Cost analysis of laparoscopy versus laparotomy for early endometrial cancer

Surgical Treatment for Endometrial Cancer, Hysterectomy Performed via Minimally Invasive Routes Compared with Open Surgery: A Systematic Review and Network Meta-Analysis

Background: Total hysterectomy with bilateral salpingo-oophorectomy via minimally invasive surgery (MIS) has emerged as the standard of care for early-stage endometrial cancer (EC). Prior systematic reviews and meta-analyses have focused on outcomes reported solely from randomised controlled trials (RCTs), overlooking valuable data from non-randomised studies. This inaugural systematic review and network meta-analysis comprehensively compares clinical and oncological outcomes between MIS and open surgery for early-stage EC, incorporating evidence from randomised and non-randomised studies. Methods: This study was prospectively registered on PROSPERO (CRD42020186959). All original research of any experimental design reporting clinical and oncological outcomes of surgical treatment for endometrial cancer was included. Study selection was restricted to English-language peer-reviewed journal articles published 1 January 1995-31 December 2021. A Bayesian network meta-analysis was conducted. Results: A total of 99 studies were included in the network meta-analysis, comprising 181,716 women and 14 outcomes. Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time. Compared with laparoscopic surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR = 0.40, 95% CrI: 0.17-0.87) and total intra-operative complications (OR = 0.38, 95% CrI: 0.17-0.75) as well as a higher disease-free survival (OR = 2.45, 95% CrI: 1.04-6.34). Conclusions: For treating early endometrial cancer, minimal-access surgery via robotic-assisted or laparoscopic techniques appears safer and more efficacious than open surgery. Robotic-assisted surgery is associated with fewer complications and favourable oncological outcomes.

Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update

BACKGROUND

This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery.

METHODS

A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly.

CONCLUSIONS

The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.

Evaluation of costs and time required for laparoscopic-assisted versus open cystotomy for urinary cystolith removal in dogs: 43 cases (2009-2012)

OBJECTIVE

To compare required time and costs of surgery and hospitalization as well as prevalence of incomplete urinary cystolith removal associated with laparoscopic-assisted cystotomy versus open cystotomy in dogs.

DESIGN

Retrospective case series.

ANIMALS

20 dogs with urolithiasis treated by laparoscopic-assisted cystotomy and 23 dogs treated by open cystotomy.

PROCEDURES

Medical records were reviewed. Surgery cost, hospitalization cost, total cost, surgery time, days in hospital, incomplete cystolith removal, and number of doses of analgesic administered IV after surgery were compared between the laparoscopic-assisted cystotomy and open cystotomy groups. Results-Surgery cost and total cost were significantly higher in the laparoscopic-assisted cystotomy group. Hospitalization cost, days in hospital, and prevalence of incomplete cystolith removal did not differ significantly between groups. Number of doses of analgesic was significantly lower in the laparoscopic-assisted cystotomy group.

CONCLUSIONS AND CLINICAL RELEVANCE

Laparoscopic-assisted cystotomy was more time-consuming and expensive but associated with fewer postoperative doses of injectable analgesics, compared with open cystotomy. Laparoscopic-assisted cystotomy is an acceptable, more expensive, and minimally invasive alternative to open cystotomy for the removal of urinary cystoliths in dogs.

Surgical treatment for apparent early stage endometrial cancer

Most experts would agree that the standard surgical treatment for endometrial cancer includes a hysterectomy and bilateral salpingo-oophorectomy; however, the benefit of full surgical staging with lymph node dissection in patients with apparent early stage disease remains a topic of debate. Recent prospective data and advances in laparoscopic techniques have transformed this disease into one that can be successfully managed with minimally invasive surgery. This review will discuss the current surgical management of apparent early stage endometrial cancer and some of the new techniques that are being incorporated.

Update on surgical treatment for endometrial cancer

In the USA, carcinoma of the endometrium consistently ranks as the most common malignancy of the female genital tract. Since the majority of cases present with abnormal clinical symptoms, these patients are typically identified at an early, curable stage when the neoplasm is still confined to the uterus. Surgical removal of the organ involved remains the cornerstone of treatment for this disease, and in light of this, surgery has replaced clinical examination as the staging modality of this malignancy. Surgery also appears to have a role in the management of advanced and recurrent disease. The surgical treatment of this disease is the focus of this review.

Predictors and costs of surgical site infections in patients with endometrial cancer

OBJECTIVE

Technological advances in surgical management of endometrial cancer (EC) may allow for novel risk modification in surgical site infection (SSI).

METHODS

Perioperative variables were abstracted from EC cases surgically staged between January 1, 1999, and December 31, 2008. Primary outcome was SSI, as defined by American College of Surgeons National Surgical Quality Improvement Program. Counseling and global models were built to assess perioperative predictors of superficial incisional SSI and organ/space SSI. Thirty-day cost of SSI was calculated.

RESULTS

Among 1369 EC patients, 136 (9.9%) had SSI. In the counseling model, significant predictors of superficial incisional SSI were obesity, American Society of Anesthesiologists (ASA) score >2, preoperative anemia (hematocrit <36%), and laparotomy. In the global model, significant predictors of superficial incisional SSI were obesity, ASA score >2, smoking, laparotomy, and intraoperative transfusion. Counseling model predictors of organ/space SSI were older age, smoking, preoperative glucose >110 mg/dL, and prior methicillin-resistant Staphylococcus aureus (MRSA) infection. Global predictors of organ/space SSI were older age, smoking, vascular disease, prior MRSA infection, greater estimated blood loss, and lymphadenectomy or bowel resection. SSI resulted in a $5447 median increase in 30-day cost.

CONCLUSIONS

Our findings are useful to individualize preoperative risk counseling. Hyperglycemia and smoking are modifiable, and minimally invasive surgical approaches should be the preferred surgical route because they decrease SSI events. Judicious use of lymphadenectomy may decrease SSI. Thirty-day postoperative costs are considerably increased when SSI occurs.

