Gynecologic Oncology 120 (2011) 362–367
Contents lists available at ScienceDirect
Gynecologic Oncology
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / y g y n o
Twelve-year experience with laparoscopic radical hysterectomy and pelvic
lymphadenectomy in cervical cancer
Xiaojian Yan a, Guangyi Li b, Huiling Shang b,⁎, Gang Wang b, Yubin Han b, Tiecheng Lin b, Feiyun Zheng a
a
b
Department of Obstetrics and Gynecology, The First Affiliated Hospital of Wenzhou Medical College, 325000 Wenzhou, China
Department of Obstetrics and Gynecology, The First People's Hospital of Foshan, No. 81, North Lingnan Street, Chancheng District, Foshan, Guangdong, 528000, China
a r t i c l e
i n f o
Article history:
Received 30 August 2010
Available online 18 December 2010
Keywords:
Cervical cancer
Laparoscopy
Radical hysterectomy
a b s t r a c t
Objectives. This study aims to evaluate the morbidity, oncological outcome, and prognostic factors of
cervical cancer patients treated with laparoscopic radical hysterectomy and pelvic lymphadenectomy (LRH).
Methods. Patients with cervical cancer undergoing LRH at the First People's Hospital of Foshan between
August 1998 and March 2010 were enrolled in this study. The medical records were reviewed.
Results. A total of 240 patients were identified. According to FIGO stage, the number of patients with stage
Ia2, Ib1, Ib2, IIa, and IIb was 2, 163, 34, 35, and 6, respectively. The conversion rate was 1.25%. Intraoperative
and postoperative complications occurred in 7.08% and 9.16% patients, respectively. Other medical problems
included 74 cases (30%) of bladder dysfunction. Excluding the lost cases, the median follow-up of 221 cases
was 35 months, and 5-year survival rate for Ia2, Ib1, Ib2, IIa was 100%, 82%, 66%, 60%, respectively. Univariate
analysis showed factors impacting the survival rate were FIGO stage N Ib1, non-squamous histologic type,
deep cervical stromal invasion, and lymph node metastasis (P = 0.027, 0.023, 0.007, 0.000). The Coxproportional hazards regression analysis indicated that only lymph node metastasis (OR = 3.827, P = 0.000)
was independent of poor prognostic factor. The 5-year survival rates in Ib1 were 88% with negative lymph
nodes and 59% with positive lymph nodes (P = 0.000).
Conclusions. Our data demonstrate that LRH can be performed in stage Ia2–Ib1 or less advanced node
negative cervical cancer patients without compromising survival. The feasibility of LRH for more advanced
patients needs further investigations.
© 2010 Elsevier Inc. All rights reserved.
Introduction
Acceptance of a new surgical technique in gynecologic oncology
depends on several aspects, including technical feasibility, reasonable
perioperative morbidity, adequacy of surgery, and better or at least
same survival as the standard approach. Laparoscopic radical
hysterectomy (LRH) has been reported since the early 1990s by
Canis et al. [1] and Nezhat et al. [2]. Several teams throughout the
world have recently reported promising results for early cervical
cancer with this procedure, although the acceptance of LRH had been
slow over the past 10 years [3]. LRH is technically feasible and
associated with accepted intraoperative and postoperative complications. Its histopathologic outcome is also similar to that of radical
abdominal hysterectomy (RAH) in terms of local radicality and lymph
nodes yield. However, the currently existing recurrence and survival
data are still immature to draw safe conclusions on its long-term
oncological outcomes. It is particularly difficult to conceive a
randomized trial for LRH. This is due to the limited number of
⁎ Corresponding author. Fax: +86 757 83812566.
E-mail address: [email protected] (H. Shang).
0090-8258/$ – see front matter © 2010 Elsevier Inc. All rights reserved.
doi:10.1016/j.ygyno.2010.11.033
gynecologic oncologic departments where the procedure is available
and to the relatively low frequency of recurrence, which implies a
large sample size. In this paper, we present a comprehensive
summary of 12 years of experience in LRH for cervical cancer.
Materials and methods
A retrospective review of LRH for 240 consecutive cervical cancers
from August 1998 to March 2010 performed by the Gynecologic
Division at the First People's Hospital of Foshan was conducted. The
operations were performed by the team including 8 surgeons under
the leading of Dr. Guangyi Li, who has extensive experience in
gynecologic oncology and laparoscopic procedures. Informed consent
was obtained from each patient after a thorough counseling therapeutic
option, risks of the procedure, and possibility of conversion to
laparotomy.
The techniques described previously [4] had been modified in
recent years. After induction of general anesthesia, patients were placed
in lithotomic position. Traditionally, a simple uterine manipulator was
inserted into the uterine cavity and with gauze attached to the uterine
manipulator in the vagina. Recently, a new modified uterine
manipulator with three different sizes of ring has been used to
X. Yan et al. / Gynecologic Oncology 120 (2011) 362–367
maintain sufficient pneumoperitoneum, which allows a complete
circumferential incision around the apex of the vaginal cuff before the
specimen is removed. These ovaries were either resected or left in situ
according to the stage and the patient's desire to preserve ovarian
function. Systematic bilateral pelvic lymphadenectomy included
dissection of common iliac nodes, external iliac nodes, internal iliac,
obturator nodes, and deep inguinal lymph nodes. Lymph nodes were
placed into a bag. LRH was performed by Piver-III standard
transperitoneal route as described previously [4]. The specimen was
removed, and the vagina was closed vaginally with drains, which
were placed into vaginal cuff.
Operative time was measured from the time of placement of the
first trocar. Hospital stay was counted from the first postoperative
day. Most patients received a voiding trial approximately 1 week after
operation. Bladder dysfunction was defined by the criteria reported by
Ramirez et al. [5] (more than 100 ml residual urine over 14 days).
Patients failed the voiding trial had the catheter replaced for further
bladder rest.
Adjuvant therapy
Among all the patients, 17 patients received neoadjuvant
chemotherapy, radiotherapy, or concomitant CRT including 4 Ib2
patients, 7 IIa patients, 6 IIb patients. Neoadjuvant concomitant CRT
with a platinum-based chemotherapy in combination with external
beam radiotherapy to the pelvis (40–50 Gy) was given to IIb patients
for down-staging. Adjuvant therapy after surgery was given to
patients who had one or more risk factors such as lymph node
metastases, bulky tumors, parametrial involvement, positive surgical
margins, and deep cervical stromal invasion. Radiotherapy in these
cases was administered as whole pelvis external beam radiation at a
mean dose of 45 Gy (range, 40–50 Gy). Recently, chemotherapy based
on cisplatin at a dose of 40 mg/m2 per week or 75 mg/m2 per
3 weeks was given postoperatively to patients with poor prognostic
histological type or high-risk factors along with external beam pelvic
irradiation.
Follow-up
Follow-up data were available for 221 patients. Univariate analysis
of prognosis was performed using the log-rank test. The Life tables
were used to calculate the overall survival rate. Survival curves were
performed with the Kaplan–Meier method. The Cox-proportional
hazards regression was employed to model the multivariate association
of survival. The level of significance was P b 0.05.
Results
The patient's characteristics are shown in Table 1. There were 209
patients of squamous cell carcinoma (87.05%), 69.58% had grade 2
lesions. The mean number of resected pelvic lymph nodes was 23
(range, 8–58). Pelvic lymph node metastasis occurred in 58 patients
(24.16%).
Intraoperative data
LRH was performed laparoscopically in 237 patients (98.75%).
Bilateral salpingo-oophorectomy was performed in 156 patients (65%),
whereas the remaining 84 patients (35%) had one or both adnexa
preserved. Mean operative time was 264 min (range, 100–480 min).
Median operative blood loss was 255 ml (range, 50–2000 ml). The
transfusion rate was 8.33%. The median time to normal urine residual
was 13 days (2–90 days), and the median length of hospital stay was
13 days (6–66 days).
363
Table 1
Patient characteristics of LRH (n = 240), among them 221 patients were followed up.
Age (years)
Weight (kg)
FIGO stage
Ia2
Ib1
Ib2
IIa1
IIa2
IIb
Histology
Squamous
Adenocarcinoma
Adenosquamous
Adenoacanthoma
Carcinomasarcoma
Grade
G1
G2
G3
Pelvic lymph nodes metastases
n = 240 (total)
n = 221 (followed up)
45 (24–74)
55 (35–80)
45 (24–74)
55 (35–80)
2
163
34
25
10
6
2
151
32
21
9
6
209
21
6
3
1
192
19
6
3
1
32
167
41
58
29
155
37
52
Intraoperative complications
Intraoperative complications occurred in 17 patients (7.08%),
including vascular injury (7), bladder injury (6), ureteral injury (3),
and obturator nerve injury (1) (Table 2). All injuries were recognized
intraoperatively and 3 (1.25%) patients required conversion to an
open procedure.
