Laparoscopic-assisted radical vaginal hysterectomy is being performed with increasing frequency in highly selected patients. In one large series of 200 women with stages IA1 to IIB cervical cancer treated with laparoscopic lymphadenectomy followed by radical vaginal hysterectomy, the authors found a 5-year survival rate comparable to patients treated with a similar abdominal approach and a comparable rate of intraoperative complications (81).
The use of laparoscopy in cervical cancer patients is appealing because it may lead to less blood loss, improved cosmetic results, shorter duration of hospitalization, and faster recovery.
Robotic laparoscopic radial hysterectomy is a relatively new technique. Proponents argue that in highly selected patients it can decrease hospital admission time and decrease the surgical morbidity in obese patients. One study reports comparable body mass index, operative times, parametrial margin, and number of lymph nodes collected when compared to open cases. Robotic cases had significantly shorter hospital stays and blood loss, while having significantly larger incidence of postoperative bladder dysfunction. The technique is still too new to tabulate cancer outcome data (82,83).
Sentinel lymph node detection has become an integral part of the management strategy for breast cancer and melanoma and is being investigated as a diagnostic tool in multiple human malignancies, including carcinoma of the cervix. The sentinel node is a specific lymph node (or nodes) that is the first to receive drainage from a malignancy and is a primary site of nodal metastasis. In theory, the presence or absence of metastatic disease in the sentinel node should reﬂect the status of the nodal basin as a whole. Thus, a negative sentinel lymph node would allow omission of lymphadenectomy of the involved nodal basin. Sentinel lymph nodes are detected through perilesional injection of radiolabeled technicium-99 or blue dye followed by intraoperative identification of the sentinel lymph nodes utilizing handheld gamma probes or visual identification of blue-stained nodes. These techniques are primarily applicable in patients with early-stage disease and clinically negative lymph nodes, in whom lymph node status may inﬂuence the extent of the procedure or the use of adjuvant treatment.
Although data utilizing sentinel lymph node detection techniques in cervical cancer are limited, several interesting conclusions can be drawn from completed studies. Sentinel nodes can be detected in 80% to 100% of cervical cancer patients, and these rates were confirmed by both laparotomy and laparoscopy. A combination of dye and radiolabeled techniques appears to be superior for the detection of sentinel lymph nodes over either technique used alone. Test sensitivity of 65% to 87% can be expected with a 90% to 97% negative predictive value. The likelihood of detecting sentinel nodes may depend on the tumor volume, the time from injection to retrieval of the sentinel nodes, and the volume of dye or radiolabeled tracer injected. Sentinel node detection rates do not appear to be inﬂuenced by prior cold knife cone biopsy. False-negative results were reported. The role of sentinel node detection in cervix cancer is investigational; although the technique is promising, complete lymphadenectomy, when indicated, remains the standard of care (84).
Patients treated with radical hysterectomy who have intermediate or high risk factors have a 30% and 40% risk, respectively, of recurrence within 3 years (100–102).