Title
A Randomized Controlled Trial of Robotic versus Open Surgery for Early Stage Cervical Cancer (ROCC trial)

Description
This is a multi-center, open-label, randomized, non-inferiority clinical trial with the hypothesis that robotically assisted radical hysterectomy with tumor containment prior to colpotomy is non-inferior to abdominal radical hysterectomy with respect to disease free survival.

A t the commencement of surgery, a thorough inspection of all peritoneal surfaces should be performed. The location of any suspected metastatic disease should be documented in the operative report and a biopsy should be performed to confirm the diagnosis. If intraperitoneal disease is detected, the radical hysterectomy should be abandoned. In patients with macroscopic evidence of metastatic disease to the lymph nodes, intraoperative frozen section should be performed to confirm the presence of metastatic disease. Intraoperative management will be left to the discretion of the surgeon. Patients who have confirmed macroscopic lymph node metastases intraoperatively will be excluded from final analysis and replaced due to the controversy surrounding the decision to perform a radical hysterectomy in this setting. Patients in whom the radical hysterectomy is abandoned will be deemed non-evaluable and excluded from final analysis and will be replaced. For all patients, the surgeon should document operative time from incision to close, detailed description of operative findings, intraoperative complications, and blood loss. For patients randomized to the robotic arm, the surgeon should document the use of and specify the type of vaginal manipulator and the reason for conversion to laparotomy (if applicable). Transcervical manipulators are not permitted.

Standard arm: Radical hysterectomy is performed as per standard technique (peon radical hysterectomy (Piver type 2 or 3 or Querleu & Morrow Type B or C) with salpingectomy +/- oophorectomy. Ovaries may be removed or preserved +/- transposition. Prior to colpotomy, the vagina must be closed over the tumor (ie, Wertheim clamps, contour stapling device).

Study arm: Radical hysterectomy is performed as per standard robotic technique (Querleu & Morrow Type B or C) with salpingectomy +/- oophorectomy. Ovaries may be removed or preserved +/- transposition. Colpotomy may be made intracorporally or vaginally. Vagina must be closed prior to intracorporeal colpotomy.

Objective
Primary objective:
To compare disease-free survival (DFS) at 3 years for women who undergo robotic radical hysterectomy (RRH) vs open radical hysterectomy (ORH) for early stage cervical cancer.

Secondary Objectives:
-Compare disease specific survival (DSS) and overall survival (OS) between the two arms
-Compare patterns of recurrence between the two arms
-Compare intra- and immediate post-operative complications between the two arms within 30 days of surgery
-Compare long-term morbidity between the two arms within 12 months of surgery
-Compare the impact on patient reported outcomes (PROs) between the two arms
-Compare patient-reported lower extremity lymphedema between SLN mapping and lymphadenectomy

Treatment Active Comparator: Open radical hysterectomy
Other: open surgery
open radical hysterectomy

Experimental: Robotic radical hysterectomy
Device: da Vinci
Minimally invasive robotic-assisted surgical device

Key Eligibility Inclusion Criteria:

Patient must have histologically confirmed adenocarcinoma (usual/classic/NOS), squamous cell carcinoma, adenosquamous carcinoma (Including glassy cell)

Patient must be FIGO Stage IA2, IBI, IB2 (2018 staging) without evidence of definitive parametrial, vaginal, nodal or distant metastases on exam or imaging.

Patient must have uterine size <12 cm AND felt to be appropriate for vaginal delivery of the specimen per investigator.

Patient must be suitable surgical candidate with preoperative assessments such as labs and EKG performed per institutional standard.

Patient must be age 18 years or older.

Patient must have ECOG performance status 0-1.

Patient must have a negative urine pregnancy test within 30 days of surgery in pre-menopausal women.

Patient must have signed an approved informed consent and authorization permitting the release of personal health information.

Patients with any tumor histology other than those listed above, specifically excluding the following histologies: neuroendocrine, other adenocarcinoma (gastric type, endometrioid, clear cell, serous, signet ring, minimal deviation)

Patients with FIGO stage 1A1, IB3, II-IV (2018 staging).

Patient with inability to receive an MRI.

Patients with a tumor size >/=4cm or with definite evidence of vaginal/parametrial involvement on MRI (if MRI findings are not definitive, then clinical examination must also reveal parametrial or vaginal extension).

Patients with evidence of metastatic disease (imaging or histologically positive lymph nodes).

Patients with a history of prior pelvic or abdominal radiotherapy.

Patients with a prior malignancy < 5 years from enrollment with the exception of non-melanoma skin cancer.

Patients who are unable to withstand prolonged lithotomy or steep trendelenberg.

Patient compliance and geographic proximity that do not allow adequate follow-up.

Patients with poorly controlled HIV with CD4 counts <500.

Applicable Disease Sites
Cervix

Participating Institutions
UW Health Eastpark Medical Center; UW Health University Hospital