Postoperative data
Among 22 patients (9.16%) who experienced postoperative
medical or surgical problems, 4 patients had vesicovaginal fistula, 2
patients had ureterovaginal fistula, 6 patients had lymphocyst,
8 patients had lymphedema, and 2 patients had bowel obstruction
(Table 2). Other medical problems included 74 cases (30.8%) of
bladder dysfunction.
Table 2
Intraoperative and postoperative complications of 240 patients.
Complications
Type of
complication
No.
Treatment and outcome
patient
Intraoperative
Vascular injury 7
complications
2
One was converted to laparotomy and
successfully repaired
Six were successfully treated
laparoscopically
One was converted to laparotomy and
successfully repaired
Five were successfully repaired
laparoscopically
One was converted to laparotomy
Two were successfully treated by
cystoscopic placement of double-J
Successfully repaired laparoscopically
with 3/0 Prolen
Three closed by conservation
treatment
One successfully repaired vaginally
Placed double-J ureteral stents
6
8
2
Observe
Chinese medicine treatment
Conservative management
Bladder injury
6
Ureteral injury
3
Obturator
nerve injury
Postoperative
Vesicovaginal
complications fistula
Ureterovaginal
fistula
Lymphocyst
Lymphedema
Bowel
obstruction
1
4
364
X. Yan et al. / Gynecologic Oncology 120 (2011) 362–367
Fig. 1. Five-year survival after a median follow-up time of 35 months in 221 patients
treated with LRH according to stage ≤ Ib1or stage N Ib1.
Fig. 3. Five-year survival in stage Ib1 patients treated with LRH according to tumor
diameter ≤ 2 cm (n = 74) or tumor diameter N 2 cm(n = 77).
Oncological data
regression analysis indicated that only lymph node metastasis
OR = 3.827, P = 0.000) was independent of poor prognostic factors.
There were 52 cases of patients with positive retroperitoneal nodes
and 169 cases of patients with negative nodes. The 1-year, 3-year,
5-year overall survival rates in all stages were 93%, 89%, 84% with
negative lymph nodes and 71%, 68%, 57% positive lymph nodes,
P = 0.000. The 1-year, 3-year, 5-year survival rates were 90%, 87%, 82%
in Ib1 (n = 151) and 80%, 76%, 66% in Ib2 (n = 32), P = 0.073. The
1-year, 3-year, 5-year survival rates in Ib1 were 96%, 92%, 88% with
negative lymph nodes (n = 124) and 68%, 68%, 59% with positive
lymph nodes (n = 27), P = 0.000. The 1-year, 3-year, 5-year survival
rates in Ib1 were 92%, 89%, 89% with tumor diameter ≤ 2 cm (n = 74)
and 88%, 86%, 76% with tumor diameter N2 cm(n = 77) (Fig. 3,
P = 0.282).
Among 240 cases, 19 cases were lost to follow-up, 25 cases
were followed up to June 2007, and 196 cases were followed up
to June 2010. The distribution of 221 cases according to FIGO stage
was Ia2 n = 2, Ib1 n = 151, Ib2 n = 32, IIa n = 30, and IIb n = 6. The
median follow-up was 35 months (range, 2–125 months). Eightyseven patients (39.4%) with one or more high-risk factors received
postoperative adjuvant radiotherapy. Twenty-nine of these patients
(33.3%) received concomitant CRT with a platinum-based chemotherapy. The other 134 (60.6%) received no future adjuvant
therapy.
Thirty-eight patients (17.19%) had recurrences or metastasis.
Stage of recurrence was 24 at stage Ib1 (15.89%), 7 at stage Ib2
(21.88%), 7 at stage IIa (23.33%). No recurrence was found among the
six patients at stage IIb within follow-up (median 27 months; range,
4–38 months). Sites of recurrence were pelvic or vaginal stump (13),
abdominal cavity (3), lymph nodes (8), distant sites (8), and multiple
sites (6). Among 38 patients with recurrence, 30 have died of their
disease and 8 are alive with disease.
