|
The most common presenting symptom is abnormal vaginal bleeding e.g. postcoital bleeding, intermenstrual or postmenopausal bleeding. However, in the dysplasia (precancer) stage and very early cancer, there are usually no
symptoms. In the advanced cases, patients may present with other symptoms such as foul smelling vaginal discharge or even vaginal passage of urine or faeces.
The five-year survival rate in Singapore is about 80% for early stage cervical cancers. This is comparable to the international FIGO statistics. However for advanced cancers, the survival is less than 20%. Fortunately, many patients do present at preinvasive or early stages resulting in a better outcome.
Traditional Surgical Management
 Surgery is generally reserved for medically fit patients with cancers up to FIGO Stage IIA. Concurrent Chemoradiation is used as a standard form of treatment for locally advanced cervical cancers. For decades, the standard surgical management of early cervical cancer has been via laparotomy to perform the radical hysterectomy
(Wertheim’s procedure). This involves surgical removal of the uterus, cervix, the supporting ligaments and the upper vagina, together with removal of the pelvic lymph nodes and sometimes the para-aortic lymph nodes (See Figure 1).
This procedure is associated with the risk of injury to the ureter, bladder, rectum and pelvic blood vessels. Often the patient may require blood transfusions because of intraoperative blood loss. Post-operatively, there is usually
bladder dysfunction requiring an in-dwelling catheter for up to 3 weeks.
Laparoscopic Surgical Management
The use of laparoscopy in the treatment of gynaecological cancers was first reported in Europe twenty years ago. However, it has only been accepted as a standard of care in the last five years. The technique of total laparoscopic
radical hysterectomy and systematic pelvic lymphadenectomy for early cervical cancer is now well described in medical literature.
Western clinical studies have shown that this approach reduces blood loss, hospital stay, ileus, wound pain and wound infection when compared to the traditional laparotomy approach. More importantly, it is not inferior in terms of long-term survival and prognosis when compared to the traditional approach.
In Singapore, this novel approach was introduced to patients at KKH’s Gynaecological Cancer Centre around end of last year. Total laparoscopic radical hysterectomy and pelvic lymphadenectomy is currently indicated for early stages of cervical cancer (up to Stage IB1), where the tumour is less than 4cm and there is no clinical evidence of metastatic spread. Since November 2009, seven patients with early cervical cancer have had this surgery.
“Even when performed via laparotomy, it is a technically challenging operation requiring the expertise of a gynaecological oncology surgeon with a good knowledge of the pelvic anatomy. For the laparoscopic alternative, it is preferable that two oncologic surgeons operate in tandem to achieve the same oncologic clearance as a laparotomy case. The procedure is technically demanding as it requires multiple dissections around major blood vessels and key organs such as the ureter, rectum, urinary bladder, which commands high-precision laparoscopic
manipulation,” said Dr Chia Yin Nin, Consultant, Head of Gynaecological Cancer Unit, KKH.
“The seven patients who underwent the procedure recovered well and were discharged between three
and five days. This compares to about five to eight days of hospital stay with abdominal surgery,”
said Dr Timothy Lim Yong Kuei, Consultant Gynaecological Oncologist, KKH.
 “Another major benefit of laparoscopic radical hysterectomy is the superior visualisation of pelvic anatomy through high definition optical magnification (See Figure 2). This is especially so in the recognition of fine pelvic innervation which can lead to nerve sparing techniques. This may confer a reduction in bladder dysfunction which is a norm after a radical hysterectomy,” added Dr Lim.
“Laparoscopy has been increasingly used worldwide as an alternate route of surgery in the practice of oncology. The advantages of less pain and less wound infection associated with small abdominal incision are beneficial to patients suffering from gynaecological cancer without compromising survival outcomes. However, not all
cases of early stages of cervical cancer are suitable for laparoscopic surgery and they must be counselled regarding the benefits and the complications of the surgery,” said A/Prof Phillip Yam, Head and Senior Consultant, Department of Gynaecological Oncology, KKH.
“We will continue to evaluate the role of laparoscopy in the management of gynaecological cancers to increase options for our patients and enable them to make informed choices about their preferred route of surgery,” said Dr Lim.
|