Vaginal hysterectomy using the ERBE BiClamp® bipolar vessel sealing system as a surgical approach for endometrial cancer—single surgeon experience from a district general hospital

Uterine cancer is the most common gynaecological malignancy with increasing incidence due to rising ageing, increasing obesity within the population and falling rates of hysterectomy for benign disease. European and British guidelines advocate a minimally invasive surgery (MIS) even in patients with high-risk endometrial cancer (EC). The standard surgical procedure is total hysterectomy with bilateral salpingo-oophorectomy. Our study examines vaginal hysterectomy (VH) performed using the ERBE BiClamp® bipolar vessel sealing system as a surgical approach for EC following studies demonstrating its safety in VH for benign disease. Retrospective review of a single surgeons practice of patients booked for VH as the surgical treatment of EC (2011–2019). Patients’ electronic records and paper charts were reviewed. Primary outcome was oncological safety and secondary outcomes were intra-operative blood loss, complications encountered, and length of hospital stay (LOS). The comparison group where previously studied patients undergoing BiClamp® VH by the same surgeon for benign/pre-malignant conditions. A total of 127 patients were included (median age 64 years, median BMI 32 kg/m2). Mean Hb drop was 9.3 g/L. 50.4% of patients were discharged on the 1st post-operative day and 82.7% by day 2. A total of 35 patients received adjuvant treatment. There were 2 cases of vault recurrence and 2 patients died from disease progression. Overall, 5 year survival was 92.9% with the majority of deaths dues to cardiac causes or a separate malignancy. The rate of disease progression was 3.1%. This study suggests that BiClamp® VH is an oncologically safe procedure and could be considered as an alternative MIS approach in the cohort of patients who are not suitable for laparoscopic or robot-assisted staging surgery. The technique affords a short operative time, minimal bloods loss, short LOS with acceptable surgical outcomes and similar oncologic outcomes to other surgical approaches.

Endometrial cancer; Vaginal hysterectomy; BiClamp®

[1] Crosbie E, Morrison J. The emerging epidemic of endometrial cancer: time to take action. Cochrane Database of Systematic Reviews. 2014; ED000095.

[2] Parazzini F, Ricci E, Bulfoni G, Cipriani S, Chiaffarino F, Malvezzi M, et al. Hysterectomy rates for benign conditions are declining in Lombardy, Italy: 1996–2010. European Journal of Obstetrics, Gynecology, and Reproductive Biology. 2014; 178: 107–113.

[3] Cancer-Research UK. Uterine Cancer Statistics. 2022. Available at: https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/uterine-cancer (Accessed: 16 May 2022).

[4] Cancer-Registry NI. Uterine Cancer Statistics. 2022. Available at: https://www.qub.ac.uk/research-centres/nicr/CancerInformation/official-statistics/BySite/Uterinecancer/ (Accessed: 16 May 2022).

[5] Kurnit KC, Ward KK, McHale MT, Saenz CC, Plaxe SC. Increased prevalence of comorbid conditions in women with uterine cancer. Gynecologic Oncology. 2015; 138: 731–734.

[6] Morrison J, Balega J, Buckley L, Clamp A, Crosbie E, Drew Y, et al. British Gynaecological Cancer Society (BGCS) uterine cancer guide-lines: recommendations for practice. European Journal of Obstetrics, Gynecology and Reproductive Biology. 2022; 270: 50–89.

[7] Concin N, Matias-Guiu X, Vergote I, Cibula D, Mirza MR, Marnitz S, et al. ESGO/ESTRO/ESP guidelines for the management of patients with endometrial carcinoma. International Journal of Gynecological Cancer. 2021; 31: 12–39.

[8] Janda M, Gebski V, Davies LC, Forder P, Brand A, Hogg R, et al. Effect of total laparoscopic hysterectomy vs total abdominal hysterectomy on disease-free survival among women with stage I endometrial cancer: a randomized clinical trial. JAMA. 2017; 317: 1224–1233.

[9] Galaal K, Donkers H, Bryant A, Lopes AD. Laparoscopy versus laparotomy for the management of early stage endometrial cancer. Cochrane Database of Systematic Reviews. 2018; 10: CD006655.

[10] Massi G, Savino L, Susini T. Vaginal hysterectomy versus abdominal hysterectomy for the treatment of stage I endometrial adenocarcinoma. American Journal of Obstetrics and Gynecology. 1996; 174: 1320–1326.

[11] Chan JK, Lin YG, Monk BJ, Tewari K, Bloss JD, Berman ML. Vaginal hysterectomy as primary treatment of endometrial cancer in medically compromised women. Obstetrics and Gynecology. 2001; 97: 707–711.

[12] Susini T, Massi G, Amunni G, Carriero C, Marchionni M, Taddei G, et al. Vaginal hysterectomy and abdominal hysterectomy for treatment of endometrial cancer in the elderly. Gynecologic Oncology. 2005; 96: 362–367.

[13] Occelli B, Samouelian V, Narducci F, Leblanc E, Querleu D. The choice of approach in the surgical management of endometrial carcinoma: a retrospective serie of 155 cases. Bulletin du Cancer. 2003; 90: 347–355.