Excluding the lost cases, the 5-year overall survival rate was 100%
for Ia2, 79% for Ib (82% for Ib1, 66%for Ib2), 60% for IIa. Univariate
analysis showed factors impacting the survival rate were FIGO
stage N Ib1 (Fig. 1, P = 0.027), non-squamous histologic type
(P = 0.023), deep cervical stromal invasion (P = 0.007), and lymph
node metastasis (Fig. 2, P = 0.000). The Cox-proportional hazards
Fig. 2. Five-year survival after a median follow-up time of 35 months in 221 patients
treated with LRH according to lymph node involvement.
Discussion
Radical hysterectomy as described by Ernst Wertheim remains as
the gold standard in the surgical management of operable cervical
cancer. Introduction of laparoscopic pelvic lymphadenectomy (LPL)
by Querleu et al. opened new perspectives for gynecologic oncology
[6]. During the past 15 years, there has been an increasing interest in
the possible role of laparoscopy in the treatment of cervical cancer,
several teams worldwide have recently reported promising results
[5,7–19] (Table 3).
In most of these studies, patients enrolled were strictly selected
from the stage Ib1 or less advanced or with node negative, which may
explain the better prognosis. Although the feasibility of LRH has
currently been proven in some stage Ib2–IIIb patients with an
acceptable rate of complications, the follow-up time in those reported
series is still too short to provide mature recurrence and survival data.
In this study, six stage IIb patients received a neoadjuvant concomitant CRT and were alive at the last follow-up. Colombo et al. [18] have
mentioned that TLRH after preoperative CRT is feasible for patients
with locally advanced cervical cancer in 85% of the cases. TLRH
compared with ARH was associated with favorable surgical outcome
with comparable oncological results. However, effects of radiation on
tissues could increase the difficulties of surgical dissection and the
role of LRH after CRT for advanced cervical carcinoma remains
controversial.
Most of these studies have shown that LRH was a relatively timeconsuming procedure and the operative times ranged from 159 to
363 min [20], while Puntambekar et al. [10] reported an impressive
92 min (65–120 min), which was the shortest in the literature.
Learning curve has been naturally confirmed in all series. Spirtos et al.
[7,21] published 2 series of patients with cervical cancer treated with
X. Yan et al. / Gynecologic Oncology 120 (2011) 362–367
Table 3
Studies of LRH including more than 18 patients each.
Time Country
Authors
Number of case
Palo Alto Women's Cancer
Center
2003 France
Institute Gustave Roussy
Comprehensive Cancer Centre
2003 Australia King Edward Memorial
Hospital for Women
2006 USA
The University of Texas M.D.
Anderson Cancer Center
2007 India
The Galaxy Laparoscopy
Institute, Pune
2007 China
Southwest Hospital, Third
Military Medical University
Institute
Spirtos et al.
[7]
Pomel et al.
[8]
Obermair et
al. [9]
Ramirez et al.
[5]
Puntambekar
et al. [10]
Xu et al. [11]
78 (26Ia2, 38Ib1,
14Ib2)
50 (5Ia1, 6Ia2,
39Ib1)
39 (13Ia, 24Ib,
1IIa, 1IVb)
18 (5Ia2, 13Ib1)
2007 Italy
University of Insubria
2007 USA
The University of Texas M. D.
Anderson Cancer Center
The Mount Sinai School of
Medicine, Mount Sinai
Medical Center
San Gerardo Hospital,
University of Miland Bicocca
The First People's Hospital of
Foshan
Malzoni Medical Center,
Avellino
CRLC Val d'Aurelle
Uccella et al.
[12]
Frumovitz et
al. [13]
Zakashansky
et al. [14]
2002 USA
2007 USA
2009 Italy
2009 China
2009 Italy
2009 France
2009 Korea
Kyungpook National
University Hospital
248 (32Ia2,
216Ib1)
317 (82Ia2,
73Ib1, 52Ib2,
65IIa, 58IIb)
50 (7Ia2, 36Ib,
7IIa)
35 (2Ia1, 5Ia2,
28Ib1)
30 (1Ia1, 8Ia2,
17Ib1, 2 Ib2, 2IIa)
Pellegrino et 101Ib1
al. [15]
Yan et al. [16] 117 96Ib, 21IIa
Malzoni et al.
