Abstract
Aim: to compare surgical outcomes and health-related quality of life (HRQOL) between total laparoscopic (TLRH) and total robotic radical hysterectomy (TRRH) for cervical cancer. Patients and Methods: Surgical outcomes and HRQOL were compared between the two groups. Pre- and postoperative HRQOL data from 36-item Short Form (SF-36) and European Organization Research and Treatment of Cancer Quality of Life-C30(EORTC QOL-C30) questionnaires were recorded. Results: In the TRRH group, there were more cases of para-aortic lymphadenectomy (p<0.01), longer operative time (p<0.01), less estimated blood loss (p<0.01), and more harvested pelvic lymph nodes (p=0.04). There were no significant differences in the SF-36 and the EORTC QOL-C30 between the two groups. Conclusion: TRRH surgical outcomes were associated with less blood loss and more harvested pelvic lymph nodes but longer operative times with statistical significance. The short-term postoperative HRQOL outcomes did not show any significant inter-group differences.
The first laparotomy for uterine leiomyoma was performed by McDowel in 1809. In 1895, Clerk performed radical hysterectomy in patients with cervical cancer. Transvaginal hysterectomy was performed by Schauta in 1901. In 1921, Okabayashi reported radical abdominal hysterectomy for cervical cancer (1). Regional lymphadenectomy and radical hysterectomy were performed in 1951 by Meigs (2). Dargent conducted minimal-invasive surgery for cervical cancer in 1987 by combining laparoscopic lymphadenectomy with Schauta's technique (3). In 1992, Nezhat et al. reported radical hysterectomy and pelvic lymphadenectomy in patients with cervical cancer that was performed only with laparoscopic surgery (4). Robotic surgery is currently being widely applied. For gynecological diseases, in 2005, Marchal et al. performed robot-assisted surgery in patients with endometrial adenocarcinoma and cervical cancer (5). In 2008, Boggess et al. published a study comparing robot-assisted radical hysterectomy with open radical hysterectomy (6).
Other than basic data on morbidity, mortality and survival, health-related quality of life (HRQOL) is generally accepted as an additional outcome parameter in patients undergoing oncological surgery, and interest in postoperative patient's HRQOL is increasing.
Robotic radical hysterectomy has been performed gradually over time, and many studies have compared surgical outcomes in various types of surgeries such as open laparotomic, total laparoscopic (TLRH), laparoscopy-assisted, total robotic (TRRH), and robot-assisted radical hysterectomy. This study aimed to compare surgical outcomes and effects on HRQOL for patients who had undergone TLRH and TRRH for cervical cancer.
Patients and Methods
We retrospectively reviewed 98 patients who had undergone TLRH or TRRH for cervical cancer between January 2010 and June 2014 at the Kyungpook National University Medical Center, Daegu, Korea (Figure 1). Of those patients, 35 were excluded for not completing both pre- and postoperative 36-item Short Form (SF-36) questionnaires or European Organization Research and Treatment of Cancer Quality of Life-C30 (EORTC QOL-C30) questionnaires (7-9). The patients were divided into TLRH (n=34) and TRRH (n=29) groups.
Data were collected to compare surgical and HRQOL outcomes. Patient characteristics, including age, body mass index, FIGO stage, neoadjuvant treatment, adjuvant treatment, radiation and paraaortic lymphadenectomy, operative time, estimated blood loss, number of harvested pelvic lymph node, hospital stay, time to normal residual urine volume, complications, and postoperative procedures, were reviewed. The pre- and postoperative HRQOL data from the SF-36 and EORTC QOL-C30 questionnaires were recorded. SF-36 and EORTC QOL-C30 data were available for 63 patients. Each patient's HRQOL was assessed preoperatively; at 3, 6, 9, and 12 months postoperatively; and annually until 3 years after the surgery. In this study, pre- and postoperative 3-month short-term HRQOL were used.
Upper panel: Left inferior hypogastric artery (A), left uterine artery (B), left ureter (C), and inferior hypogastric (pelvic) plexus (D) during surgery with the Da Vinci Robot surgical system. Lower panel: The same anatomy after laparoscopic radical hysterectomy.
