Comparative Study Between Total Laparoscopic and Total Robotic Radical Hysterectomy for Cervical Carcinoma: Clinical Study

Discussion

Since it was first performed for gynecological malignancies in 2005, robotic surgery has rapidly gained popularity (5). Many comparative studies have examined surgical and short-term survival outcomes between robotic and laparoscopic radical hysterectomy, but there has been no large randomized study. The surgical outcomes differed among studies. A recent review article concluded that robot-assisted and total laparoscopic radical hysterectomy appear to be equally adequate and feasible (10).

The present results showed different surgical outcomes between the two groups, even though the patients' characteristics were comparable. These present results were comparable with our previous reports. At our Institute, TRRH was associated with, significantly longer operative time and significantly less blood loss. TRRH was associated with an insignificantly increased number of harvested pelvic lymph nodes, shorter length of hospital stay, and shorter time to normal residual urine after surgery. The complication rates were insignificantly different between the previous and present results. These results suggest that TRRH is a more meticulous surgery, requiring for greater surgical time (11).

A previous summary provided different results from ours. This summary reported that the TRRH group had less blood loss, shorter hospital stay, and more median harvested lymph nodes but a shorter operative time (12). The shorter operative time in robotic surgery groups differed from our results. In our study, one of the causes of the longer operative time may be the small number of cases and new surgical technique requiring training and creating a learning curve for each surgeon. The other cause, especially in the current study, was more frequent para-aortic lymphadenectomy in the TRRH group. For para-aortic lymphadenectomy in robotic surgery, location changes and re-docking are necessary, which require a longer operative time. Another study that reported a shorter operative time for TRRH was associated with less frequent para-aortic lymphadenectomy (13).

One review article reported that the amount of blood loss did not differ between TRRH and TLRH; however, it did not include all comparative studies, which leads to a bias in group comparisons (10). A previous summary of six comparison studies provided that all studies revealed less blood loss in TRRH (12). A patient's HRQOL is defined as the extent to which their usual or expected physical, emotional, and social well-being is affected by a medical condition or its treatment (14). Caixeta et al. reported that after at least 2 years, HRQOL and the mental health of the women treated for invasive cervical carcinoma were similar to those of women without malignancy (15). This finding suggests that patients need significant time to adapt to the long-term physical and psychological effects of treatment. All SF-36 scales improved except for Social Functioning in this study. This result demonstrated that the patients had some limitations while performing physical activities. Considering that all eight SF-36 scales correlated with each other, the reason was usually multifactorial and included geographical location, socioeconomic status, and treatment modalities (16, 17).

After radical hysterectomy, anxiety about lymphedema, incomplete recovery due to recent surgery and the addition of adjuvant therapy, including chemotherapy/radiation or concurrent chemoradiation, might further restrict patients' physical activities.

Postoperative changes in HRQOL measured by the EORTC QOL-C30 were similar between the two groups. The Global QOL and Pain items also improved in the TRRH group in contrast to those of the TLRH group. Despite a lack of statistical significance, these improvements might imply that TRRH is a more sophisticated and safer surgical procedure with less blood loss. All symptom scales and items, except for Nausea/Vomiting and Constipation, in both groups improved. Postoperative adjuvant chemotherapy and concurrent chemoradiation might aggravate nausea and vomiting (18).

Certain studies suggested that direct injury to the parasympathetic nerve lateral to the vaginal fornix and in the broad ligament of the uterus are responsible for postoperative constipation. Postoperative chemotherapy and radiation therapy might also aggravate constipation (19, 20).

There was no statistically significant difference in the SF-36 scale and EORTC QOL-C30 item changes after surgery between the two groups. This finding indicates that the two surgical methods had similar effects on HRQOL.

The correlation and statistical significance between SF-36 and EORTC QOL-C30 scale and item pairs strengthen the similar effect on HRQOL between the two groups. Two different HRQOL measurement tools gave similar results and their results were strongly correlated.

The limitations of this study are as follows. Firstly, it was non-randomized, unmatched and retrospective, a weak design for deriving objective facts for comparing two groups. Secondly, the postoperative 3-month HRQOL measurements are considered short-term data. Thirdly, the authors did not use a specific HRQOL measurement tool for cervical cancer such as the EORTC QOL-CX24, which requires long-term follow-up data. Therefore, this study focused on overall postoperative changes in HRQOL. However, this is one of only a few studies to compare TLRH and TRRH using surgical outcomes and HRQOL measurements.

The surgical outcomes of TRRH involved significantly less blood loss and more harvested pelvic lymph nodes but longer operative times. The short-term postoperative HRQOL outcomes of TLRH and TRRH did not differ.