Introduction

Surgery remains the cornerstone of managing women affected by gynaecological malignancies. Gynaecological oncology is a well-established sub-specialty of the field of cancer care owing to a well-defined training path for doctors and centralised referral of patients, which takes place in most countries.

In 1995, the Calman–Hine report developed the concept of centralisation of cancer care aimed at improving cancer survival in the UK. A recent report has confirmed that centralising the care of women with gynaecological malignancies in specialised centres has improved the quality of care and the survival outcomes.

In response to an increased complex clinical scenario, the surgical approach in gynaecological oncology has undergone major changes. For women with early stage disease, the effort has generally been to move radical surgery from open- to minimal-access surgery. For women with advanced stage of disease, the attempt has been to reduce the tumour load by using multivisceral surgery and staging the extent of disease to tailor the adjuvant treatment. Surgical options for women with recurrent disease, or in the context of symptom palliation, has also been evaluated.

In this review, we focus on minimal-access surgery, radical multivisceral surgery, limits of fertility-sparing surgery, and exenterative procedures.

Minimal-access surgery

The concept of minimal access was introduced in the late 1980s, with the advent of laparoscopic surgery. The traditional concept of laparoscopy refers to the direct use of straight instruments over a few ports. Currently, robotic surgery (i.e. instruments that have a full rotation and are activated by electric arms) and single-port surgery (i.e. use of a single larger port) are variants of the original laparoscopic surgery.

Since the time of the first laparoscopic-assisted vaginal hysterectomy and laparoscopic-assisted radical vaginal hysterectomy with pelvic and para-aortic lymph-node dissection, laparoscopy has gained a definite role in the management of women with endometrial and cervical cancer. In addition, interest has increased in the use of laparoscopy in women with ovarian cancer.

The minimal-access route is used in women with all types of gynaecological malignancies, either to diagnose stage or treat the tumour. After the publication of several studies, including a few clinical trials, it has become the method of choice to treat women with early endometrial cancer. The traditional advantages of laparoscopy over laparotomy (e.g. decreased surgical morbidity, hospital stay, wound infection and dehiscence) are coupled with similar survival outcomes.

In women with endometrial cancer, the results of three large clinical trials, including the GOG lap2 and the LACE trial failed to show any significant difference in survival, but confirmed the advantage for women randomised to the laparoscopic arm.

In view of the results of these and other studies, precise guidelines have been issued from national institutions to mandate the use of laparoscopy in the management of women with early endometrial and cervical cancer. An encouraging statement has also been released on the use of laparoscopy for women with cervical cancer. The lack of a clinical trial, however, has only allowed for an approval statement.

Meanwhile, robotic-assisted laparoscopy was introduced and quickly gained popularity. Since the US Food and Drug Administration approval of the daVinci robotic system in 2004 for gynaecological surgery, the number of centres using robotic system has boosted. Although most surgical procedures have successfully been carried out with the assistance of the robot, a recent Cochrane review of both benign and malignant disease failed to show a significant advantage for the patient. The first robotic-assisted laparoscopic radical hysterectomy for cervical cancer was reported in 2006. At present, one randomised trial has recruited participants for radical hysterectomy for cervical cancer comparing robotic-assisted laparoscopy with conventional laparoscopy. So far, all the studies concur with one of the major advantages of robotic-assisted surgery: the obvious ergonomic benefit for the surgeon. Other benefits are a shorter learning curve and the availability of a validated virtual training system avoiding any risk for the patient. The few available randomised trials of robotic-assisted laparoscopy compared with conventional laparoscopy did not reveal an advantage for robotic assistance, although the results are conflicting. One study found a higher conversion rate to laparotomy (16.3%) after conventional laparoscopic surgery compared with 7.8% in women who had undergone robotic-assisted surgery. Another study reported opposite results, with 5.5% and 9.6% conversion rate in the laparoscopy and robotic group, respectively. A single-centre prospective randomised study comparing robotic-assisted laparoscopic, conventional laparoscopic and open surgery showed a significant conversion rate to laparotomy after conventional laparoscopic surgery.

Another development of the laparoscopic surgery has been the introduction of the single port approach. The main merit is the reduced number of incisions, possibly translating to less pain. One of the limits is the restriction of the range of movements and the working space. The surgeon and assistant must manoeuver in a small space outside the abdomen, resulting in hand collisions.

Minimal-access surgery

The concept of minimal access was introduced in the late 1980s, with the advent of laparoscopic surgery. The traditional concept of laparoscopy refers to the direct use of straight instruments over a few ports. Currently, robotic surgery (i.e. instruments that have a full rotation and are activated by electric arms) and single-port surgery (i.e. use of a single larger port) are variants of the original laparoscopic surgery.

Since the time of the first laparoscopic-assisted vaginal hysterectomy and laparoscopic-assisted radical vaginal hysterectomy with pelvic and para-aortic lymph-node dissection, laparoscopy has gained a definite role in the management of women with endometrial and cervical cancer. In addition, interest has increased in the use of laparoscopy in women with ovarian cancer.

The minimal-access route is used in women with all types of gynaecological malignancies, either to diagnose stage or treat the tumour. After the publication of several studies, including a few clinical trials, it has become the method of choice to treat women with early endometrial cancer. The traditional advantages of laparoscopy over laparotomy (e.g. decreased surgical morbidity, hospital stay, wound infection and dehiscence) are coupled with similar survival outcomes.

