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Keywords:

  • Early cervical cancer;
  • laparoscopic assisted radical vaginal hysterectomy;
  • urologic complications;
  • vaginal assisted laparoscopic radical hysterectomy

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

Please cite this paper as: 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;119:254–262.

Radical hysterectomy with pelvic lymphadenectomy is the standard surgical treatment for patients with early stage cervical cancer. The majority of radical hysterectomies are performed with the open technique. However, laparoscopic, combined laparoscopic and vaginal, and robotic-assisted approaches may also be used. Compared with the abdominal radical hysterectomy (ARH), laparoscopic techniques are associated with less blood loss, shorter hospital stay, better cosmesis, and faster recovery. A further breakthrough in laparoscopic technique can only be made if safety and oncological clearance are comparable with ARH. We describe the technique and results of laparoscopic assisted radical vaginal hysterectomy and the transition to vaginal assisted laparoscopic radical hysterectomy.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

After safe and oncologically adequate laparoscopic pelvic lymphadenectomy was demonstrated by Dargent and Querleu in 1989 and 1991,1,2 the way was open for a renaissance of Schauta’s procedure in combination with laparoscopic pelvic (with or without paraaortic) lymphadenectomy. This technique was named by French colleagues as laparoscopic assisted radical vaginal hysterectomy (LARVH).3–5 Several Anglo-American and European gynaecologic centres subsequently embarked on this innovative technique.

Almost simultaneously, total laparoscopic radical hysterectomy was described,6 and the first and only randomised comparison between radical hysterectomy and radiotherapy in early stage cervical cancer was reported by Landoni et al.7 In this study, the oncological equality of radical hysterectomy and primary (only) radiation for the treatment of patients with cervical cancer stages IB1–IIA, with different profiles of toxicity, was demonstrated. Careful patient selection of patients to one of these treatments, i.e. unimodal modality, is essential in order to avoid increased toxicity when both therapies, i.e. bimodal modality, must be used. Only surgical staging, most accurately demonstrated by laparoscopy, can provide the exact staging of disease, and helps to identify patients with early stage cervical cancer without lymph node metastases, who profit the most from radical hysterectomy alone without the need for adjuvant chemoradiation (Figure S1).8

So far various techniques for radical hysterectomy have been described: abdominal (ARH), with and without nerve sparing (e.g. total mesometrial resection, TMMR); total laparoscopic (TLRH); laparoscopic assisted vaginal (LARVH); and robotic (RRH). In conjunction with the technical details, all available publications provide prospective, retrospective, or match-paired data (with historical cohorts) to characterise each procedure. Except for one phase-II randomised study comprising only 15 patients, no large prospective randomised study exists comparing different radical hysterectomy approaches.9,10

All comparisons between open and laparoscopic-based radical operations for the treatment of women with early cervical cancer favour laparoscopy with respect to blood loss, hospital stay, recovery, and cosmetic result, and show an identical oncological outcome, if reported.11-45 LARVH and TLRH have been successfully performed in more than 2000 patients. TLRH is performed using an uterine manipulator, which makes estimation of adequate vaginal resection difficult, and can potentially lead to tumour spillage, especially when the vagina is opened and the tumour surface is exposed to circulating CO2.13–17 The first studies on RRH seemed to overcome a few limitations of conventional laparoscopy, such as two-dimensional visualisation, limited degree of instrument motion, and discomfort of surgeons, which may lead to a better acceptance of minimally invasive techniques in gynaecologic oncology.18–24 However, with the robot in place vaginal access is impossible, and problems with vaginal cuff creation are similar to those in TLRH. Moreover, the use of the robotic system is associated with increased costs. So far conflicting oncological results have been reported,25,26 and therefore RRH is still under evaluation.

Therefore, we have developed a new technique that avoids the disadvantages of TLRH and can be used in a conventional and robotic laparoscopic setting.

In accordance with LeBlanc we modified LARVH into vaginal assisted laparoscopic radical hysterectomy (VALRH), which ideally combines the advantages of vaginal and laparoscopic approaches after comprehensive staging.27

In the following section we analyse the results of LARVH and describe the rationale for the modification to VALRH, together with reporting on the operative and early oncological data collected.