Statistical analyses were performed using SPSS statistics version 20 (IBM Corp., Armonk, NY, USA). Patient characteristics, including surgical outcomes, were compared between the TLRH and TRRH groups using paired t-test and χ2 test. The postoperative changes in SF-36 scale and EORTC QOL-30 scores were compared between the two groups using paired t-test. Spearman's correlation analysis was used to examine the correlation between SF-36 and EORTC QOL C-30 scores. Values of p<0.05 were considered statistically significant. Kyungpook National University Medical Center does not require Institutional Review Board approval for retrospective chart reviews. Therefore, this analysis was exempt from the approval process.
Results
In the TLRH group, there were significantly fewer cases of para-aortic lymphadenectomy (p<0.01), shorter operative time (p<0.01), more estimated blood loss (p<0.01), and fewer harvested pelvic lymph nodes (p=0.04). There were no significant intergroup differences in age, body mass index, stage, cases of neoadjuvant, adjuvant treatment and radiation, hospital stay, time to normal residual volume, complication rate, and postoperative procedures performed for the complications (Table I).
Patients' characteristics and surgical outcomes according to group.
Overall, all of the SF-36 scale scores improved after surgery except for Physical Functioning, which decreased. This trend occurred for both groups. General Health (p<0.01), Vitality (p<0.01), Social Functioning (p<0.01), Mental Health (p<0.01), and Mental Component Summary (p<0.01) showed statistically significant improvements. In the TLRH group, all SF-36 scale scores improved except for Physical Functioning. General Health (p<0.01), Vitality (p<0.01), Social Functioning (p=0.02), Role-Emotional (p<0.01), Mental Health (p=0.01) and Mental Component Summary (p<0.01) showed statistically significant improvement. In the TRRH group, SF-36 scales showed improvement, except for Physical Functioning and Role-Emotional. Vitality (p=0.01), Mental Health (p<0.01), and Mental Component Summary (p=0.02) showed statistically significant improvements (Table II). There was no significant difference in any of the SF-36 scale score changes between the two groups (Table III).
Overall, all the EORTC QOL-C30 functional and symptom scales and items improved after surgery except for Global QOL status, Nausea/Vomiting, Pain and Constipation, which worsened after surgery. The Role (p=0.01), Emotional (p<0.01), Cognitive (p<0.01), and Social (p<0.01) Functioning scales, as well as Fatigue (p<0.01), Sleep Disturbance (p=0.01), Diarrhea (p<0.01), and Financial Problems (p<0.01) items showed statistically significant improvement. In the TLRH group, all scales and items showed improvement except for Global QOL status, Nausea/Vomiting, Pain and Constipation. The Emotional (p<0.01), Cognitive (p=0.01), and Social (p=0.03) Functioning scales as well as the Fatigue (p<0.01), Diarrhea (p=0.01), and Financial Problems (p<0.01) items showed statistically significant improvement. In the TRRH group, all scales/items showed improvement except for Global QOL status and Nausea/Vomiting and Constipation. The Role (p=0.02), Emotional (p<0.01), Cognitive (p<0.01), and Social (p<0.01) Functioning scales, as well as the Fatigue (p<0.01), Diarrhea (p=0.03), and Financial Problems (p=0.04) items showed statistically significant improvements (Table IV). There was no significant difference in any of the functional and symptom scale and item changes of the EORTC QOL-C30 between the two groups (Table V).
There were strong correlations with statistical significances between SF-36 and EORTC QOL-C30 factor pairs measuring similar dimensions such as physical, role, and pain scales. Some pairs including emotional, social, and general or global health scales did not show strong correlations but these were statistically significant (Table VI).
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).
Health-related quality of life scores measured using the Short Form-36 (SF-36).
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).
Comparison of changes in Short Form-36 (SF-36) score between groups.
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.
Health-related quality of life measured using the European Organization Research and Treatment of Cancer Quality of Life-C30 (EORTC QOL-C30) questionnaire.
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.
Comparison of changes in European Organization Research and Treatment of Cancer Quality of Life-C30 (EORTC QOL-C30) score between groups.
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.
Correlation between European Organization Research and Treatment of Cancer Quality of Life-C30 (EORTC QOL-C30) EORTC QOL-C30 and Short Form-36 (SF-36) scales.
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.
Footnotes
Conflicts of Interest
There are no conflicts of interest with regard to this study.
- Received April 27, 2015.
- Revision received May 31, 2015.
- Accepted June 4, 2015.
- Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved