Long-Term Follow-Up After Laparoscopic Management of Endometrial Cancer in the Obese: A Fifteen-Year Cohort Study

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.

Association of Obesity and Surgery Outcomes in Patients with Endometrial Cancer: A Single-Center Analysis

OBJECTIVE

 Although obesity can result in high morbidity and mortality in surgical outcomes because of multiple comorbidities, determinants of outcome in obese patients who underwent endometrial cancer surgery remain unclear. The aim of this study is to assess the relationship between body mass index (BMI) and surgical outcomes in obese patients with endometrial cancer.

METHODS

 An institutional retrospective review of the demographic details, clinical characteristics, and follow-up data of 142 patients with endometrial cancer who underwent surgery during a 72-month period was performed. The patients were divided into three groups based on their BMI; patients with BMI < 25 were identified as normal weight, patients with BMI between 25 and 30 were accepted as overweight, and those with BMI ≥ 30 kg/m² were identified as obese. The groups' demographic and clinical variables were compared.

RESULTS

 Of the 142 patients, 42 were in the normal weight group, 55 in the overweight group, and 45 in the obese group. Age, surgical procedures, blood loss, preoperative health status, and metastatic lymph nodes did not show a significant difference between groups. However, surgery time and total lymph nodes were higher in the obese group. (p = 0.02, p = 0.00, and p = 0.00, respectively). Common complications were anemia, fever, intestinal injury, deep vein thrombosis, fascial dehiscence and urinary infection. There was no significant difference according to the complications.

CONCLUSION

 Our results indicated that higher BMI was significantly associated with a longer duration of endometrial cancer surgery. Minimally invasive surgeries and conventional laparotomy could be performed safely in obese patients.

Impact of Morbid Obesity on the Outcomes of Type II Endometrial Cancer: a Cohort Study

Obesity has long been associated with endometrial cancer. However, there is a paucity of studies addressing the impact of morbid obesity in type II endometrial cancer on oncologic and surgical outcomes. In this study, the author retrospectively compared morbid to non-morbid obese in clinico-epidemiologic, surgical, and oncologic outcomes. Both groups were comparable as regards all clinico-epidemiologic parameters. Vaginal involvement, survival, and recurrence were also comparable between the 2 groups. Para-aortic adenopathy and treatment with preoperative therapy were the only significant predictors of DFS. Surgery is feasible with equivalent complications and oncologic outcomes in morbidly obese patients with type II endometrial cancer.

Perioperative outcomes of women with and without class III obesity undergoing hysterectomy for endometrioid endometrial cancer: A population-based study

OBJECTIVE

Population-based data on perioperative complications among women with endometrial cancer and severe obesity are lacking. We evaluated 30-day complication rates among women with and without class III obesity (body mass index ≥ 40 kg/m²) undergoing primary surgical management for endometrioid endometrial cancer (EEC), and how outcomes differed according to surgical approach (open vs. minimally invasive).

METHODS

We performed a retrospective population-based cohort study of women with EEC undergoing hysterectomy in Ontario, Canada, between 2006 and 2015. We evaluated perioperative complications in the whole cohort, and in a 1:1 matched analysis using hard and propensity score matching to ensure similar distributions of patient, tumour, provider and institution-level factors between women with and without class III obesity (identified using a surgical billing code). The primary outcome of interest was the 30-day perioperative complication rate.

RESULTS

12,112 women met inclusion criteria; 2697 (22.3%) had class III obesity. We matched 2320 (86%) women with class III obesity to those without. The composite complication rate was significantly higher among women with class III obesity (23.2% vs. 18.4%, standardized mean difference [SMD] = 0.12), primarily due to wound infection/disruption (12.1% vs. 6.2%). There was no difference in outcomes for women with and without class III obesity when a minimally invasive approach was used.

CONCLUSIONS

Wound infection/disruption was increased for women with class III obesity compared to women without. Otherwise, perioperative complications were similar between the matched pairs. When minimally invasive approaches were used, women with class III obesity had a similar risk of complications as women without obesity.

Periaortic Abdominal Fat Area as a Predictor of Surgical Difficulties during Extraperitoneal Laparoscopic Para-aortic Lymphadenectomy

STUDY OBJECTIVE

To evaluate whether obesity is a marker of surgical difficulty during extraperitoneal para-aortic lymphadenectomy.

DESIGN

Retrospective observational cohort study.

SETTING

Tertiary medical center in the Kanazawa area of Japan.

PATIENTS

Eighty-four patients with primary endometrial cancer who underwent extraperitoneal laparoscopic para-aortic lymphadenectomy (LPAND) between January 2005 and December 2017 were included.

INTERVENTIONS

We investigated the correlation between operative times and body mass indexes, visceral fat areas, and periabdominal artery fat areas (PAFAs). The number of lymph nodes harvested was used as an indicator of the degree of surgical completion.