Laparoscopy and body mass index: feasibility and outcome in obese patients treated for gynecologic diseases

STUDY OBJECTIVE

To compare feasibility and surgical outcome of laparoscopic gynecologic surgery between obese, overweight, normal-weight, and underweight women.

DESIGN

Retrospective case control study (Canadian Task Force classification II-3).

SETTING

Surgery Unit of Minimally Invasive Gynaecology.

PATIENTS

A total of 503 women who underwent laparoscopic procedures for both benign disease and malignancies.

INTERVENTIONS

Four main categories of gynecologic disease were identified: uterine fibroids, benign adnexal masses, endometriosis, and endometrial cancer (stage I). For each category patients were divided into 4 groups: underweight (BMI <18.5 kg/m(2)), normal-weight (BMI 18.5-24.9 kg/m(2)), overweight (BMI 25-29.9 kg/m(2)), and obese (BMI ≥30 kg/m(2)).

MEASUREMENTS AND MAIN RESULTS

Selected outcomes were duration of surgery, rate of laparotomy conversion, intraoperative and postoperative complications, and duration of hospital stay. No statistical difference regarding demographic data, surgical and medical history, and intraoperative findings was present between groups. No laparotomy conversion occurred. Regarding duration of surgery, we found no statistical difference among the BMI groups with regard to benign diseases, whereas pelvic lymphadenectomy in obese patients with endometrial cancer had a statistically significant longer duration than in the control group (122 +/- 47 min vs 65 +/- 21 min, p <.001). The postoperative complication rate was 0.01%: 3 cases of blood transfusion and 1 case of hemoperitoneum among myomectomies; 1 ureteral fistula in surgery for pelvic endometriosis; and 1 case of postoperative lymphocele in endometrial cancer group. No statistically significant difference was found in duration of hospital stay among the BMI groups in any of the categories of disease. For each category we conducted an analysis to identify any possible risk factors other than BMI in the surgical outcomes.

CONCLUSION

Laparoscopic approach in the various applications of gynecologic surgery does not appear to be significantly influenced by BMI in terms of surgical outcomes, laparotomy conversion rate, intraoperative and postoperative complications rate, and duration of hospital stay. The technical difficulties can be solved if skilled surgeons and anesthetists are available.

The laparoscopic-assisted vaginal approach to early endometrial cancer

INTRODUCTION

For the surgical treatment of endometrial cancer laparotomy still is regarded as the gold standard. Over the past decade, the laparoscopic approach has gained equivalence in FIGO stage I carcinomas.

RESULTS

Laparoscopic-assisted vaginal hysterectomy and bilateral salpingooophorectomy plus pelvic/paraaortic lymphadenectomy have shown short-term advantages such as reduced blood loss and shorter hospitalization without reducing oncological safety or outcome. This has already been confirmed by numerous smaller studies and recent randomized controlled trials with sufficient numbers of patients are being published.

CONCLUSION

Further acceptance of the technique is necessary to enable every gynecological oncologist to individualize treatment by offering minimal access options.

Laparoscopic versus abdominal hysterectomy for endometrial cancer: comparison of patient outcomes

OBJECTIVE

To compare the demographics, cancer characteristics, and hospital outcomes of endometrial cancer patients undergoing a laparoscopically assisted vaginal hysterectomy (LAVH) versus a total abdominal hysterectomy (TAH).

METHODS

Two California population databases (Office of Statewide Health Planning and Development and the California Cancer Registry) were linked using patient identifiers. Patients who underwent endometrial cancer surgery from 1997 to 2001 were identified. The combined database was queried for type of surgery, patient demographics, hospital outcomes, comorbidities, and cancer characteristics. Statistical analyses included the t test, chi2 test, and logistic regression.

RESULTS

In this study, 978 endometrial cancer patients (7.7%) had an LAVH and 11,765 (92.3%) had a TAH. The mean ages for the 2 groups were 63.3 and 64.8 years, respectively. Lymphadenectomy was performed more frequently in LAVH patients compared with TAH patients (45.6 vs 41.1%; P = 0.006). Patients undergoing LAVH were more likely to be younger and healthier and have stage I or grade 1 disease (P < 0.0001). Total abdominal hysterectomy patients were more likely to have significant medical comorbidities. Mean length of stay for LAVH was 2.40 versus 4.36 days for TAH (P < 0.001), but mean hospital charges were comparable. Perioperative complications such as vascular and bowel injuries, pulmonary embolism, wound problems, and transfusions were significantly more common in TAH patients.

CONCLUSION

Surgeons seem to carefully select endometrial cancer patients for laparoscopic surgery. Although surgical staging was performed in less than 50% of endometrial cancer patients, the rate was not worse in laparoscopic procedures. Short-term hospital complications were less common in the laparoscopy group.

Quality of life of patients with endometrial cancer undergoing laparoscopic international federation of gynecology and obstetrics staging compared with laparotomy: a Gynecologic Oncology Group study

PURPOSE

The study's objective was to compare the quality of life (QoL) of patients with endometrial cancer undergoing surgical staging via laparoscopy versus laparotomy.

PATIENTS AND METHODS

The first 802 eligible patients (laparoscopy, n = 535; laparotomy, n = 267) participated in the QoL study in a Gynecologic Oncology Group (GOG) randomized trial of laparoscopy versus laparotomy (GOG 2222). Patients completed QoL assessments at baseline; at 1, 3, and 6 weeks; and at 6 months postsurgery.

RESULTS

In an intent-to-treat analysis, laparoscopy patients reported significantly higher Functional Assessment of Cancer Therapy-General (FACT-G) scores (P = .001), better physical functioning (P = .006), better body image (BI; P < .001), less pain (P < .001) and its interference with QoL (P < .001), and an earlier resumption of normal activities (P = .003) and return to work (P = .04) over the 6-week postsurgery period, as compared with laparotomy patients. However, the differences in BI and return to work between groups were modest, and the adjusted FACT-G scores did not meet the minimally important difference (MID) between the two surgical arms over 6 weeks. By 6 months, except for better BI in laparoscopy patients (P < .001), the difference in QoL between the two surgical techniques was not statistically significant.

CONCLUSION

Although the FACT-G did not show a MID between the two surgical groups, and only modest differences in return to work and BI were found between the two groups, statistically significantly better QoL across many parameters in the laparoscopy arm at 6 weeks provides modest support for the QoL advantage of using laparoscopy to stage patients with early endometrial cancer.

Role of robotic surgery in endometrial cancer

OPINION STATEMENT

Uterine cancer is the most common gynecologic cancer in women in the United States with an estimated number of 40,100 women diagnosed in 2008, the great majority of which belongs to endometrial classification. The traditional approach to treatment of endometrial cancer has been primarily surgery via an open, laparotomy incision. Minimally invasive approaches with smaller incisions, i.e., laparoscopy for the management of endometrial cancer was initially reported in 1992; however, its adoption has been slow due to the prolonged learning curve needed to become proficient in such a technique. Robotic-assisted surgery, a further advancement of traditional laparoscopy, using computer-based controls has been developed enabling the performance of complex procedures that otherwise had been too difficult to accomplish in a minimally invasive fashion. Robotic-assisted laparoscopic radical prostatectomy is one such example that has gained rapid acceptance in recent years. Although the use of robotic-assisted laparoscopy for endometrial cancer is still in its early phase, this approach is anticipated to become similarly, a common approach to the management of endometrial cancer in the future.

The role of comprehensive surgical staging in patients with endometrial cancer

BACKGROUND

The cornerstone of the management of patients with endometrial cancer is hysterectomy. Since 1988, the role of lymphadenectomy for patients with endometrial cancer has been debated. Patients who undergo pelvic and para-aortic lymphadenectomy are more likely to be accurately staged and are less likely to receive adjuvant radiation therapy.

METHODS

The authors perform a narrative review of the recent literature. Overall survival, utilization of radiation therapy, impact on quality of life, and alternative approaches to surgical staging are discussed.

RESULTS

Although a survival benefit from comprehensive surgical staging has not been clearly demonstrated in patients diagnosed with endometrial cancer, surgical staging allows one to determine the need for adjuvant therapy. Preoperative and intraoperative assessment of lymph node metastasis and tumor grade lacks accuracy. Unstaged patients are more likely to receive postoperative radiation therapy.

CONCLUSIONS

Comprehensive surgical staging with lymphadenectomy allows patients to be classified accurately into risk categories. Risk status can be definitively determined only with final pathology. Surgically staged patients are more likely to receive appropriate adjuvant therapy or observation when warranted.

Comparison of Laparoscopy and Laparotomy for Management of Endometrial Carcinoma: A Meta-analysis

Background:

This meta-analysis was performed to investigate the outcome of laparoscopic surgery for endometrial carcinoma compared with laparotomy.

Methods:

We searched the MEDLINE (PubMed), EMBASE, and Cochrane Review databases in September 2007. Three independent evaluators selected the articles according to predetermined selection criteria.

Results:

Thirteen comparative studies (5 prospective and 8 retrospective) that met the selection criteria were included. In a fixed-effects meta-analysis, the overall survival and therecurrence rate showed no significant differences between the laparoscopy and the laparotomy groups, with odds ratios of 0.84 (95% confidence interval, 0.64-1.62) and 0.90 (95% confidence interval, 0.49-1.16), respectively. However, the complication rate was lower in the laparoscopy group than in the laparotomy group with an odds ratio of 0.43 (95% confidence interval, 0.32-0.58).

Conclusions:

The survival outcome and recurrence rate after laparoscopic surgery for endometrial carcinoma were similar to those in the laparotomy procedures. However, the complication rate was lower after laparoscopy compared with laparotomy.

Laparoscopic surgery vs laparotomy for early stage endometrial cancer: long-term data of a randomized controlled trial

OBJECTIVE

The purpose of the study was to compare the long-term safety and efficacy of laparoscopic surgery and laparotomy approaches to early stage endometrial cancer.

STUDY DESIGN

This was a prospective long-term extension study of a randomized controlled study that included 84 patients with clinical stage I endometrial cancer (laparoscopic surgery group, 40 women; laparotomy group, 38 women). Safety and efficacy data were evaluated and analyzed by the intention-to-treat principle.

RESULTS

After a follow-up period of 78 months (interquartile range, 7; range, 19-84 months) and 79 months (interquartile range, 6; range, 22-84 months) for laparoscopic surgery and laparotomy groups, respectively, no difference in the cumulative recurrence rates (8/40 [20.0%] and 7/38 [18.4%]; P = .860) and deaths (7/40 [17.5%] and 6/38 [15.8%] patients; P = .839) was detected between groups. No significant differences in overall (P = .535) and disease-free (P = .512) survival were observed.

CONCLUSION

The laparoscopic surgery approach to early stage endometrial cancer is as safe and effective a procedure as the laparotomy approach.

Robotic versus open radical hysterectomy: a comparative study at a single institution

OBJECTIVE

To compare the short-term surgical outcome of patients undergoing robotic radical hysterectomy (RRH) versus open radical hysterectomy (ORH) for the treatment of early stage cervical cancer.

METHODS

IRB approval was obtained for a retrospective chart review of all radical hysterectomies (RHs) for Stage I and II cervical cancer performed at Brigham and Women's Hospital between August 1, 2004 and August 1, 2007. Prior to August 1, 2006 all procedures were ORHs. After this date, all procedures were RRHs. Demographic data, operative data and short-term outcomes were compared. Statistical analysis using t-tests and Fisher's Exact test were performed with SAS software.