Laparoscopic assisted radical vaginal hysterectomy (LARVH)

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

The LARVH technique is described in Appendix S1.

Operative results

The operative data from more than 1000 operations is available in Table 1.

Table 1.   Number of patients, conversion rate, blood loss, transfusion rate, operating time, and number of lymph nodes in patients undergoing LARVH
 PatientsStageConversionsBlood lossTransfusion rateOperating time (min)Hospital stay (days)Lymph nodes
Querleu48IA2–IIBNo300 ml24%283 513
Nezhat et al.3619IA2–IIA1× (5.2%)200 ml 315 2.122 (6 aort)
Lee et al.3724IA–IIA (using ureteral stents)No540 ml 325 8.213
Sardi et al.1256IA2–IIB9× (16%)  267 417
Renaud et al.3857IA2–IIA2× (3.5%)300 ml4%270 527 (3 aort)
Park et al.1152IB1 <3 cm2× (3.8%) 58%380 28 (22 aort)
Holub et al.395IA2 (using ultracision)No     
Hertel et al.28200IA1 L1–IV1× (0.5%) 19.2%3331422 (8 aort)
Steed et al.3071IA1–IB2No300 ml7%210  
Nam et al.3184IA1–IB1 < 2 cm [DOWNWARDS ARROW]Hb 0.017 g/ml 23210–1526
Jackson et al.4057IA2–IB25× (8.7%)350 ml16%180 515
Sharma et al.4127only IB1 479 ml5.8%160 524
Morgan et al.4230IA–IB2× (6.7%) 16.7%187 5.915
Marchiole et al.43139I–IIA  17.3%187 –17
Mehra et al.4453≤IB1No  210 523
Pahisa et al.2967IA2–IIABlood loss + transfusion rate sign. lower than abd. rad. HE260 515
Naik et al.107IB1 <2 cm400 180 5 
Lee et al.32139IA2–IIA 666 ml44%231 –16
 Σ = 1095 different stages 

The conversion rate of planned LARVH varies between 0 and 16%. Despite significantly lower blood loss compared with abdominal radical hysterectomy, transfusion rates are still considerable (Table 1).

The appropriate number of lymph nodes to harvest is between 13 and 28. However, the average operation time for LARVH is still relatively long (Table 2).

Table 2.   Complications associated with the LARVH procedure, and oncological results after LARVH
  Complication rate (%)Intraoperative complications (%)Postoperative complications (%)Urologic complicationsFollow-up (months)Recurrences (%) 
Querleu41993    2412 
Nezhat et al.361993    100 
Lee et al.371997      
Sardi et al.1219998.5  1x ureter, 1x hydronephrosis 477.1OS IA1 100%, IB1 88%
Renaud et al.382000  7103x bladder (5%) 36 4 
Park et al.1120027.7  2x ureter injury, 2x ureter stenosis 3.8 
Holub et al.392003       
Hertel et al.2820036 8 Intraop.: bladder 7%, ureter 3,5% postop.: fistula 1%, stenosis 3,5% 40 5 year-OS 83%, IB1 98%
Steed et al.30200413  7x bladder, 1x ureter injury, 2x ureteral fistula  5 year-DFS 94%
Nam et al.312004 21.625.51x bladder, 1x ureter stenosis, 1x ureter fistula 348.53 year-DFS 97% (<2 cm)
Jackson et al.4020048  3x bladder (6%) 52 OS 94%
Sharma et al.41200622  4x urinary tract (15%) 347.4 
Morgan et al.42200713  Fistula (6,7%) 316.7(equal to abd. rad. hyst)
Marchiole et al.4320075.819.4 2x bladder, 3x ureter, 4x fistula1133.5OS 95%
Mehra et al.442010   No fistula, no bladder or ureter injury, 12% persistent voiding problems 417.5OS 89%
Pahisa et al.29201014.9 7.5 7.56% bladder or ureter injury intraop. 5.9DSF 94%, OS 97%
Lee et al.322010  615(mainly urologic) 92 DSF 91%, OS 93%

A number of possible intra- and postoperative complications can be encountered in LARVH (Tables 2 and S2).22 The rate of intra- and postoperative urologic complications is quite high.