MEASUREMENTS AND MAIN RESULTS

There was no correlation between the operative time and body mass index. Significant correlations were observed between operative time and visceral fat area (p = .026; r = 0.243) and between operative time and PAFA (p = .007; r = 0.293). A multivariate analysis showed that PAFA was a significant independent marker that could be used to predict prolonged operative times for extraperitoneal LPAND (p = .045; odds ratio, 3.05). The number of para-aortic lymph nodes harvested was not significant in the high- and low-PAFA groups (22 and 25, respectively; p = .525).

CONCLUSION

PAFA is an adequate marker of prolonged operative time for extraperitoneal LPAND among patients with endometrial cancer.

Laparoscopic and robotic hysterectomy in endometrial cancer patients with obesity: a systematic review and meta-analysis of conversions and complications

OBJECTIVE DATA

Robotic assistance may facilitate completion of minimally invasive hysterectomy, which is the standard of care for the treatment of early-stage endometrial cancer, in patients for whom conventional laparoscopy is challenging. The aim of this systematic review was to assess conversion to laparotomy and perioperative complications after laparoscopic and robotic hysterectomy in patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²).

STUDY

We systematically searched MEDLINE, EMBASE, and Evidence-Based Medicine Reviews (January 1, 2000, to July 18, 2018) for studies of patients with endometrial cancer and obesity (body mass index, ≥30 kg/m²) who underwent primary hysterectomy.

STUDY APPRAISAL AND SYNTHESIS METHODS

We determined the pooled proportions of conversion, organ/vessel injury, venous thromboembolism, and blood transfusion. We assessed risk of bias with the Institute of Health Economics Quality Appraisal Checklist for single-arm studies, and Newcastle-Ottawa Quality Scale for double-arm studies.

RESULTS

We identified 51 observational studies that reported on 10,800 patients with endometrial cancer and obesity (study-level body mass index, 31.0-56.3 kg/m²). The pooled proportions of conversion from laparoscopic and robotic hysterectomy were 6.5% (95% confidence interval, 4.3-9.9) and 5.5% (95% confidence interval, 3.3-9.1), respectively, among patients with a body mass index of ≥30 kg/m², and 7.0% (95% confidence interval, 3.2-14.5) and 3.8% (95% confidence interval, 1.4-9.9) among patients with body mass index of ≥40 kg/m². Inadequate exposure because of adhesions/visceral adiposity was the most common reason for conversion for both laparoscopic (32%) and robotic hysterectomy (61%); however, intolerance of the Trendelenburg position caused 31% of laparoscopic conversions and 6% of robotic hysterectomy conversions. The pooled proportions of organ/vessel injury (laparoscopic, 3.5% [95% confidence interval, 2.2-5.5]; robotic hysterectomy, 1.2% [95% confidence interval, 0.4-3.4]), venous thromboembolism (laparoscopic, 0.5% [95% confidence interval, 0.2-1.2]; robotic hysterectomy, 0.5% [95% confidence interval, 0.1-2.0]), and blood transfusion (laparoscopic, 2.8% [95% confidence interval, 1.5-5.1]; robotic hysterectomy, 2.1% [95% confidence interval, 1.6-3.8]) were low and not appreciably different between arms.

CONCLUSION

Robotic and laparoscopic hysterectomy have similar rates perioperative complications in patients with endometrial cancer and obesity, but robotic hysterectomy may reduce conversions because of positional intolerance in patients with morbid obesity. Existing literature is limited by selection and confounding bias, and randomized trials are needed to inform practice standards in this population.

Obesity in total laparoscopic hysterectomy for early stage endometrial cancer: health gain and inpatient resource use

OBJECTIVE

To explore relationships between BMI (morbid/severe obesity; BMI ≥ 35 kg/m2 vs. non morbid/severe obesity; BMI < 35 kg/m2), postoperative health gain and hospital resource use for women who receive a Total Laparoscopic Hysterectomy (TLH) for early stage endometrial cancer.

DESIGN

Secondary analysis of RCT data (LACE Study; Total Abdominal Hysterectomy vs. TLH).

SETTING

20 tertiary gynaecological cancer centres in Australia, New Zealand and Hong Kong.

POPULATION

About 404 women who received TLH to treat early stage endometrial cancer.

METHODS

For women with BMI < 35 vs. BMI ≥ 35 kg/m2, we compared (i) postoperative health gain, using utility scores derived from responses to the EQ-5D-3L health-related quality of life instrument, and (ii) inpatient hospital resource use, using adverse events, surgery duration and postoperative length of stay as indicators, to 6 months post-surgery.

MAIN OUTCOME MEASURES

Health gain, resource use.

RESULTS

Mean postoperative health gain was 0.07 units, and did not vary by BMI. Women with a BMI ≥ 35 had an increased rate of severe postoperative AEs (BMI ≥ 35 RR = 1.95, P = 0.02), and the surgery took on average 9.6 min longer (BMI < 35 kg/m2 122.5 min 95% CI 117.4-127.8; BMI ≥ 35 kg/m2 132.1 min 95% CI 126.3-138.2; P = 0.02).