RESULTS

A total of 48 RHs were identified, including 16 RRHs and 32 ORHs. The groups did not differ significantly in age, body mass index, stage, or histology. Mean operative time was significantly longer for RRH than ORH (4:50 vs 3:39 h, p=0.0002). The mean estimated blood loss was significantly less for RRH than ORH (81.9 vs 665.6 mL, p<0.0001). The mean number of lymph nodes resected did not differ between RRHs and ORHs (15.6 vs 17.1, p=0.532). There were no intra-operative complications in the RRH group and one ureteral transection in the ORH group. Three RRH patients (18.8%) suffered post-operative complications which included a vaginal cuff infected hematoma, a transient ureterovaginal fistula, and a pelvic lymphocele, in comparison to seven in the ORH group (21.9%) which included 3 wound infections, two patients with pulmonary emboli, a partial small bowel obstruction with a mesenteric abscess, and a post-operative ileus (p=0.999). Mean length of stay was significantly shorter for the RRH group (1.7 vs. 4.9 days, p<0.0001).

CONCLUSION

RRH results in lower blood loss and shorter length of stay, compared to ORH. Intra-operative and post-operative complication rates are comparable. RRH is a promising new surgical technique that deserves further study.

Small cell neuroendocrine carcinoma of the endometrium and laparoscopic staging: a clinicopathologic study of a case and a brief review of the literature

Small cell neuroendocrine (NE) carcinoma is one of the most aggressive tumors that arise in the female genital tract. Small cell carcinoma of the endometrium (SCCE) is an extremely rare disease. Because of its rarity, the only clinical reports are limited to case studies, and therefore, clinical behavior and optimal treatment modalities are not well defined. To the best of our knowledge, we present the first case of SCCE staged by laparoscopic approach. A 54-year-old parous woman admitted with intermittent vaginal spotting. On physical examination, she had a 4- x 3-cm mass fungating out of the cervical os. Magnetic resonance imaging showed an endometrial mass of 25 x 30 x 50 mm in dimensions, invading less than 50% of the depth of the myometrium at the uterine fundus. Pathologic examination revealed undifferentiated malign NE tumor of endometrium of small cell type. The patient underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and laparoscopic pelvic and para-aortic lymphadenectomy. The disease was surgically staged as IB. Histologically, tumor cells were monotone, with scanty, ill-defined cytoplasm and hyperchromatic nuclei. Immunohistochemically, tumor showed positive immunoreactivity for P16, neuron-specific enolase, and synaptophysin. She underwent pelvic external radiation and brachytherapy postoperatively. Patient has no evidence of disease after 26 months of follow-up. Small cell NE carcinoma of the endometrium is an extremely rare and aggressive disease. With the availability of skilled endoscopic surgeons, laparoscopic management of women, even with SCCE in early stage, can be a feasible option.

Safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic nodal dissection for locally advanced cervical carcinoma

OBJECTIVE

To report on the safety, feasibility, and costs of outpatient laparoscopic extraperitoneal aortic lymph node dissection (LEPSS) for locally advanced cervical carcinoma.

METHODS

A retrospective analysis of all outpatient LEPSS procedures performed at our institution between August 2005 and February 2007 was performed. All patients with clinical stage IIB-IVA cervical carcinoma with no evidence of bulky aortic lymphadenopathy (>1.0 cm) on pre-operative computed tomography were offered the procedure. If present, pelvic nodal disease could not exceed greater than 1.5 cm. Records were reviewed for demographics, operative findings, complications, length of stay, and CT scan aortic nodal status. As a comparison, the average costs for outpatient LEPSS and outpatient CT, MRI, and PET scan at our institution were calculated.

RESULTS

A total of eighteen outpatient LEPSS procedures were identified. The median age was 49 (22-72). The median BMI was 29 (18-51). The median operative time was 108 min (60-135 min). The median aortic nodal count was 10 (5-20 nodes). The median blood loss was 25 ml (10-50 ml). There were no intraoperative complications. There was no conversion from a retroperitoneal to a transperitoneal approach. No patient required overnight hospitalization. One patient experienced a lymphocyst postoperatively. There was no delay in the initiation of chemoradiation for any of the patients with a median onset of 10 days from the date of surgery. At least 20% of the patients had one or more medical co-morbidities such as obesity, diabetes, hypertension, or a prior abdominal surgery. Occult aortic nodal metastasis was detected in 11% of the patients with a negative pre-operative CT scan. The average calculated costs at our institution for outpatient LEPSS was $5233 dollars versus $1520 dollars for CT scan, $4830 dollars for MRI and $5494 dollars for a PET scan.

CONCLUSIONS

To our knowledge this is the first reported experience of outpatient laparoscopic extraperitoneal aortic lymph node dissection for locally advanced cervical cancer. Outpatient LEPSS appears to be a safe and feasible procedure in the hands of an experienced surgeon, however further study is warranted. From a cost analysis perspective, outpatient LEPSS appears equivalent to PET scan and MRI, but is more expensive than CT scan.

Comparison of total laparoscopic and abdominal radical hysterectomy for patients with early-stage cervical cancer

OBJECTIVE

To compare intraoperative, pathologic, and postoperative outcomes of total laparoscopic radical hysterectomy with abdominal radical hysterectomy and pelvic lymphadenectomy for women with early-stage cervical cancer.

METHODS

We reviewed all patients who underwent total laparoscopic radical hysterectomy or abdominal radical hysterectomy and pelvic lymphadenectomy between 2004 and 2006.