Oncological results

The results available clearly demonstrate oncological equality with open radical hysterectomy, especially in tumours ≤ 4 cm in diameter (Table 2).1

Learning curve

Intraoperative complication rates and operation time for LARVH depend mainly on the skill and experience of the gynaecological oncologist. Hertel et al. could demonstrate a significant reduction of complications after 100 operations,28 whereas Pahisa et al. and Sardi et al. see 20 operations as being sufficient to become familiar with this technique.12,29 The learning curve for the vaginal part has not been analysed separately, but in our own experience approximately 50 procedures are necessary in order to master the transvaginal aspect of the operation.

Rationale for modification

Even though LARVH is associated with an acceptable oncological outcome, compared with ARH and TLRH the rate of intra- and postoperative problems, especially urological complications, is considerable.28–32 Moreover, the key part of this operation, the vaginal part (Figure S2–S6), is difficult to teach.33 Therefore, the reasons for modifying LARVH (Table S1, Figure S7) into VALRH are:

  •  comprehensive laparoscopic staging is mandatory to select appropriate patients for radical hysterectomy;
  •  the creation of a vaginal cuff and oncological clearance margins are more easily achieved using the vaginal approach;
  •  there is no need for any uterine manipulation throughout the surgery;
  •  the rate of urologic complications must be diminished;
  •  the new technique should be easy to learn by fellows and residents.

Vaginal assisted laparoscopic radical hysterectomy (VALRH)

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

Technique

The VALRH procedure consists of three stages.

  • 1
     Laparoscopic staging, including lymphadenectomy, to evaluate lymph node status, and dissection of vesicocervical and vesicovaginal septum to evaluate the relationship between the tumour and adjacent organs.
  • 2
     Creation of a tumour-adapted vaginal cuff.
  • 3
     Laparoscopic radical hysterectomy.

For laparoscopic staging, the positioning of patient and trocar placement are identical to that in LARVH. Depending on the tumour size, pelvic (with or without paraaortic) lymphadenectomy is performed, as previously described.2,8 During pelvic lymphadenectomy paravesical and pararectal spaces are opened. All lymph nodes removed are sent for frozen section. While waiting for the frozen section results, dissection of the bladder up to the level of the ventral vaginal wall is performed. In the occurence of lymph node metastasis radical hysterectomy is abandoned and patients are referred for primary chemoradiation. If the frozen section reveals tumour-free lymph nodes, the patient is placed in the lithotomy position, with legs extended, for the vaginal stage of the procedure.

The only aim of the vaginal part is to create a tumour-adapted cuff and to open vesicovaginal and rectovaginal spaces. In relation to tumour size, an adequate length of vagina is grasped with six straight clamps (Figure S8).

A diluted solution of epinephrine is injected under the vaginal mucosa for vasoconstriction, followed by a monopolar incision distally to the clamps. The vaginal cuff is now closed with a continuous suture (Figure S9), and thus the tumour is always covered to prevent spillage of cancer cells.

With six serrated clamps, tension is brought upon the closed vaginal cuff in order to open the vesicocervical and rectovaginal space, as well as the cul-de-sac. The most inferior part of the rectovaginal ligament is now transected bilaterally, and the uterus can be pushed intra-abdominally after the removal of the serrated clamps (Figure S10).

The vaginal stump is continuously sutured for haemostasis. Additionally, interrupted sutures are placed, but not knotted, for the later closure of the vagina (Figure S11). To preserve the pneumoperitoneum, a surgical towel is placed into the vagina.

For the third part of VALRH the patient is placed again in the Trendelenburg position, with straight, slightly abducted legs. The parametrium is now resected. As a result of the vaginal route both bladder pillars and the transacted vagina are easy to identify (Figure S12). The operation begins by coagulation and transection of the uterine vessels at their origin, from the iliac internal vessels (Figure S13).

In the case of salpingoophorectomy, the infundibulopelvic ligaments are coagulated and cut. By retracting the vascular part of the cardinal ligament medially, the ureter is freed from its tunnel up to it’s entry into the bladder. Now the remaining part of the paracervix is identified, coagulated, and transected under permanent visualisation of the ureter (Figure S14). Plexus pelvicus as well as nervi splanchnici and hypogastrici are separated and preserved.