[14] Moscarini M, Ricciardi E, Quarto A, Maniglio P, Caserta D. Vaginal treatment of endometrial cancer: role in the elderly. World Journal of Surgical Oncology. 2011; 9: 74.

[15] Beck TL, Morse CB, Gray HJ, Goff BA, Urban RR, Liao JB. Route of hysterectomy and surgical outcomes from a statewide gynecologic oncology population: is there a role for vaginal hysterectomy? American Journal of Obstetrics and Gynecology. 2016; 214: 348.e1–348.e9.

[16] Nitschmann C, Multinu F, Bakkum-Gamez J, Langstraat C, Occhino J, Weaver A, et al. Vaginal vs. robotic hysterectomy for patients with endometrial cancer: a comparison of outcomes and cost of care. Gynecologic Oncology. 2017; 145: 555–561.

[17] Gauthier T, Huet S, Marcelli M, Lamblin G, Chêne G; French College of Obstetrics and Gyneacology (CNGOF). Hysterectomy for benign gynaecological disease: Surgical approach, vaginal suture method and morcellation: guidelines. Journal of Gynecology Obstetrics and Human Reproduction. 2015; 44: 1168–1182.

[18] American College of Obstetricians and Gynecologists. Committee Opinion No 701: Choosing the route of hysterectomy for benign disease. Obstetrics and Gynecology. 2017; 129: e155–e159.

[19] Committee on Practice Bulletins—Gynecology and the Society of Gynecologic Oncology Practice Bulletin No. 149: Endometrial Cancer. Obstetrics & Gynecology. 2015; 125: 1006–1026.

[20] Moss EL, Morgan G, Martin AP, Sarhanis P, Ind T. Surgical trends, outcomes and disparities in minimal invasive surgery for patients with endometrial cancer in England: a retrospective cohort study. BMJ Open. 2020; 10: e036222.

[21] Cassis C, Mukhopadhyay S, Sule MM, Kuruba N. Feasibility of early discharge following vaginal hysterectomy with a bipolar electrocoagulation device. International Journal of Gynecology & Obstetrics. 2018; 142: 182–186.

[22] Chia KV, Tandon S, Moukarram H. Vaginal hysterectomy is made easier with ERBE Biclamp® forceps. Journal of Obstetrics and Gynaecology. 2007; 27: 723–725.

[23] Clavé H, Baar H, Niccolaï P. Painless vaginal hysterectomy with thermal hemostasis (results of a series of 152 cases). Gynecological Surgery. 2005; 2: 101–105.

[24] Ghirardini G, Mohamed M, Bartolamasi A, Malmusi S, Dalla Vecchia E, Algeri I, et al. Minimally invasive vaginal hysterectomy using bipolar vessel sealing: preliminary experience with 500 cases. Journal of Obstetrics and Gynaecology. 2013; 33: 79–81.

[25] Zubke W, Hornung R, Wässerer S, Hucke J, Füllers U, Werner C, et al. Bipolar coagulation with the BiClamp® forceps versus conventional suture ligation: a multicenter randomized controlled trial in 175 vaginal hysterectomy patients. Archives of Gynecology and Obstetrics. 2009; 280: 753–760.

[26] Leo L, Riboni F, Gambaro C, Surico D, Surico N. Vaginal hysterectomy and multimodal anaesthesia with bipolar vessel sailing (Biclamp® forceps) versus conventional suture technique: quality results’ analysis. Archives of Gynecology and Obstetrics. 2012; 285: 1025–1029.

[27] Samulak D, Wilczak M, Michalska MM, Pięta B. Vaginal hysterectomy with bipolar coagulation forceps (BiClamp) as an alternative to the conventional technique. Archives of Gynecology and Obstetrics. 2011; 284: 145–149.

[28] Richter S, Kollmar O, Schilling MK, Pistorius GA, Menger MD. Efficacy and quality of vessel sealing: comparison of a reusable with a disposable device and effects of clamp surface geometry and structure. Surgical Endoscopy. 2006; 20: 890–894.

[29] Blayney GV, Beirne JP, Hinds L, Quinn D, Dorman GJ. Vaginal hys-terectomy using the ERBE BiClamp® BIPOLAR VESSEL SEALING SYSTEM: A CASE Series. The Ulster Medical Journal. 2017; 86: 167–171.

[30] Raglan O, Kalliala I, Markozannes G, Cividini S, Gunter MJ, Nautiyal J, et al. Risk factors for endometrial cancer: an umbrella review of the literature. International Journal of Cancer. 2019; 145: 1719–1730.

[31] Fung-Kee-Fung M, Dodge J, Elit L, Lukka H, Chambers A, Oliver T. Follow-up after primary therapy for endometrial cancer: a systematic review. Gynecologic Oncology. 2006; 101: 520–529.

[32] Smith SM, Hoffman MS. The role of vaginal hysterectomy in the treatment of endometrial cancer. American Journal of Obstetrics and Gynecology. 2007; 197: 202.e1–202.e7.

[33] Berretta R, Merisio C, Melpignano M, Rolla M, Ceccaroni M, DE Ioris A, et al. Vaginal versus abdominal hysterectomy in endometrial cancer: a retrospective study in a selective population. International Journal of Gynecological Cancer. 2008; 18: 797–802.