RESULTS

Fifty-four patients underwent abdominal radical hysterectomy, and 35 underwent total laparoscopic radical hysterectomy. Mean age was 41.8 years, and mean body mass index 28.1. There was no difference in demographic or tumor factors between the two groups. Mean estimated blood loss was 548 mL with abdominal radical hysterectomy compared with 319 mL with total laparoscopic radical hysterectomy (P=.009), and 15% of patients who underwent abdominal radical hysterectomy required a blood transfusion compared with 11% who underwent total laparoscopic radical hysterectomy (P=.62). Mean operative time was 307 minutes for abdominal radical hysterectomy compared with 344 minutes for total laparoscopic radical hysterectomy (P=.03). On pathologic examination, there was no significant difference in the amount of parametrial tissue, vaginal cuff, or negative margins obtained. A mean 19 pelvic nodes were obtained during abdominal radical hysterectomy compared with 14 during total laparoscopic radical hysterectomy (P=.001). The median duration of hospital stay was significantly shorter for total laparoscopic radical hysterectomy (2.0 compared with 5.0 days, P<.001). For abdominal radical hysterectomy, 53% of patients experienced postoperative infectious morbidity compared with 18% for total laparoscopic radical hysterectomy (P=.001). There was no difference in postoperative noninfectious morbidity. There was no difference in return of urinary function.

CONCLUSION

Total laparoscopic radical hysterectomy reduces operative blood loss, postoperative infectious morbidity, and postoperative length of stay without sacrificing the size of radical hysterectomy specimen margins; however, total laparoscopic radical hysterectomy is associated with increased operative time.

Laparoscopy-assisted vaginal hysterectomy compared with abdominal hysterectomy in clinical stage I endometrial cancer: safety, recurrence, and long-term outcome

OBJECTIVE

To determine the feasibility of laparoscopic-assisted vaginal hysterectomy (LAVH) in the treatment of clinical FIGO stage I endometrial adenocarcinoma and long-term survival outcome.

STUDY DESIGN

Prospective cohort study without randomization of 169 consecutive patients. Laparoscopy or laparotomy was selected based on size and mobility of the uterus and Body Mass Index (BMI). Lymphadenectomy was only performed in cases at high-risk for nodal metastases.

RESULTS

Sixty-nine patients (41%) treated successfully by LAVH (LAVH group) while 100 (59%) by total abdominal hysterectomy (TAH) (laparotomy group). Four out of 73 patients initially approached by laparoscopy were converted to laparotomy (5.5%). Lymphadenectomy was performed in 40% of the LAVH and 57% of TAH group (P = 0.03). The median number of pelvic lymph nodes removed by LAVH and laparotomy was 15 (range 2-31) and 21 (range 2-65), respectively (P = 0.05). LAVH was associated with more surgical FIGO stage IA disease and a smaller tumor diameter. Operative time was significantly longer with laparoscopy compared with laparotomy, while blood loss and duration of hospitalization was significantly lower in the LAVH group. The recurrence rate in the LAVH group was 8.7%, compared with 16% in the laparotomy group (not significant, NS). The actuarial overall survival (OS) and disease-free survival (DFS) for the LAVH were 93% and 91% compared with 86% and 84% in the TAH, respectively (NS). In the multivariate analyses histological subtype was the only independent prognostic factor for DFS, while surgical technique was not.

CONCLUSION

LAVH with lymphadenectomy in selected population in high-risk patients with clinical stage I endometrial adenocarcinoma and with favorable body mass index of less than 35 kg/m2, appears to be safe procedure.

Total laparoscopic versus open surgery for stage 1 endometrial cancer: The LACE randomized controlled trial

PURPOSE

Endometrial cancer is the most common gynaecological malignancy in Australia and the US. Current standard treatment involves open surgery to remove the uterus, and both tubes and ovaries (TAH). The Laparoscopic Approach to Cancer of the Endometrium (LACE) trial was designed to assess equivalence of performing this in a total laparoscopic approach (TLH).

METHODS

Patient recruitment was designed to proceed along two stages to accommodate for a potential increase in patient requests of laparoscopic surgery. During the first stage, patients are randomised in a 2:1 allocation to receive TLH or TAH, with the primary endpoint quality of life (QoL) at 6 month post-surgery, requiring 180 patients to be enrolled to have 80% power at alpha=0.05 to detect a clinically significant difference of 8 points on the Functional Assessment of Cancer General (FACT-G) QoL instrument. If additional recruitment of patients seems impossible after accrual of 180 patients, this cohort will be followed for 4 years, and disease free survival (DFS) of patients treated by TLH will be compared to DFS within the endometrial cancer population. During the second stage, recruitment will be extended to a total of 590 patients in a 1:1 TLH:TAH allocation, to assess the equivalence with respect to DFS with 80% power and alpha=0.05. Equivalence will be assumed if the difference in DFS does not exceed 7% at 4 years. Secondary outcomes include treatment related morbidity; costs and cost-effectiveness; patterns of recurrence; and overall survival. All data from this multicentre study will be entered using online electronic case report forms (e-CRF), allowing real time assessment of data completeness and patient follow-up.

CONCLUSIONS

The LACE trial will establish the equivalence of a TLH approach for patients with stage 1 endometrial cancer following a two stage protocol to accommodate potential threats to patient recruitment through requests for laparoscopic surgery.

Participation of the general gynecologist in surgical staging of endometrial cancer: analysis of cost and perioperative outcomes

OBJECTIVE

To compare the cost and perioperative outcomes of endometrial cancer staging when the procedure is performed by a gynecologic oncologist alone or when a general gynecologist participates in the procedure.

METHODS

A retrospective analysis was performed on a series of women with clinical stage I endometrial cancer treated at a single institution between 1/98 and 12/00. The patients were grouped according to the participation of a general gynecologist in their surgery. The 48 patients in Group 1 underwent surgery with a general gynecologist who consulted a gynecologic oncologist intraoperatively. Group 2 included 77 patients whose procedure was performed completely by a gynecologic oncologist. The two groups were compared with the chi-square, Fisher's exact, and Wilcoxon rank sum tests. Cost analysis included total hospital costs (room, pharmacy, and ancillary services) and total surgical costs (anesthesia, operating room, procedure, and perioperative physician evaluation costs).