The suture of the vaginal cuff is easy to identify and marks the endpoint of resection. The specimen is removed transvaginally and the vagina is now closed using the preplaced interrupted sutures (Figure S15). Finally haemostasis is verified, and a suprapubic catheter and two drains are placed. The extent of parametrial resection in correlation to tumour size according to a type-II (B) or type-III (C) radical hysterectomy is chosen by the surgeon intraoperatively. No uterine manipulator is used at any time.

Operative results

Between January 2007 and December 2009 122 patients underwent VALRH at the Department of Gynaecology at Charité– Universitätsmedizin Berlin, at both Benjamin Franklin and Mitte campuses. Indications for VALRH were histologically proven cervical cancer (n = 110) or endometroid endometrial cancer (n = 12). One patient requested to undergo a radical hysterectomy type B in the case of an extensive cervical intraepithelial neoplasia (CIN) III lesion that had not been completely resected by conisation (Table 3).

Table 3.   Data on patient characteristics, operative data, and postoperative histologic results
Number of women122
Age (years)47 (27–82)
BMI (kg/m2)24.9 (17.3–46.3)
Parity2 (0–6)
Histology
Adenocarcinoma cervix40 (32.8%)
Squamous cell carcinoma cervix67 (54.9%)
Neuroendocrine cervical carcinoma2 (1.7%)
CIN III1 (0.8%)
Endometrial cancer (diagnosed by D&C)12 (9.8%)
VALRHn = 122
VALRH type II (B)n = 82
VALRH type III (C)n = 40
Operation time (min)301 (175–655)
Blood loss in ml123 (10–400)
Median nodal yield (nodes)36 (4–83)
Pelvic21 (4–43)
Paraaortic15 (2–36)
Median time to urine residuals < 50 ml (days)7.9 (2–40)
Median hospital stay (range)10.4 (4–31)
Blood transfusions3 (not surgically related)
Intraoperative complications0
Postoperative complications16 (13.1%)
4 re-laparoscopies
 2× for suspected ileus
 1× for lost drainage
 1× for chylaskos
2 pulmonary embolism in CT scan (without clinical evidence)
3 ureterovaginal fistula
1 vaginal suture dehiscence
1 cardiomyopathy
1 symptomatic lymphocele
4 fever
 2× unknown reason
 1× colitis ulcerosa
 1× UTI (E. coli)
Cervical cancer n = 110No (%)
Postoperative stage
CIN III1 (0.9)
IA1 L110 (9.1)
IA25 (4.5)
1B183 (75.5)
ypT1B12 (1.8)
1B22 (1.8)
IIA1 (0.9)
IIB6 (5.5)
Grading
114 (12.7)
261 (55.5)
327 (24.5)
Unknown8 (7.3)
Histologic type
CIN III1 (0.9)
Adenocarcinoma40 (36.4)
Squamous cell carcinoma67 (60.9)
Neuro-endocrin carcinoma2 (1.8)
Lymphangiosis (L)
No85 (77.3)
Yes25 (22.7)
Haemangiosis (V)
No103 (93.6)
Yes7 (6.4)
Endometrial cancer n = 12No (%)
Postoperative stage (new FIGO system)
1A9 (75)
1B1 (8.3)
2B2 (16.7)
Grading
14 (33,3)
28 (66,7)
30 (0)
Lymphangiosis
No11 (91.7)
Yes1 (8.3)
Haemangiosis
No12 (100)
Yes0 (0)

All 122 patients underwent VALRH without conversion to laparotomy. Type-II (B) and type-III (C) operations were performed in 82 and 40 patients, respectively. VALRH was combined with pelvic lymphadenectomy in 37 patients, and with pelvic and paraaortic lymphadenectomy in 85 patients. The mean operating time was 301 minutes. The operation time was nearly identical for type-B and -C procedures. The duration of surgery differed significantly for two patients: one with infiltrative sigmoid endometriosis, who had to undergo bowel resection simultaneously (operating time 665 minutes); and one patient with a body mass index (BMI) of 46 (605 minutes).

