Early-stage cervical cancer is treatable either by radiation therapy or surgical removal of the cancer. The standard surgical treatment for this condition is radical hysterectomy, which entails the removal of the uterus, cervix, bilateral parametria (connective tissue in the pelvis), upper vagina, and a portion of the uterosacral ligament—combined with a pelvic lymphadenectomy (complete removal of the pelvic lymph nodes). In cases where the patient wants to preserve the option to have a child in the future, a radical trachelectomy, in which all the aforementioned organs are surgically removed except for the uterus, may be an option. This can only be decided after careful discussion with the patient’s gynecologic oncologist, however.
Robotic surgery is particularly well-suited to both of these procedures, thanks to its excellent visualization of the operating field and the fact that it enhances the ability of surgeons to perform the meticulous dissections required in these surgeries.
Once five ports have been placed in the patient’s abdomen using quarter-inch incisions, the surgeon begins by dissecting the spaces inside the pelvis to define the operating field. Next, the bladder is moved away from the uterus, cervix and upper vagina, and the uterine artery is tied off and cut at its origin from the internal iliac (or hypogastric) artery. The ureter is then completely dissected away from its surrounding tissue, allowing for a resection of the entire parametrial tissue, after which the rectovaginal space is opened by incising the peritoneum and the uterosacral ligaments are resected. Finally the upper vagina is excised and the uterus, cervix, both parametria, the uretral sacral ligaments and upper vagina are all removed en bloc (together) through the vagina, after which the remaining vagina is sutured shut.
In the case of a radical trachelectomy, the procedure is performed in much the same fashion, except that an incision is made at the cervico-uterine junction and at the level of the vagina, and the cervix is then excised at the junction where it meets the uterus in order to preserve the top and body of the uterus. The vagina is then sutured to the lower uterine segment.
A pelvic lymphadenectomy (total removal of the pelvic lymph nodes) is a critical part of these procedures, both from a standpoint of staging and cancer control. This step can be performed either before or after a radical hysterectomy. It is always performed prior to a radical trachelectomy, however, since the uterine-sparing approach may be abandoned mid-procedure if the lymph nodes appear to be suspicious for cancer. First, the peritoneum overlying the external iliac artery is incised, and all visible lymphatic tissue is then surgically removed from the upper and lower pelvis. Careful dissection is performed to preserve the genitofemoral nerve, which is important for sensation.
It simplifies an inherently difficult procedure. This highly complex operation is made significantly easier by the fact that the da Vinci surgical system’s 3-D, high-definition image allows the surgeon to easily visualize all aspects of the operating field and precisely dissect fine tissues such as the ureters and major blood vessels.
Less blood loss during surgery. Robotic radical hysterectomy/trachelectomy is associated with less intra-operative blood loss compared to open or traditional laparoscopic surgery—reducing the need for blood transfusion.
Superior visualization of the operating site. The magnified 3-D, high-definition image provided by the da Vinci Si surgical system enables excellent visualization of the ureters, blood vessels, and other organs during surgery.
Less scarring. When radical hysterectomy/trachelectomy is performed robotically, the quarter-inch incisions result in significantly less scarring than with an open procedure.
Less post-operative pain. The smaller incisions used in robotic radical hysterectomy/trachelectomy also result in less post-operative pain than the large abdominal incision employed in open surgery. In addition, there may be less manipulation of the incision sites when using the da Vinci Si surgical system compared to laparoscopic surgery. This may also contribute to decreased post-operative pain—something that is the subject of an ongoing prospective investigation by the gynecologic surgeons at NYU Langone’s Robotic Surgery Center.
Faster recovery and shorter hospital stay. Most patients undergoing robotic radical hysterectomy are able to resume normal activities within 2 to 3 weeks, compared to 6 to 8 weeks for open surgery.
Fewer post-operative complications. Compared to open surgery, minimally-invasive hysterectomy procedures, including robotic radical hysterectomy/trachelectomy, are associated with reduced risk of complications, including infection of the incision sites.
Our gynecologic oncology surgeons, Dr. Bhavana Pothuri and Dr. John Curtin, are among the most highly-skilled laparoscopic and robotic surgeons in the New York area, and have spent many years perfecting minimally-invasive surgical techniques for the treatment of gynecologic cancers. Over the past several years, they have built on their extensive experience with laparoscopy to expand into the robotic realm. During this time they have performed a number of radical hysterectomies for the treatment of early-stage cervical cancer.