In women with endometrial cancer, the results of three large clinical trials, including the GOG lap2 and the LACE trial failed to show any significant difference in survival, but confirmed the advantage for women randomised to the laparoscopic arm.

In view of the results of these and other studies, precise guidelines have been issued from national institutions to mandate the use of laparoscopy in the management of women with early endometrial and cervical cancer. An encouraging statement has also been released on the use of laparoscopy for women with cervical cancer. The lack of a clinical trial, however, has only allowed for an approval statement.

Meanwhile, robotic-assisted laparoscopy was introduced and quickly gained popularity. Since the US Food and Drug Administration approval of the daVinci robotic system in 2004 for gynaecological surgery, the number of centres using robotic system has boosted. Although most surgical procedures have successfully been carried out with the assistance of the robot, a recent Cochrane review of both benign and malignant disease failed to show a significant advantage for the patient. The first robotic-assisted laparoscopic radical hysterectomy for cervical cancer was reported in 2006. At present, one randomised trial has recruited participants for radical hysterectomy for cervical cancer comparing robotic-assisted laparoscopy with conventional laparoscopy. So far, all the studies concur with one of the major advantages of robotic-assisted surgery: the obvious ergonomic benefit for the surgeon. Other benefits are a shorter learning curve and the availability of a validated virtual training system avoiding any risk for the patient. The few available randomised trials of robotic-assisted laparoscopy compared with conventional laparoscopy did not reveal an advantage for robotic assistance, although the results are conflicting. One study found a higher conversion rate to laparotomy (16.3%) after conventional laparoscopic surgery compared with 7.8% in women who had undergone robotic-assisted surgery. Another study reported opposite results, with 5.5% and 9.6% conversion rate in the laparoscopy and robotic group, respectively. A single-centre prospective randomised study comparing robotic-assisted laparoscopic, conventional laparoscopic and open surgery showed a significant conversion rate to laparotomy after conventional laparoscopic surgery.

Another development of the laparoscopic surgery has been the introduction of the single port approach. The main merit is the reduced number of incisions, possibly translating to less pain. One of the limits is the restriction of the range of movements and the working space. The surgeon and assistant must manoeuver in a small space outside the abdomen, resulting in hand collisions.

Radical multivisceral surgery

The concept of ‘debulking surgery’ for women with ovarian cancer has been the standard of care for the past 4 decades, but the extent of the operation has evolved significantly during the past few years. The amount of residual disease after surgery is the single most important prognostic factor for survival in women with ovarian cancer. Women with ‘no visible disease’ are associated with the best outcome. This remains true for women having primary surgery as well as for those having surgery after neoadjuvant chemotherapy.

In order to achieve complete or optimal debulking, a multi-visceral surgery is necessary. A retroperitoneal ‘en-bloc resection’ of the pelvic tumour, including the uterus, tubes, ovaries, the entire pelvic peritoneum, and the sigmoid resection, has become more commonly used owing to the reduced blood loss and the achievement of sound dissection plans.

One of the most common sites of tumour metastasis in women with ovarian cancer is the upper abdomen, namely the omentum, the diaphragmatic peritoneum, and the spleen. Diaphragmatic disease is found in 70–80% of all stage IIIc–IV disease, and surgery for complete resection has proved feasible with acceptable morbidity, even when it includes a resection of the pleura with access of the thorax.

Consistent reports of women who have undergone successful surgery of the pancreas, the spleen and the porta hepatis to remove deposits of ovarian cancer in the frame of an optimal debulking have been published. The factors that most commonly affect the rate of complete debulking are the patient’s performance status, surgical expertise, and institutional practice. Although no randomised-controlled has compared radical multivisceral surgery with less radical surgery, the aim of ‘no visible residual disease’ remains the goal of any surgery for women with ovarian cancer.

Fertility-sparing options

Fertility preservation is one of the most controversial areas in gynaecological oncology. The idea of potentially jeopardising the survival outcome of women with a curable disease in order to preserve fertility is still under debate. The paradigmatic example is the use of a radical trachelectomy for women with early stage cervical cancer, conventionally treated with a radical hysterectomy. The radical trachelectomy involves the removal of the entire uterine cervix, the upper third of the vagina and the parametrial tissues, following a bilateral pelvic lymphadenectomy usually carried out by laparoscopy.

A number of retrospective studies and a large review have been published, which overwhelmingly support the safety of surgery in the treatment of cancer. An encouraging fertility rate (around 70% of women are able to conceive) has been reported, making radical trachelectomy the option of choice for young women with FIGO stage Ib1cervical cancer.

The option of fertility preservation has also been investigated, with interesting results in women with early stage ovarian cancers, namely stage IA. In an attempt to spare fertility in these women, the standard treatment has to be modified twice: leaving behind one ovary, tube and the uterus, but also holding back from using chemotherapy. Although the latter issue has been solidly supported by the publication of the ICON and ACTION trial, preserving one ovary and the tube has only been reported in the retrospective studies. The results of these studies have failed to show any additional risk on survival, with few results on fertility and obstetric outcome.