The median number of lymph nodes harvested was 36 (4–83), with 21 (4–43) pelvic and 15 (2–36) paraaortic lymph nodes. One patient (cervical cancer pT1a2 N0 L0 V0 R0) opted for sentinel lymph node dissection only, and four sentinel lymph nodes were removed, which were tumour free upon histology (Table 3).

There was not a single intraoperative complication, in particular there was neither bladder nor ureter injury. The mean blood loss was 123 ml (10–400 ml). One patient required blood transfusion because of stress-induced cardiomyopathy, and on the anaesthesiologists’ advice two patients required blood transfusion because of preoperative anaemia. The postoperative complication rate was 13.1% (Table 3).

No patients required a referral to a urogynaecologist for postoperative bladder dysfunction, and only one patient needed longer than 25 days to void her bladder adequately. The median time to urine residuals of < 50 ml was 7.9 days. Four patients had to undergo re-laparoscopy: one because of lost drainage; two for suspected ileus (that could not be verified intraoperatively), and one for chyloperitoneum. Between 10 and 40 days postoperatively, three patients developed a ureterovaginal fistula, which was treated with ureteral stents without complication.

Histologically clear margins were obtained in parametrial and vaginal resection for all patients. In all patients with endometrial cancer, tumour involvement of the cervical stroma was diagnosed through dilation and curettage, but was confirmed postoperatively in only two patients. Cervical cancer was diagnosed preoperatively by biopsy or conisation in 109 patients. One patient with extensive CIN III and non in sano conisation insisted on radical hysterectomy in order to get the highest possible oncological safety. The majority of patients were found to have FIGO stage IB1 (75.5%). In six patients (5.5%) the final pathology revealed parametrial involvement. Histological types were distributed as follows: squamous cell carcinoma 60.9%, adenocarcinoma 36.4%, and neuroendocrine carcinoma 1.8% (Table 3).

Two patients underwent VALRH after neoadjuvant chemotherapy. Five of 110 (4.5%) patients with cervical cancer had positive micrometastases/metastases in the final histopathological examination, which had been undetected in the frozen section.

Oncological results

Postoperative adjuvant therapy (radiation, chemotherapy, or chemoradiation) was recommended for 30/122 patients (24.6%): eight as a result of endometrial cancer and 22 as a result of cervical cancer. A recommendation for adjuvant chemoradiation or chemotherapy was given for cervical cancer patients with proven high risk factors (N1, M1, or stage IIB), or with a combination of two intermediate risk factors [tumour size > 4 cm, lymphovascular space invasion (LVSI), adenocarcinoma, G3, and deep stromal invasion]. In two out of 22 patients a neuroendocrine tumour was found, which was treated according to a multimodal protocol. The final histological results revealed stage-IIB in six patients and lymph node positivity in four patients, and therefore indicated the need for adjuvant chemoradiation. Other reasons for chemoradiation were the combination of L1 and V1 in three patients, stage-IIA and G3 in one patient, G3 and L1 in one patient, and L1 in an adenocarcinoma in a another young patient.

Only one patient (0.9%) underwent vaginal brachytherapy based on the surgical result (close vaginal margin of 5 mm). Individualised protocols were performed in two patients: one patient with cervical cancer stage IB2 was treated by neoadjuvant chemotherapy, VALRH, and postoperative chemoradiation; another patient received brachytherapy for a grading of 3. In one patient with ovarian metastasis, six cycles of platin-based chemotherapy were administered. Two patients refused the recommended chemoradiation.

After a median follow-up of 19 months (4–40 months) the total recurrence rate in the entire cohort is 6.7% (8/120), for cervical cancer patients 6.4% (7/110), and for endometrial cancer 8.3% (1/12), respectively. The disease-free survival (DFS) and overall survival (OS) rates for all 110 cervical cancer patients are 93.5 and 98.1%, and for the subgroup of patients (n = 90) with tumours ≤ pT1B1 N0 V0 L0/1 R0 are 96.7 and 97.8%, respectively.

Learning curve

The learning curve was not separately analysed, because VALRH had to be standardised for 25 operations, and one side of the lymphadenectomy and parametrial resection was performed by another resident or fellow. However, from 2007 to 2009 the operating time decreased for VALRH types-II and –III, from 317 to 268 minutes and from 345 to 303 minutes, respectively.

