Regarding "30-day Postoperative Adverse Events in Minimally Invasive versus Open Abdominal Radical Hysterectomy for Early-stage Cervical Cancer"

To the Editor: In September 2017, the Laparoscopic Approach to Cer- vical Cancer (LACC) trial was suspended for enrollment because of the high rate of recurrence and cancer-related death in the minimally invasive group [1]. After its publica- tion, we assisted in a dramatic decrease in the adoption of minimally invasive surgery [1]. Interestingly, Obermair et al [2], in an ancillary publication of the randomized LACC trial, observed that the type of surgical approach does not affect the risk of developing adverse events. However, in this large retrospective experience, evaluat- ing data extracted from the American College of Surgeons National Surgical Quality Improvement Program, open rad- ical hysterectomy is associated with higher morbidity rates than minimally invasive one [3]. Other experiences corrob- orate these findings [4]. Three points regarding this issue have to be addressed. First, because this paper evaluated data of patients treated before the publication of the LACC trial, it is possible that more challenging cases (because of patient or disease characteristics) were treated with an open approach. Second, severity grading systems (e.g., Clavien- Dindo and Accordion classifications) and standardized reporting systems (e.g., Martin criteria) have to be adopted to improve the quality of outcomes’ reporting [2,4]. Third, surgical volume and expertise in both oncologic and mini- mally invasive practices might influence the adoption of one approach rather than another and their outcomes. More importantly, we have to highlight that minimally invasive surgery represents one of the relevant advantages for patients. Hence, methods to allow a safe minimally invasive radical hysterectomy have to be implemented. Until now, minimally invasive radical hysterectomy has to be performed only in the setting of clinical trials.