Pros and Cons of Surgery Approaches in Gynecologic Cancers

From open abdominal surgery to laparoscopic surgery, there are many surgical approaches to consider for patients with gynecologic cancer.

For patients with gynecologic cancers, opting for minimally invasive surgery may be a key treatment approach, an expert explained during the CURE® Educated Patient® Gynecologic Cancers Summit. However, there are many pros and cons to weigh before choosing treatment.

Traditionally, surgery has played a large role in gynecologic cancers such as ovarian, uterine and cervical cancers, explained Dr. Jessica Parker during the Summit, but it’s important for patients to understand several surgical approaches that are used.

Parker is an assistant professor of clinical obstetrics and gynecology in the Department of Obstetrics and Gynecology at the Indiana University School of Medicine.

“The historic approach that we would always use in surgery was an open or an abdominal approach whereby we make a large incision, open up the patient's abdomen and perform our surgery that way,” she explained.

Meanwhile, minimally invasive surgery is defined as a surgical approach that helps limit the amount of damage to patients’ bodies with smaller incisions (surgical cuts) than open surgery, according to the Mayo Clinic.

Types of Minimally Invasive Surgeries in Gynecologic Cancers

There are three different ways to approach minimally invasive surgery, Parker said. They are:

• Laparoscopic surgery
• Robotic surgery
• Vaginal approach (not commonly done in gynecologic oncology)

Laparoscopic surgery is when small incisions are made and a camera is inserted to view inside the body, Parker explained. Through these small incisions, the surgeon is able to manipulate the surgical instruments to perform the surgery.

For robotic surgery, Parker noted that surgeons use a 3-dimensional camera to perform the surgery, which means surgeons are “able to further do even a little bit more robotically.”

The vaginal approach includes going through the vagina to perform the surgery and remove organs of interest, she said.

“This is done less commonly in gynecologic oncology or female cancer surgery, just due to the need to access things that are a little bit higher up than you can access only through the vagina, but this is used sometimes for certain indications,” Parker noted.

Pros and Cons: Open Surgery Versus Minimally Invasive Surgery

Parker discussed the advantages and disadvantages of each form of surgery, depending on the cancer type.

She noted that an advantage of having an open abdominal surgery is that there’s increased visibility for surgeons, especially for hard-to-see areas that cameras can’t access. With open surgery, surgeons are also able to increase their dexterity and movement of the tissue, meaning they can more easily identify where the cancer is located, she explained. Because of these advantages, she said, open abdominal surgery is the default surgical approach for patients with gynecologic cancers.

Of note, Parker also explained that if surgeons tried a laparoscopic or robotic surgical approach, but it didn’t work, open abdominal surgery is the next step.

Nevertheless, that still “comes at a cost,” Parker said, emphasizing that a main disadvantage to open abdominal surgery is typically having a large up-and-down incision made.

“Although, sometimes we can make one, and that’s side-to-side or sort of a bikini cut, if you will,” she said. “If you have a larger up-and-down incision, you have to think of the cosmetic side effects of that. We also think there are things, such as a longer recovery time and a longer hospital stay that’s associated with these open and abdominal surgeries.”

Because of these significant disadvantages, Parker added that minimally invasive surgeries have been on the rise most recently. Advantages of minimally invasive surgeries in general, according to Parker, include:

• Lower infection rates
• Decreased need for blood transfusions
• Lower risk of clotting
• Decreased time spent in the hospital (often leaving on the same day)
• Decreased cost of care
• Less post-operative pain
• Improved cosmetic result

Still, there are disadvantages of minimally invasive surgeries that must be considered, too, Parker noted. Parker said these general disadvantages include:

• Decreased access and visibility in certain cancers
• Doctors may be concerned if they are unable to feel the cancer with their hand — there is a risk of leaving some of the cancer behind
• For ovarian masses, there’s a risk of potential popping of those masses causing the tumor to spill out

“In certain circumstances, we would not recommend proceeding with a minimally invasive approach, and that's really individualized and based on the surgeons and the patient’s specific characteristics,” Parker explained. “And of course, the cost comes into play as well, especially with robotic surgery.”

Surgery Approaches Depending on Cancer Type

Ovarian Cancer

For patients with ovarian cancer, the surgical approach is commonly open abdominal surgery, Parker said, especially for people whose cancer is advanced.

“What I mean by advanced disease is when a patient has a tumor that has spread outside of that organ,” she explained. “For example, in ovarian cancer, if there’s a tumor that’s spread to other organs within the abdomen, then we would consider that to be advanced disease.

“In that case, there are benefits to being able to directly feel the tissue and feel for any tumor that might be hiding from us or in places that were unable to see very well with just a camera inside of the abdomen.”

If patients previously received systemic treatment, such as chemotherapy before surgery, and their tumor shrank, then a minimally invasive surgery may be an appropriate option.

Uterine Cancer

The minimally invasive surgical approach is just as good as open surgery for patients with uterine cancer, Parker said, according to research. However, there is still a caveat to this type of surgery.

“Historically, if we didn’t think we could get a very large uterus out through the small incisions that we're making, we will perform what's called a morcellation procedure, where, essentially, we cut that uterus up into smaller strips in order to be able to remove it through the smaller incisions,” explained Parker. “That is no longer recommended due to the small but present risk of having a type of uterine cancer called a sarcoma.”

So, patients with uterine cancer commonly undergo open abdominal surgery or an approach where the uterus itself is placed into a closed-bag system. In the closed-bag system approach, the tumor is removed via morcellation within the bag system to reduce the potential spread of the tumor cells in the abdomen, Parker noted.

Cervical Cancer

Surgical approaches for cervical cancer are not as common because there is “much less likelihood that someone might be a candidate for surgery,” Parker explained. She noted that treatment options of radiation and chemotherapy are often considered instead.

After some recent studies, researchers have determined that for patients eligible for surgery, the open surgery approach is done.

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