[17]
Colombo et
al. [18]
Chong et al.
[19]
77 (5Ia1, 24Ia2,
48Ib1)
46 (14Ib2, 4IIa,
28IIb)
100 (12Ia2,
56Ib1, 15Ib2,
15IIa, 2IIb)
TLRH in 1996 and 2002, and the mean duration of their operation had
been 253 min in the first group and 205 min in the second group of
cases, respectively. Similarly, we observed that the operation time
decreased significantly from 281 ± 70 min for the first 45 patients to
244 ± 61 min for the last 45 patients (P = 0.009) in our previous
report [4]. However, our mean operation time of 240 patients was
264 min. Some surgeons were still in the “early phase” of the learning
curves, which explained why we do not demonstrate a decrease in
operation time. Our median blood loss was 255 ml, within a wellacceptable range for a procedure such as radical hysterectomy. Four
existing comparative studies have confirmed a reduced blood loss
during TLRH in comparison to RAH at a statistically significant level
[20].
A major concern when evaluating surgical sampling is to evaluate
lymph node status. The retrieval of a total number of 20 pelvic lymph
nodes is considered to be the gold standard for an adequate complete
lymphadenectomy [22]. In this study, the mean number of nodes
obtained was 23. As we have previously mentioned, laparoscopic
lymph node dissection was comparable to laparotomy in terms of
node counts [4]. The rate of microscopic lymph node metastases was
24.16% for all patients and 17.88% for stage Ib1 in this study. It was
consistent with 12–23% of lymph node metastases in stage I patients
in the rest of the literature [23].
Our intraoperative complications rate was 7.08% with a conversion
rate of 1.25%, which was consistent with some recent reports about
LRH that the overall complication rate was between 2% and 13.2% with
a conversion rate of 0% to 10.5% [7–19]. The main complications
consist of vascular, bladder, ureteral, obturator nerve injuries. One
case of obturator nerve transection occurred during pelvic lymphadenectomy, which can be repaired immediately using laparoscopic
nerve epineural end to end with tension-free anastomosis technique.
The patient had symptoms of adductor weakness with sensory trouble
such as upper medial thigh anesthesia. A month later, the anesthesia
disappeared and she was asymptomatic. Our strategies to prevent and
treat other complications have been described previously [16]. To
365
prevent and eliminate complications, the gynecologist should be
skilled in laparoscopic technique. Raatz et al. [24] suggested that a
minimum of 50 LRH cases are needed to acquire adequate
laparoscopic skills.
Similar to laparotomy radical hysterectomy, postoperative complications were predominantly related to the urinary tract and
affected 22 (9.16%) cases in our study, including ureterovaginal
fistula, vesicovaginal fistula, lymphocyst, lymphedema, and bowel
obstruction. In our previous report [4], the postoperative complication
rate was 40% when bladder dysfunction was included. Functional
disorders of the lower urinary tract were the most common long-term
complications following radical hysterectomy for cervical cancer. The
incidence of postoperative bladder dysfunction has been reported
from 16.3% to 76% [25–28]. In this study, we found that 30.8% of
patients had voiding bladder dysfunction, and the median time of
resumption to normal bladder function was 13 days, which was
similar to Ramirez et al.'s result (16 days, ranged from 13 to 29 days)
[5]. Ralph et al. [29] revealed that the degree of postoperative voiding
dysfunction was associated with the amount of resected vaginal,
paravaginal, and parametrial tissues. Nerve-sparing concepts via a
laprarotomy or laparoscopic approach have focused on the hypogastric
nerve, the pelvic splanchnic nerve, and the distal part (vesical and
uterovaginal branches) of the IHP during the dissection of the
posterior leaf of the VUL, and have been proposed to reduce
postoperative neurologic problems [30,31]. Park et al. [32] reported
that their laparoscopic nerve-sparing technique was comparable
with laparotomy in terms of early recovery of bladder function.
Patients in their study were able to self-void at a mean of 10.3 days
(range, 6–29 days) postoperatively. The rate returning to normal
voiding function 14 and 21 days post-operatively was 92.0% and
95.2%, respectively.
In this study, the median length of hospital stay was 13 days,
which was longer than that in other series of LRH (ranged from 1 to
10.3 days). This is due to the fact that we were very conservative
with the postoperative follow-up and wanted to ensure a minimum
observation period equal to that of laparotomy. Currently, we
usually discharge the patients on the day of bladder catheter
removal.