RESULTS

The groups did not differ in age, type of surgeries performed, distribution of surgical stage, proportion of patients undergoing lymph node sampling (LNS), and length of follow-up. When LNS was performed, Group 2 had a significantly shorter median operative time (170 vs. 180 min; P=0.05) and shorter total time in the operating room (204 vs. 224 min; P=0.02). This group had a lower procedure cost when considered both in terms of payor's cost ($1,414 vs. $2,134; P<0.0001) and physician charge ($7,106 vs. $11,116; P<0.0001). Perioperative physician evaluation was reduced by almost half ($685 vs. $424; P<0.0001) in Group 2. Group 2 had a savings in total surgical cost by payor's cost ($9,142 vs. 10,294; P=0.005) or physician's charge ($14,546 vs. $19,276; P<0.0001), and in combined hospital and surgical cost by payor's cost ($15,664 vs. $17,346; P=0.004) or physician charge ($21,311 vs. $26,328; P<0.0001). Total hospital costs, however, did not differ between groups.

CONCLUSION

Operative time and costs increase when general gynecologists participate in the surgical procedure of patients with clinical stage I endometrial cancer. Although perioperative outcomes are similar, the involvement of two surgeons increases the length of the procedure as well as the cost of operating room time and physician reimbursement. The efficient use of limited health care resources must be considered as we plan the surgical approach to endometrial cancer.

The impact of obesity on surgery in gynecological oncology: a review

Surgery represents a mainstay in the treatment of gynecological cancers. It is a common belief that operating on obese patients causes more peri- and postoperative complications than operating on nonobese patients. The surgical outcome in gynecological oncology can be evaluated by comparing intra- and postoperative complications, extent of lymphadenectomy, negativity of the specimens' margins, and percentage of optimal debulking between obese and nonobese patients affected by malignancies at the same stage. In this review, we analyze how obesity affects the feasibility of a correct oncologic procedure in case of cervical, endometrial, and ovarian cancer. We also describe the techniques that have been suggested in the literature to improve the surgical outcome on obese patients.

[Role of Laparoscopy in the Treatment of Endometrial Carcinoma]

In the treatment of endometrial carcinoma of stages I and II, laparoscopic or laparoscopically assisted vaginal hysterectomy with bilateral adnexectomy is oncologically equivalent to abdominal hysterectomy. As the pelvic and para-aortal laparoscopic lymph node dissection can now be safely carried out, it is possible to decide definitely for or against adjuvant percutaneous irradiation. The removal of metastatic lymph nodes seems to improve survival significantly.

Laparoscopic treatment of endometrial cancer: feasibility and results

OBJECTIVE

The aim of this study was to compare laparoscopic and abdominal approach in the treatment of endometrial cancer in our department.

STUDY DESIGN

From January 1999 to November 2002, 77 patients underwent surgery for stages I-III endometrial cancer. The first group of 36 patients had abdominal hysterectomy as well as salpingo-oophorectomy, with or without lymphadenectomy. The remaining 41 patients received laparoscopic assisted vaginal hysterectomy as well as salpingo-oophorectomy, with or without lymphadenectomy. In this retrospective study, we have compared the surgical results, the short- and long-term morbidity and the outcome of the two patient groups.

RESULTS

Body mass index (BMI) was significantly higher in the laparoscopic group (27.3 versus 24.6; p=0.009). The average time for surgery was significantly longer for the laparoscopic group (143.6 min versus 109.7 min; p=0.0001), but lymphadenectomy was performed in more patients (63.4% versus 25%; p=0.001). Postoperative hospital stay was significantly longer in patients undergoing the abdominal approach (4.59 days versus 3.18 days; p<0.0001). No blood transfusions were performed and the rates of complications were similar in the two groups. No differences were found in recurrence and survival rate.

CONCLUSIONS

In our experience, laparoscopic and abdominal surgery can achieve similar results in the treatment of endometrial cancer. In our series, even with the BMI and the number of lymphadenectomies being higher in the laparoscopic group, the rates of complications were similar in the two groups.

A prospective randomized comparison between laparoscopic and laparotomic approaches in women with early stage endometrial cancer: a focus on the quality of life

OBJECTIVE

This study was undertaken to compare the quality of life (QoL) in women with early stage endometrial cancer treated with 2 different surgical approaches.

STUDY DESIGN

Eighty-four women with clinical stage I endometrial cancer were enrolled in a prospective randomized controlled trial design and treated with laparoscopic or laparotomic approach. Another 40 women matched for demographic characteristics were studied as controls. In patients, before and after surgery, and in their matched controls, QoL was evaluated by using the Short-Form Healthy Survey (SF-36) and the climacteric symptoms using the Kupperman Index (KI).

RESULTS

After randomization, no difference was detected in data recorded between the groups. At entry, QoL was similar in both treatment groups but significantly (P < .05) worse in comparison with controls. Throughout the study, QoL was significantly (P < .05) higher in laparoscopic group versus laparotomic group. After KI adjustment our data did not change.

CONCLUSION

In early stage endometrial cancer, the laparoscopic approach provides significant benefits compared with laparotomy in terms of QoL.

Laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in patients with stage I and II endometrial cancer

The purpose of this study was to evaluate and compare the outcomes of laparoscopic surgery with those of conventional abdominal surgery in patients with early endometrial cancer. From 1997 to 2003, 79 patients underwent laparoscopic-assisted vaginal hysterectomy with or without lymphadenectomy. Laparoscopy was performed on patients deemed clinical stage I in preoperative studies. Of the 79 patients, 74 found to be surgical stage I or II were enrolled in the comparative study. As a control group, we selected 168 laparotomy cases at the same disease stage as the laparoscopy group. Operation time, amount of blood transfusion, and hemoglobin changes were similar for both groups. In the laparoscopy group, the number of lymph nodes obtained was significantly higher, and the number of postoperative complications was lower compared to the laparotomy group. The hospital stay was significantly shorter for laparoscopy group. Three-year recurrence-free survival rates were similar, being 97.5% for the laparoscopy group and 98.6% for the laparotomy group. We conclude that laparoscopic surgery for treatment of early endometrial cancer is a safe and effective alternative to laparotomy in terms of perioperative complications. Three-year recurrence-free survival did not differ significantly between the groups. However, long-term survival and risk of recurrence have yet to be determined.

