Conrad et al. [9] evaluated the current patterns in use of MIS procedures by SGO members and compared the results against those of their 2004 and 2007 surveys. Between 2007 and 2012, there was a very large increase in the proportion of SGO members who thought minimally invasive radical hysterectomy and pelvic lymphadenectomy was appropriate for cervical cancer (from 36.7% in 2007 to 81.6% in 2012). Also between 2007 and 2012, there was an increase in conversion from minimally invasive surgery to laparotomy (with 2.8% of SGO members reporting a conversion rate >5% in 2007 and 23.6% of members reporting that same rate in 2012), and, according to the 2012 survey, 90.2% of members rarely or never referred a patient to a colleague for minimally invasive surgery, which was a significant increase from the 80.6% reported in 2004 (p=0.0004).

Several authors have noted that mastery of laparoscopic radical hysterectomy requires experience in at least 25 and up to 50 cases [1011], which means that optimal surgical outcomes of MIS for cervical cancer, which was first adopted in 2006, are just now coming about. Perhaps the rate of conversion to laparotomy increased between 2007 and 2012 because surgeons lacked the required experience or were reluctant to make referrals.

Rauh-Hain reported a 1% decrease in 4-year survival of patients treated for cervical cancer for each year after 2006 on the basis of an interrupted time series analysis of data from the National Cancer Institute Surveillance, Epidemiology, and End Results (SEER) Program. It was speculated that the decline was due to surgeons' lack of experience and disinclination toward making referrals, and we think that analysis of patient survival over the more recent years is necessary to confirm the “real” outcomes of MIS.

During the laparoscopic procedure, applying upward traction to the uterus is considered fundamental. Use of a uterine manipulator allows good exposure of the spaces around the uterus and thus a faster and safer procedure [12]. However, some authors have raised concern that use of a uterine manipulator might further disrupt the tumor and thus result in dissemination of malignant cells [1314151617]. Several authors have shown that use of a uterine manipulator during laparoscopic surgery for endometrial cancer does not increase the incidence of positive peritoneal cytology or the risk of recurrence and that it has no influence on OS [181920]. However, use of a uterine manipulator during surgery for cervical cancer remains controversial. Rakowski et al. [21] reported that the use of uterine manipulator in robotic-assisted radical hysterectomy, did not yield any clinico-pathological differences in depth of invasion, lymphovascular space invasion (LVSI), or parametrial involvement compared those seen in cases of open surgery [21]. On the contrary, artifactual displacement of cervical epithelium showing CIN III to fallopian tubes during laparoscopic hysterectomy performed with the use of an intrauterine balloon manipulator has been reported [22], which means that use of a uterine manipulator poses a theoretical possibility of peritoneal dissemination of cervical cancer.

On the basis of results of an experimental animal study, Volz et al. suggested that intraperitoneal tumor spread may be connected to inadvertent presentation of cancerous tumor cells to the circulating pneumoperitoneum CO₂ gas and disturbance of the superficial mesothelial layer caused by the high CO₂ pressure; this may provoke cancer cell implantation [23]. Kong et al. [24] investigated the pattern of recurrence after open versus laparoscopic/robotic radical hysterectomy in patients with early cervical cancer, and multivariate analysis of factors in the MIS group showed laparoscopic intracorporeal colpotomy under CO₂ pneumoperitoneum to be a strong prognostic factor related to disease recurrence. They concluded that total laparoscopic/robotic intracorporeal colpotomy under CO₂ pneumoperitoneum may pose a risk of a positive vaginal cuff margin and of intraperitoneal tumor spread in patients with early-stage cervical cancer treated by means of laparoscopic/robotic radical hysterectomy.

Several studies have shown that recurrence patterns differ according to the colpotomic approach because exposure of the cervical mass to circulating CO₂ during intracorporeal colpotomy may result in tumor spillage into the intraperitoneal space, leading to intraperitoneal dissemination [2526]. In the Laparoscopic Approach to Cervical Cancer (LACC) study, the vault was shown to be the most common site of recurrence in cases of open surgery, whereas the pelvis was shown to be the most common site of recurrence in cases of MIS. Further, pelvic recurrence was not seen in cases of open surgery. The recurrence pattern differed completely between the 2 groups, even though histopathological findings (tumor size, LVSI, parametrial margin, and vaginal margin) were identical.

In the LACC study, a fair amount of data, including the use of uterine manipulators and the precise colpotomic approach, are unknown. We must judge the usefulness of MIS for early-stage cervical cancer dispassionately and objectively on the basis of all pertinent data.

Finally, we quote Shitanshu Uppal, MD, the discussant of the two studies presented at the SGO Annual Meeting, “What will happen if we abandon minimally invasive surgery? A return to open surgery for all patients would result in 85 additional complications, 70 additional transfusions, and 4.75 lives would be saved per 1,000 cases.”