Minimally invasive radical hysterectomy for early stage cervical cancer

Evidence-based recommendations on minimally invasive radical hysterectomy for early stage cervical cancer. This involves removing the uterus, cervix, upper vagina and some lymph nodes.

# Recommendations
Evidence on minimally invasive radical hysterectomy for early stage cervical cancer shows that there are no short-term safety concerns.
The evidence on efficacy for tumours 2 cm or larger shows that minimally invasive radical hysterectomy has shorter disease-free and overall survival compared with open hysterectomy surgery. Therefore, this procedure should not be used for tumours 2 cm or above.
The evidence on efficacy for tumours smaller than 2 cm is inconclusive for disease-free and overall survival compared with open hysterectomy surgery. Therefore, for tumours smaller than 2 cm this procedure should only be used in the context of research. Find out what 'do not use' and 'only in research' mean on the NICE interventional procedures guidance page.
Further research, preferably in the form of randomised controlled trials, should describe details of patient selection, tumour histology and size and surgical technique and report overall survival, disease-free survival, tumour recurrence and patientreported outcome measures.# The condition, current treatments and procedure

# The condition
Cervical cancer is the second most common cancer in women under 35 years in the UK. The most common symptoms are abnormal vaginal bleeding or discharge, and discomfort during intercourse.
The International Federation of Gynecology and Obstetrics system is used to stage cervical cancer from 1 to 4. Early stage cervical cancer includes stage 1 (cancer confined to the cervix) to stage 2a (tumour has spread down into the top of the vagina).

# Current treatments
Radical hysterectomy is the most common surgical treatment for cervical cancer. It is conventionally done through an incision in the abdomen or through the vagina. It includes removing the uterus and supporting ligaments, cervix, upper vagina, the pelvic lymph nodes and sometimes the para-aortic lymph nodes.
Radiotherapy may be used, with or without surgery, and is usually combined with chemotherapy.

# The procedure
Minimally invasive radical hysterectomy for early stage cervical cancer is done using general anaesthesia. A uterine manipulator is often inserted through the vagina and attached to the uterus and cervix. The abdomen is insufflated with carbon dioxide, and several small incisions are made to provide access for the laparoscope and surgical instruments. A robot may be used to assist with the procedure. A hysterectomy is done by dividing the round ligaments, accessing the broad ligaments, dividing the uterine vessels and mobilising the uterus. If the ovaries are to be left in position, the utero-ovarian ligaments are transected. The pelvic lymph nodes and sometimes the para-aortic lymph nodes are removed through 1 of the abdominal incisions or through the vagina. The upper vagina, cervix and uterus are removed through the vagina.
The technique is distinct from laparoscopically assisted vaginal hysterectomy, which may include laparoscopic division of the infundibulopelvic ligaments and the uterine vessels before a vaginal hysterectomy is done.
A nerve-sparing radical hysterectomy is a modified technique that preserves pelvic nerves to prevent bladder dysfunction.
The aim is to remove all the cancer. The suggested benefits of the laparoscopic approach are shorter length of stay in hospital, shorter recovery period and minimal abdominal scarring.