Outcomes of laparoscopic treatment for endometrial cancer

PURPOSE OF REVIEW

Laparoscopy has become the standard approach for the surgical management of a variety of benign gynecological conditions. Numerous studies have reported their findings on the laparoscopic approach for the treatment of patients with endometrial cancer. It is timely and relevant to provide a review of these findings.

RECENT FINDINGS

Comparison analysis of recurrence and survival rates for patients treated by laparoscopy and laparotomy have found similar results. A similar or reduced cost is noted for the laparoscopic approach. Numerous patient advantages are indicated for the laparoscopic approach. This information is detailed in this review.

SUMMARY

The open abdominal approach is an alternative to laparoscopy for the surgical treatment of patients with early endometrial cancer.

Laparoscopic-assisted vaginal hysterectomy versus abdominal hysterectomy in stages I and II endometrial cancer. Operating data, follow up and survival

OBJECTIVE

To assess the feasibility of laparoscopy in the treatment of early stage endometrial carcinoma and follow up outcomes compared to classic laparotomy.

METHODS

A retrospective review of 90 consecutive patients with endometrial cancer managed between January 1997 and December 2003. Two groups were defined whether they had been treated by laparoscopy (N = 38; LPS group) or by laparotomy (N = 37; LPM group). Nine patients treated by vaginal hysterectomy and 6 cases with stages III-IV were excluded from the study.

RESULTS

Both groups were comparable in mean age and mean BMI. Mean operating time was longer for LPS group, 164.91 +/- 5.60 (77-240) vs. 129.97 +/- 5.08 (60-180) min (P < 0.05). Intraoperative complications were seen in 7 patients (18.9%) from LPM and in 5 cases (13.2%) in the laparoscopic group. Two patients (5.2%) initially evaluated by laparoscopy were converted into laparotomy due to an increasing and uncontrollable hypercapnia. There were more post-operative complications in patients managed by laparotomy (14 cases; 38.8%), than by laparoscopy (7 cases; 18.4%) (P < 0.05). Blood transfusion was necessary in 4 patients (10.8%) in LPM group while none was required in LPS group (P < 0.01). Hospital readmission was only recorded in 3 patients treated by laparotomy (6.7%) (P < 0.05). Hospital stay was longer in LPM group 7.06 +/- 0.58 (4-21) vs. LPS 5.04 +/- 0.73 (2-17) days (P < 0.05). With a median follow up of 53.21 +/- 4.32 months for LPM (5-90) and 36.31 +/- 2.75 months for LPS (9-65) there was no significant difference in disease recurrence between the two groups.

CONCLUSION

Laparoscopic staging combined with vaginal hysterectomy appears to be a feasible alternative to classical surgical approach in patients with early stage I or II endometrial carcinoma.

Laparoscopy versus laparotomy in endometrial cancer: first analysis of survival of a randomized prospective study

STUDY OBJECTIVE

Laparoscopy has been proved to be safe and reliable in staging of patients with endometrial cancer. It has definite advantages over laparotomy, but a comparable survival outcome is still to be verified in prospective randomized trials.

DESIGN

Prospective, randomized clinical trial.

SETTING

Department of Gynecology, Friedrich Schiller University, Jena, Germany.

PATIENTS

One hundred twenty-two women with uterine cancer.

INTERVENTIONS

Laparotomy and laparoscopy.

MEASUREMENTS AND MAIN RESULTS

Sixty-three patients were allocated to the laparoscopy arm, and 59 were allocated to the laparotomy arm. Median follow-up for all patients was 44 months (range 5-96 months). Eight patients (12.6%) in the laparoscopy group had a recurrence versus five patients (8.5%) in the laparotomy group (p = .65). At median follow-up, disease-free survival (DFS) and overall survival (OS) in the laparoscopy group and laparotomy group were 87.4% versus 91.6% and 82.7% versus 86.5%, respectively. Cause-specific survival (CSS) was 90.5% in the laparoscopy group versus 94.9% in the laparotomy group. In patients with International Federation of Gynecology and Obstetrics stage I, DFS was 91.2% in the laparoscopy group versus 93.8% in the laparotomy group, OS was 86.5% versus 89.7%, and CSS was 93.4% versus 95.9%.

CONCLUSION

Laparoscopic vaginal treatment of patients with endometrial cancer provides a survival outcome comparable with laparotomy. If these data are confirmed, laparoscopic procedures should be included in routine therapy for patients with endometrial cancer.

Analysis of morbidity in patients with endometrial cancer: is there a commitment to offer laparoscopy?

OBJECTIVE

Benefits of laparoscopy over laparotomy in patients with endometrial cancer (EC) are well known. As many patients with EC carry co-morbid conditions, surgery is exposing them to increased risk of complications. A review of the patients with EC recruited so far in a clinical trial comparing laparoscopy to laparotomy was performed. The goal was to identify patients carrying specific risk factors for complications, who would most benefit of laparoscopy and be the ideal candidates for this surgical approach.

PATIENTS AND METHODS

Between July 1995 and December 2002, 122 patients with uterine cancer entered the study. Sixty-three patients were allocated to the laparoscopy (LPS) arm (group A), while 59 were allocated to the laparotomy (LPT) arm (group B). Rate and type of intra-, early and late post-operative complications were prospectively recorded. Risk factors for complications are analyzed to define a group of patients truly benefiting from laparoscopy.