Discussion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

Various techniques of radical hysterectomy have been described: abdominal, laparoscopic-assisted vaginal, total laparoscopic, robotic assisted, and vaginal-assisted laparoscopic. LARVH was the first innovative technique in this field. Benefits of LARVH compared with abdominal radical hysterectomy include less blood loss, lower postoperative morbidity, shorter hospital stay, better cosmetic result, and earlier recovery.

Three main criteria are used to evaluate and compare different techniques of radical hysterectomy: (1) the possibility of triaging patients and therefore avoiding the combined use of surgery and chemoradiation; (2) complication rates; and (3) oncological outcomes. Comprehensive operative staging, including pelvic lymphadenectomy, with or without paraaortic lymphadenectomy, is the key step to differentiating between patients who would benefit from radical surgery and those who are better treated by primary chemoradiation.7 TLRH, RRH, LARVH, and VALRH offer the possibility to start with lymph node dissection (with or without the sentinel node) and frozen section. We have abandoned radical hysterectomy in the case of positive lymph nodes. However, the frozen section was not accurate in four out of 110 (3.6%) patients with cervical cancer in our VALRH series. Bader et al.34 reported a false-negative rate for frozen sections of up to 17%.

Most published retrospective or prospective studies on radical hysterectomy include cervical cancer patients with stages IA1 L1–IIA(B), and only a few higher stages. This is in concordance with our study population undergoing VALRH. Conversion rates are described in up to 5, 10, and 16% for RRH, TLRH, and LARVH, respectively. None of our planned VALRH procedures had to be converted to an open approach. ARH, LARVH, and our new technique of VALRH are performed without any manipulator, so as to create an adequate vaginal cuff, whereas all TLRH and RRH require a manipulator or sponge in the vagina. In our opinion the creation of the vaginal cuff by a transvaginal approach is easier, and the possible tumour seeding resulting from manipulator use is avoided. With the described technique of VALRH, we are able to resect the tumour with sound vaginal margins, in contrast to studies of ARH, TLRH, and RRH, where up to 20% of vaginal margins are reported to be involved.24

Blood loss in VALRH is low compared with ARH and LARVH, and is in the lower range of TLRH and RRH. Therefore blood transfusion was only required for three patients, where the cause was not intraoperative blood loss. The operation time of 301 min in our VALRH series is in the range of LARVH, but is longer than the average time for ARH, TLRH, and RRH, and is therefore still a major argument against combined vaginal and laparoscopic techniques. However, one must consider that in addition to VALRH 85 out of 122 (69%) of our patients also underwent paraaortic lymph node dissection, with a duration of approximately 60 min. The majority of radical hysterectomies in the literature are exclusively combined with pelvic lymph node dissection. Subsequently the mean number of harvested lymph nodes (n = 36) in our VALRH cohort is in the upper range of all described studies, and is higher than in studies using open surgery.

The rate of operative complications is a major issue for evaluating different types of radical hysterectomy. Intraoperative complications occur in 4–12.5, 0–11.8, 5.9–13.2, and 0–14% in ARH, TLRH, LARVH, and RRH, respectively. No intraoperative complications were reported in our study. The postoperative complication rate after VALRH (13.1%) is in the lower range of published data. Both intraoperative and postoperative urological complications are significantly lower, compared with LARVH or TLRH,28 probably as a result of modifying the vaginal part of the operation.

Oncological data are difficult to compare because of different follow-up intervals and various oncological cornerstones. Summarising data from open, laparoscopic, laparoscopic–vaginal, and robotic series recurrence rates vary between of 0 and 13%, DFS varies between 82 and 100%, and OS varies between 89 and 100%. Despite a relatively short follow-up of 19 months, our DFS rate of 94% and OS rate of 98% for VALRH are promising. However, a longer follow up is mandatory to confirm this observation.

