what we see on the you tube does not indicate a true radical surgery as in the open one.moreover vaginal cuff removal is not as enough as in the open surgery

I believe that further data is mandatory

A clinical trial with less missing data

(Especially those related to specimen)

A full literature review to determine factors of relapse, see if those were reported in the LACC trial and try to see if they are significant.

In any malignsncy open surgery has a better outcome compared to laparoscopy.

Further spread is the main issue in lap sugery

In genitourinary malignancy including cervical malignancy, if we are performing the Preop PET-CT and Pelvic MRI then accurate stage the or restage the disease. In the previous publish data; surgeries was based on the preop abdomino- pelvic MRI, they have not included PET-CT for staging; so early functional changes are not pick up in cancer patients. So now standard imagings (Whole body PET-CT and pelvic MRI) have to be performed before the surgery then you have to decide the type of surgery (open or laparoscopy) and taken the follow up of patients after the surgery for residual and recurrent disease.

Namita could you be more specific. What will imaging add to our surgery. I guess but ı want to listen from you

Dear sir, in routine practice now we are performing pre-op Pelvic MRI and whole body PET- CT in all cervical cancer patients. Then in tumor board, we are deciding what type of treatment has to be given. The mode of surgery whether it would be laparoscopic or open depends on regional nodal and primary disease extension on imaging.

Ok, Namita. But what do you think why the prognosis iş worse in ls surgery? Are you obgyn bu the way?

Dear Sir, I m obs gynecology doctor and actively participating in tumor board for Gynae Oncology patients. Now we are also taking the follow up of all patients who underwent for surgery for CA cervix. In my thinking, the statement regarding inferiority of laparoscopic surgery than open surgery in CA cervix patients, probably due to inappropriate patient selection for CA cervix surgery.

An explanation could be that when insufflating the abdominal cavity to perform laparoscopic or robotic surgery can spread tumor cells

This is an interesting explanation and should be considered for research. İn fact, there are some pro and con papers for this thougt. Thank you Mauro.

Kong et al. Found a significant increase of relapse when the vaginal vault was opened laparoscpillay compared to when its opened vaginally

Stating that at that time CO2 could help spreading tumor cells

Kong TW, Chang SJ, Piao X, et al. Patterns of recurrence and survival after abdominal versus laparoscopic/robotic radical hysterectomy in patients with early cervical cancer. J Obstet Gynaecol Res 2016;42:77-86

Thank you all for your comments. It is interesting to know that we do not always have scientific explanation to our observation.

However the question at this point is not why the results are as it is reported, but what we should do to our practice and counselling our patients for treatment.

We all need to have our own prospective credible data to appropriately guide our patients to choose treatment options.

The future research has to focus on some fundamental aspect of cancer cell behaviour in the context of open versus laparoscopic or robotic surgery.

My oppinion regarding radical hysterectomy by laparoscopy is inferior than open surgery is:

1. By open surgery you can operate by using your 5 senses, especialy by using your finger.(Laparoscopy is like you eat noodle by using long chopstick.).

2. Opening the vaginal cuff by laparoscopy, it is posible to spread the tumor cells and cause ent-metastasis.

3.By Open abdominal, explore the whole abdomen, you can palpate how long you want to cut the vagina.Before we cut the vagina we place werthein klemp to the vagina distal to the tumor ,rinse the vagina from the vagina with Hgcl2 solution, and than cut the vigina distal from the klemp.to prevent spreading cancer cells to the operative wound.

4. In more severe Stage IIA with involvement > 3cm vagina. We performend modified Wertheim, by performing vaginal manchet . Vaginally we cut distal from the tumor circular incision ,disect the vagina proximally and close the vaginal manchet by putting alcohol tampon, before abdominal surgery. So we can know exactly.the border between cancerous and normal vagina .

5. Cervical carcinoma is clinical staging .