics of the tumor. Additionally, we collected operative outcomes including operating time, blood loss, operative complications as well as postoperative wound infections, length of hospital stay and adjuvant chemotherapy treatment.All data points were used for comparison between the2techniques to determine the feasibility of the laparoscopic technique as an alternative method to abdominal technique. Analysis was further done and all the patients were categorized into2groups. Group I comprised of patients from the year2008and2009and Group II comprised of patients from the year2010and2011. In Group I there were26patients in LRH and111patients ARH. In Group II there were73patients in LRH and95patients in ARH.The statistical analysis was done using SPSS version16.0. Associations between the variables were analyzed by two independent samples t-test or correction t-test, Wilcoxon rank sum test, Chi square test or correction chi square test. The test results were considered significant at p≤0.05.Results1. A total of99patients were found to have undergone LRH and206patients had undergone ARH, the average age being45.6versus47.2years (p=1.195). The mean age of patients in LRH was43.8in Group I and44.0in Group II (p=0.930). The mean age of patients in ARH was47.1in Group I and48.3in Group II (p=0.437)2. Average length of hospital stay was17.1days for both the procedures however it was significantly decreased in patients who did not receive post operative chemotherapy; p=0.002and p<0.001in laparoscopic and abdominal procedure respectively. The analysis of the two groups showed that there was a significant decrease in the duration of hospital stay in Group Ⅱ of LRH which was15±7.3days(p<0.001).3. The estimated blood loss was significantly reduced in LRH as compared to ARH (p<0.001). On comparing the two groups, the blood loss in Group Ⅱ LRH was lesser than that of Group Ⅰ (p=0.002).4. The mean operating time was226.5minutes for LRH and199.3minutes for ARH (p=0.003). There was no significant difference in the operating time in Group Ⅰ and Group Ⅱ of LRH (p=0.388) and ARH (p=0.201)5. The total cost of the LRH and ARH was found to be20,953.5RMB and16,814.3RMB respectively (p<0.001). The cost of LRH in Group I was18,301RMB and in Group II was21,898RMB. Although there seems to be an increase in the cost of Laparoscopic approach, it was not statistically significant (p=0.073). The cost of abdominal radical hysterectomy in Group I was15,274RMB and that of Group II was18,597RMB (p<0.001). So there was significant increment in the total cost of abdominal radical hysterectomy in the two groups.Conclusions1. Both the approaches to radical hysterectomy are feasible and effective methods in patients with cervical cancer so the minimally invasive procedure should be considered.2. The estimated blood loss in the procedure is significantly less inLRH than in ARH.3. LRH is more expensive than ARH with no difference in the hospital stay of the patient.4. The operating time for ARH is shorter than LRH.5. The duration of hospital stay was directly proportional to the post operative chemotherapy the patient received.