Outcomes and complications of total laparoscopic hysterectomy after conization

Objective: High-grade squamous intraepithelial lesion (HSIL)/cervical intraepithelial neoplasia (CIN) 3, and stage IA1 cervical cancer are often diagnosed after cervical conization. Additional resection is required in some cases, and total laparoscopic hysterectomy (TLH) after conization requires attention due to the postoperative changes around the cervix. Methods: This single-center retrospective study investigated the perioperative outcomes and complications of TLH with or without conization. Patients diagnosed with CIN or stage IA1 cervical cancer were grouped according to whether conization was performed before TLH. The perioperative outcomes, complications, and oncological outcomes were compared for 32 patients who underwent TLH after conization (cone-TLH group) and 18 patients who underwent TLH alone (TLH group). Results: The mean interval between conization and TLH was 14.8 ± 5.2 weeks. There were no significant differences between the cone-TLH and TLH groups in terms of surgical time (186.3 $\pm$ 48.1 min vs. 179.8 $\pm$ 34.6 min, P = 0.61), blood loss (100 [5-500] mL vs. 100 [5-560] mL, P = 0.79), length of hospital stay (4.7 $\pm$ 1.4 days vs. 4.6 $\pm$ 1.0 days, P = 0.86), or recurrence rate. One patient in the cone-TLH group experienced a ureter injury. Conclusions: Although the outcomes were comparable between TLH alone and TLH after conization, care is needed to avoid ureter complications.

Conization; Total laparoscopic hysterectomy; TLH; Cervical intraepithelial neoplasia; CIN; Cervical cancer; Uterine manipulator

[1] Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians. 2018; 68: 394-424.

[2] World Health Organization. Cancer fact sheets. 2018. Available at: https://gco.iarc.fr/today/fact-sheets-cancers (Accessed: 8 November 2020).

[3] National Cancer Center Japan. Cancer information service. 2017. Available at: https://ganjoho.jp/reg_stat/statistics/stat/summary. html (Accessed: 8 November 2020).

[4] Annual Report of Japan Society of Obstetrics and Gynecology. 2020. Available at: http://fa.kyorin.co.jp/jsog/readPDF.php?file= 72/6/072060676.pdf (Accessed: 8 November 2020) (In Japanese).

[5] McCredie MR, Sharples KJ, Paul C, Baranyai J, Medley G, Jones RW, et al. Natural history of cervical neoplasia and risk of invasive cancer in women with cervical intraepithelial neoplasia 3: a retrospective cohort study. The Lancet Oncology. 2008; 9: 425-434.

[6] Wright, TC, Cox JT, Massad LS, Carlson J, Twiggs LB, Wilkinson EJ. 2001 consensus guidelines for the management of women with cervical intraepithelial neoplasia. Journal of Lower Genital Tract Disease. 2003; 7: 154-167.

[7] Lu C, Liu F, Kuo C, Chang C, Ho ES. Prediction of persistence or recurrence after conization for cervical intraepithelial neoplasia III. Obstetrics & Gynecology. 2006; 107: 830-835.

[8] Park J, Lee KH, Dong SM, Kang S, Park S, Seo S. The association of pre-conization high-risk HPV load and the persistence of HPV infection and persistence/recurrence of cervical intraepithelial neoplasia after conization. Gynecologic Oncology. 2008; 108: 549-554.

[9] Prato B, Ghelardi A, Gadducci A, Marchetti I, Di Cristofano C, Di Coscio G, et al. Correlation of recurrence rates and times with posttreatment human papillomavirus status in patients treated with loop electrosurgical excision procedure conization for cervical squamous intraepithelial lesions. International Journal of Gynecological Cancer. 2008; 18: 90-94.

[10] Serati M, Siesto G, Carollo S, Formenti G, Riva C, Cromi A, et al. Risk factors for cervical intraepithelial neoplasia recurrence after conization: a 10-year study. European Journal of Obstetrics & Gynecology and Reproductive Biology. 2012; 165: 86-90.

[11] Cavanagh D, Rutledge F. The cervical cone biopsy-hysterectomy sequence and factors affecting the febrile morbidity. American Journal of Obstetrics and Gynecology. 1960; 80: 53-59.