In conclusion, our new technique of VALRH is an oncologically valid alternative to ARH, LARVH, TLRH, and RRH in patients with cervical cancer < IB2. It offers low blood loss and few intraoperative complications. During the vaginal part of the operation it is always possible to create an adequate vaginal cuff to avoid tumour spillage, and the use of any manipulators should be disregarded. LARVH should be superseded by VALRH because it introduces fewer urological complications, and is an easily reproducible technique. The only argument for a gynaecological oncologist to continue with LARVH is to gain familiarity with the vaginal part, in order to perform radical vaginal trachelectomy.35 Further studies comparing the VALRH technique with other types of radical hysterectomies are necessary to underline the promising results of our mono-institutional series.

Contribution to authorship

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

The first two authors contributed equally to the article. CHK made a substantial contribution to the conception and design of the surgical technique, to the acquisition, analysis and interpretation of data, and to the drafting of the article. EG made a substantial contribution to the acquisition, analysis, and interpretation of data, and the final approval of the version to be published. VCH and KH made substantial contributions to the conception and design of the surgical technique, and to the acquisition of data. SM has substantially contributed to the neoadjuvant and postoperative adjuvant therapy (radiation, chemotherapy, and chemoradiation), as well as to the follow-up and revising the article critically for important intellectual content. AS has substantially contributed to the conception and design of the surgical technique, to the acquisition of data and revising the article critically for important intellectual content.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information
  • 1
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  • 2
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  • 3
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Supporting Information

  1. Top of page
  2. Abstract
  3. Introduction
  4. Laparoscopic assisted radical vaginal hysterectomy (LARVH)
  5. Vaginal assisted laparoscopic radical hysterectomy (VALRH)
  6. Discussion
  7. Disclosure of interests
  8. Contribution to authorship
  9. Details of ethics approval
  10. Funding
  11. Acknowledgement
  12. References
  13. Supporting Information

Figure S1. Flowchart for staging and surgical options for patients with early stage cervical cancer.

Figure S2. Creation of tumour-adapted vaginal cuff.

Figure S3. The left bladder pillar, limited by the paravesical space laterally and the vesicocervical space medially.

Figure S4. Identification of the right ureter by the click manoeuvere.

Figure S5. Isolation of the left ureter.

Figure S6. Doederlein manoeuvere.

Figure S7. Specimen after LARVH.

Figure S8. Creation of vaginal cuff.

Figure S9. Closure of the vaginal cuff with a continuous suture.

Figure S10. Transsection of distal rectovaginal ligament after opening of cul-de-sac.

Figure S11. Vaginal margin is covered by a continuous suture.

Figure S12. Laparoscopic situs after vaginal part.

Figure S13. Transsection of uterine vessels and bladder pillar.

Figure S14. Intraoperative situs of parametrial resection type II (continuous line) and type III (interrupted line).

Figure S15. Postoperative specimen after type-II procedure.

Table S1. Technique of LARVH step by step.38

Table S2. Spectrum of possible perioperative complications in LARVH.

Appendix S1. Technique of LARVH.

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BJO_3202_sm_AppendixS1.pdf32KSupporting info item
BJO_3202_sm_FigureS1.pdf111KSupporting info item
BJO_3202_sm_FigureS10.pdf116KSupporting info item
BJO_3202_sm_FigureS11.pdf121KSupporting info item
BJO_3202_sm_FigureS12.pdf154KSupporting info item
BJO_3202_sm_FigureS13.pdf130KSupporting info item
BJO_3202_sm_FigureS14.pdf118KSupporting info item
BJO_3202_sm_FigureS15.pdf138KSupporting info item
BJO_3202_sm_FigureS2.pdf116KSupporting info item
BJO_3202_sm_FigureS3.pdf113KSupporting info item
BJO_3202_sm_FigureS4.pdf105KSupporting info item
BJO_3202_sm_FigureS5.pdf66KSupporting info item
BJO_3202_sm_FigureS6.pdf92KSupporting info item
BJO_3202_sm_FigureS7.pdf147KSupporting info item
BJO_3202_sm_FigureS8.pdf117KSupporting info item
BJO_3202_sm_FigureS9.pdf115KSupporting info item
BJO_3202_sm_SupportingInformationLegends.docx15KSupporting info item
BJO_3202_sm_TableS1.pdf18KSupporting info item
BJO_3202_sm_TableS2.pdf18KSupporting info item

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