Oncological adequacy
Oncological safety is the key to compare a new surgical technique
with the currently gold standard in the management of a malignant
disease.
Recurrence of cervical cancer treated by LRH usually follows the
same patterns as in patients treated with RAH. In a series of 221
cases of FIGO stage Ia2–IIb, with a median follow-up of 35 months,
we observed a 17.19% recurrence rate, while it ranged from 12% to
25% for laparotomy [33,34]. The higher proportion of Ib2 and more
advanced (30.77%) and positive node (23.53%) cervical cancer
patients may explain our higher recurrence rate compared with
those LRH studies in the literature (2.8–10%). Spirtos et al. [7]
observed a 10.3% recurrence rate and 93.6% 5-year survival rate in
78 cases of stage Ia2–Ib (14 cases of Ib2) with a mean follow-up of
68.3 months. Obermair et al. [9] reported a 7.9% recurrence rate in a
series of 39 cases after a median follow-up of 36.5 months. Pomel et
al. [8] reported 50 cases of 6% recurrence rate and an estimated
disease-free survival of 100% for stage Ia1 and 90.5% for stage Ia2
and Ib1. Puntambekar et al. [10] reported a 2.8% recurrence rate but
no deaths in a series of 248 cases with stage Ia2–Ib1 after a median
follow-up of 36 months. Pellegrino et al. [15] reported an 11%
relapse rate and 95% survival rate in 101 cases of stage Ib1 with
tumor size b3 cm after a median follow-up of 30 months. In Chong
et al.' s series of 100 cases, after a median follow-up of 66.5 months,
10 patients had a recurrence, 9 of whom died. The 5-year overall
survival rate was 96% in the first 50 patients and 90% in the second
366
X. Yan et al. / Gynecologic Oncology 120 (2011) 362–367
50 cases [19]. In this study, we reported an estimated 5-year survival
rate of 100% for Ia, 79% for Ib (82% for Ib1, 66%for Ib2), 60% for IIa.
Among 221 cases, 196 cases were followed-up to June 2010, while
25 cases were only followed-up to June 2007, which may affect the
survival to some extent. As far as the survival rate of early stage of
cervical cancer is concerned, lymph node is the only significant
independent predictor for overall survival. The 5-year survival rate
in Ib1 was 88% with negative lymph nodes and 59% with positive
lymph nodes. This is consistent with other laparotomy studies on
5-year survival rate in patients of stage Ib–IIb, which reported a range
from 87.3% to 94.7% with negative pelvic lymph nodes, whereas a
range from 64% to 68.2% with positive pelvic lymph nodes [35]. Tumor
size is recognized as a more important prognostic survival. However,
in this study, no significant difference in 5-year survival rate was found
in Ib1 patients when the tumor diameter N2 cm and ≤2 cm were
compared (76% vs. 89%, P = 0.282). This needs to be warranted by
further investigations.
Patients with stage Ib2–IIa cervical cancer have rarely been
reported in this setting. Chen et al. [36] reported the 5-year
metastasis survival rate was 85.4%, which was almost identical to
the data of Landoni et al. [33] following open surgery (83.9%). In
Hertel et al.'s study, stage II and III patients were included and an
overall 5-year survival rate of 83% was reported [37]. Sardi et al.
[38] reported a better projected overall survival of 88% for Ib1
and 85% for Ib2. To our surprise, the current series demonstrates
that the oncological outcome of LRH in patients of stage Ib2–IIa is
worse than ever before. These results suggested that the
oncological outcome of laparoscopic radical hysterectomy in
advanced stage cases may differ from that of open surgery or
concurrent chemoradiotherapy. We suggested that patients later
than or equal to Ib2 stage and radiological positive nodes were
not considered suitable for laparoscopy. And concomitant CRT
may be the best choice for treatment. The US National Cancer
Institute advised in 1999 that patients with stage Ib2 and
advanced should be treated with CCRT. Laparoscopic radical
hysterectomy is increasingly being performed by many gynecologists. The short-term follow-up in this study does not allow us
to draw a definitive conclusion on the impact of laparoscopic
technique on the outcome. More multicenter studies and longterm follow-up are required to identify the oncologic outcomes of
this procedure.
Conflict of interest statement
The authors have no conflicts of interest to declare.
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