[12] Decenzo JA, Malo T, Cavanagh D. Factors affecting cone-hysterectomy morbidity. American Journal of Obstetrics and Gynecology. 1971; 110: 380-384.

[13] Li H, Jang JY, Li H, Chen K, Shao XG. The influence of interval between conization and laparoscopic radical hysterectomy on the morbidity of patients with cervical cancer. European Journal of Gynaecological Oncology. 2012; 33: 601-604.

[14] Malinak LR, Jeffrey RA, Dunn WJ. The conization-hysterectomy time interval. Obstetrical & Gynecological Survey. 1964; 19: 709-711.

[15] Osoba D. Febrile morbidity in relation to cone biopsy followed by hysterectomy: a study of 38 patients. Canadian Medical Association Journal. 1958; 79: 805-809.

[16] Phongnarisorn C, Srisomboon J. Surgical morbidity associated with total laparoscopic hysterectomy in women with prior diagnostic excision of the cervix. Journal of Obstetrics and Gynaecology Research. 2007; 33: 519-523.

[17] Yin X, Zhu L, Tan W, Zhu X, Liu S, Xu W. Time intervals between prior cervical conization and posterior hysterectomy influence postoperative infection in patients with cervical intraepithelial neoplasia or cancer. Medical Science Monitor. 2018; 24: 9063-9072.

[18] Kanda Y. Investigation of the freely available easy-to-use software ‘EZR’ for medical statistics. Bone Marrow Transplantation. 2013; 48: 452-458.

[19] Tae Kim Y, Sung Yoon B, Hoon Kim S, Hoon Kim J, Wook Kim J, Won Park Y. The influence of time intervals between loop electrosurgical excision and subsequent hysterectomy on the morbidity of patients with cervical neoplasia. Gynecologic Oncology. 2005; 96: 500-503.

[20] Ramirez PT, Frumovitz M, Pareja R, Lopez A, Vieira M, Ribeiro R, et al. Minimally invasive versus abdominal radical hysterectomy for cervical cancer. New England Journal of Medicine. 2018; 379: 1895-1904.

[21] He J, Hao M, Liu P, Liu Z, Lang J, Bin X, et al. Comparison of laparoscopic and abdominal radical hysterectomy for early stage cervical cancer: oncologic outcomes based on tumor diameter. International Journal of Gynecologic Cancer. 2020; 30: 1308-1316.

[22] Köhler C, Hertel H, Herrmann J, Marnitz S, Mallmann P, Favero G, et al. Laparoscopic radical hysterectomy with transvaginal closure of vaginal cuffa multicenter analysis. International Journal of Gynecologic Cancer. 2019; 29: 845-850.

[23] Pedone Anchora L, Turco LC, Bizzarri N, Capozzi VA, Lombisani A, Chiantera V, et al. How to select early-stage cervical cancer patients still suitable for laparoscopic radical hysterectomy: a propensity-matched study. Annals of Surgical Oncology. 2020; 27: 1947-1955.

[24] Bogani G, Ditto A, Chiappa V, Pinelli C, Sonetto C, Raspagliesi F. Primary conization overcomes the risk of developing local recurrence following laparoscopic radical hysterectomy in early stage cervical cancer. International Journal of Gynecology & Obstetrics. 2020; 151: 43-48.

[25] Chao A, Chen T, Hsueh C, Huang C, Yang J, Hsueh S, et al. Human papillomavirus in vaginal intraepithelial neoplasia. International Journal of Cancer. 2012; 131: E259-E268.

[26] Tanaka M, Kashimura M, Matsuura Y, Kawagoe T, Toki N. A clinicopathologic study in 20 patients with vaginal intraepithelial neoplasia. The Japanese Society of Clinical Cytology. 2003; 42: 281-287. (In Japanese)

[27] Tanaka H, Ito K, Minami Y, Ito M, Kobayashi Y, Asakura T, et al. Preliminary study of total laparoscopic hysterectomy for cases of very early cervical cancer or its precancerous state. Japanese Journal of Gynecologic and Obstetric Endoscopy. 2013; 29: 308-312.(In Japanese)