RESULTS

Overall, 12 patients out of 122 (9.8%) have experienced intra-operative, 43 patients out of 122 (35.2%) early post-operative and 25 patients out of 122 (20.4%) late post-operative complications. Rate of intra-operative complications was 4.7% in group A (3 patients out of 63) vs. 15.2% in group B (9 patients out of 59), P = 0.082. Early post-operative complications rate was 23.8% in group A (15 out of 63) and 47.4% in group B (28 out of 59), P = 0.011. Rate of late post-operative complications was 7.9% (5 out of 63) in group A vs. 35.5% (21 out of 59), P = 0.001. Univariate analysis shows co-morbid medical conditions, weight >80 kg, Quetelet index >30 and age >65 years to be predictive of complications and, in fact, a subgroup of patients presenting with these characteristics (n = 57, 30 in group A and 27 in group B) has been recognized to accumulate 60% of the overall complications. In these patients, multivariate analysis identifies the surgical technique (LPS vs. LPT) to be the only significant risk factor for complications.

CONCLUSION

At least one third of the patients with EC carry serious co-morbidities with an increased surgical risk for complications. For this subgroup of patients, a laparoscopic-vaginal approach significantly reduces the rate of complications and should be the standard of surgical treatment.

Laparoscopic training and practice in gynecologic oncology among Society of Gynecologic Oncologists members and fellows-in-training

OBJECTIVE

To determine the proportion of Society of Gynecologic Oncologists (SGO) members performing laparoscopic procedures and to determine SGO members' and fellows' opinions regarding indications for and the adequacy of training in laparoscopy.

METHODS

Surveys were mailed to SGO members and fellows-in-training in December 2002. Anonymous responses were collected by mail or through a Web site. The survey was mailed twice and was estimated to take 5 min to complete. The data were analyzed using frequency distributions and nonparametric tests.

RESULTS

Three hundred thirty-six SGO members (45%) and fifty-seven fellows (49%) responded. Among SGO members, 272 (84%) currently performed laparoscopic surgeries. Reasons cited for performing laparoscopy were decreased length of hospital stay (74%), improved patient quality of life (57%), patient preference (48%), improved cosmesis (46%), and better visualization (18%). Among those who did not perform laparoscopy, 50% cited increased operating time as their main reason. When asked to indicate the laparoscopic procedure most commonly performed in their practice, 69% reported diagnosis of an adnexal mass; 11%, prophylactic bilateral salpingo-oophorectomies; and 10%, laparoscopically assisted vaginal hysterectomy and lymph node staging for uterine cancer. Only 3% of SGO respondents performed more than 50% of their procedures laparoscopically, and all respondents reported converting from laparoscopy to laparotomy less than 25% of the time. Most respondents had limited laparoscopic training during their fellowships: 39% received none, and 46% received limited (less than five procedures per month) training. Nevertheless, 78% of SGO respondents rated their laparoscopic skills as either very good or good. Among fellows, only 25% believed they were receiving very good or good laparoscopic training. Eighty percent of SGO respondents believe that at least six procedures per month were necessary for adequate training, yet only 33% of fellows performed that many procedures.

CONCLUSIONS

Most SGO respondents used laparoscopy for selective indications, and most developed their laparoscopic skills after their fellowship training. SGO respondents believed laparoscopic instruction is an important part of training, but most fellows perceived their laparoscopic training as inadequate.

Laparoscopic Pelvic and Paraaortic Lymphadenectomy in Gynecologic Oncology

In the early 1990s, different authors independently developed techniques for pelvic and paraaortic lymph node sampling. Since then, laparoscopic lymphadenectomy has been demonstrated to yield the same number of nodes when compared with the laparotomic approach. Only one microscopically involved lymph node was lost at laparoscopic lymphadenectomy when a laparotomic control followed immediately after. It seems bleeding, which is the most serious perioperative complication, is more common during laparoscopic lymphadenectomy than during laparotomy; however, the incidence will decrease with experience of the surgeon. The laparoscopic procedure does not seem to influence negatively the survival of patients with early stage endometrial and cervical cancer. There does not seem to be a significant reduction in overall hospital charges for laparoscopic surgery in oncology, but patients who undergo laparoscopic surgery recover significantly sooner than those who undergo laparotomy.

Traitement chirurgical des adénocarcinomes de l’endomètre : voies d’abord. Revue de la littérature

Three surgical approaches have been described for the treatment of women presenting an endometrial cancer. The aim of this study was to appreciate the current criteria that would offer guidelines for this choice. We reviewed the data available in the literature (search Medline). Only laparotomy and laparoscopy permit the carrying out of all the routine surgical staging according to the FIGO's criteria (classification 1988). Only one randomised study compares the results obtained by laparotomy and laparoscopy. Laparoscopy patients had significantly less morbidity. Overall survival did not differ in both groups with a limited follow-up. The other not randomised studies show that laparoscopy is usually proposed to patients having a lower IMC and presenting limited stages. No randomized study had compared laparotomy with the only vaginal surgery. The latter is generally proposed for patients having an associated comorbidity and presenting limited stages. In such cases, no difference in survival is highlighted. Obesity does not represent an absolute contra indication for any way. It makes the surgery generally more complex. A suspicious ovarian lesion, a large uterus are, currently, an indication for laparotomy. Laparoscopy can be accepted only if the uterine volume is lower than 500 g and without deep myometrial infiltration. Laparotomy surgery is the standard. The main indication of vaginal surgery is to permit treatment to high operatory risk patients. Laparoscopy is an option for the early stages. It is not recommended if an ovarian lesion or a deep uterine parietal infiltration are suspected. Whatever the route used, the surgeon must be trained.

Surgical chores and approach in the management of endometrial cancer

Carcinoma of the uterine corpus is the most common malignancy in the female pelvis. Surgical resection and staging are now the accepted approach to therapy, with excellent survival compared with other gynecologic malignancies. Several controversies exist, however, regarding optimal surgical management. Some of these controversies are addressed in this article, with a review of their recent and historic literature.