CONCLUSION

While postoperative health gain for women with BMI ≥ 35 was similar to that of women with lower BMI, the gain was achieved at the expense of greater resource use. Further work could definitively quantify the excess cost of TLH for obese patients with endometrial cancer, and investigate the potential for non-surgical treatment options, at least for those women at high risk of postoperative AEs.

The Feasibility of Laparoscopic Surgery in Gynecologic Oncology for Obese and Morbidly Obese Patients

BACKGROUND

Surgical interventions are the mainstay of treatment for many gynecological cancers. Although minimally invasive surgery offers many potential advantages, performing laparoscopic pelvic surgery in obese patients remains challenging. To overcome this, many centers have shifted their practice to robotic surgery; however, the high costs associated with robotic surgery are concerning and limit its use.

OBJECTIVE

This study aimed to examine the feasibility of performing laparoscopic gynecologic oncology procedures in obese and morbidly obese patients.

MATERIALS AND METHODS

This retrospective study evaluated patients who underwent laparoscopic surgeries by a gynecologic oncologist from January 2012 to June 2016 at a designated gynecologic oncology center. Patients were categorized as nonobese (body mass index [BMI] < 30 kg/m), obese (BMI 30-39.9 kg/m), and morbidly obese (BMI ≥ 40 kg/m). Intra and postoperative complications and outcomes were recorded. Group differences were computed with Kruskal-Wallis nonparametric test (continuous) or Fisher exact test (categorical).

RESULTS

Of 497 patients, 288 were nonobese (58%), 162 obese (33%), and 47 morbidly obese (9%). Complex surgical procedures were performed in 57.4% of obese patients and 55.3% of morbidly obese patients. Although morbidly obese and obese patients had longer operative times (mean of 181 and 166 minutes vs 144 minutes, P = 0.014), conversion from laparoscopy to laparotomy occurred in 9.05% of all patients, with no group differences. Low intraoperative (9%-11%) and severe postoperative (2.41%) complication rates were observed overall, with no group differences. There was no statistically significant difference in the rate of emergency room visits 30 days postoperation between the 3 BMI groups (P = 0.6108). Average length of postoperative stay was statistically significant (P = 0.0003) but was low overall (1-2 days). Hospital readmission rates were low, with the lowest rate among morbidly obese patients (2.13%).

CONCLUSIONS

Our data suggest that laparoscopic gynecologic-oncology procedures for obese patients are feasible and safe.

The Senhance™ surgical robotic system ("Senhance") for total hysterectomy in obese patients: a pilot study

This pilot study was aimed to value the feasibility and safety of Senhance Robotic Platform for hysterectomy in obese patients. Ten obese patients (30 < BMI < 40) underwent elective Senhance total extrafascial hysterectomy with bilateral salpingo-oophorectomy at the Division of Gynecologic Oncology of "Policlinico A. Gemelli" Foundation, Rome, Italy. Perioperative and postoperative outcomes data were recorded. The median age was 60 years (range 51-75) and the median BMI was 33.3 kg/m² (range 30.4-38.3). The median uterine weight was 112.5 g (range 77-225). Indication to total hysterectomy was early-stage (FIGO Stage IA) endometrial cancer in 100% of patients. The median operative time (OT) was 110 min (70-200). The median docking time was 10.5 min (5-25). The median estimated blood loss was 100 mL (50-200). No conversions to laparotomy were recorded. No intra- and 30-day postoperative complications were registered. The median ileus was 17 h (12-36) and the median time to discharge was 2 days (1-4). The median VAS scores registered at 2, 4, 12, and 24 h were, respectively, 2 (1-3), 2 (1-3), 4 (1-8), and 3 (1-5). Our study results suggest that Senhance platform could be safe for hysterectomy even in obese patients. More clinical data are needed to determine whether this approach would offer any additional benefits in a new middle line between standard laparoscopy and robotics.

The Impact of Obesity on Surgical Outcome in Endometrial Cancer Patients: A Systematic Review

Background: Obesity is a significant public health problem in the United States, and many studies have established obesity as a significant risk factor for endometrial cancer. Surgery is the standard of care in staging and treatment of endometrial cancer, and obesity may influence surgical outcomes because of its attendant comorbid conditions. Therefore, assessment of the impact of obesity on surgical outcome is important for decreasing morbidity and improving survival in patients with endometrial cancer. Objective: The aims of this research were to evaluate and review epidemiologic data systematically on the impact of obesity on surgical outcomes and to assess safety and feasibility of newer surgical techniques in obese patients. Materials and Methods: A systematic search of PubMed was conducted to identify articles between 2004 and 2013 that focused on the impact of obesity on surgical outcome. Reference lists of retrieved articles were also used to identify other relevant articles. Thirteen relevant articles were reviewed. Results: Evidence from epidemiologic studies showed that obesity impacts surgical outcome adversely. On average, obese patients have worse surgical outcomes than their nonobese counterparts. In addition, surgical outcome worsens as level of obesity increases. However, surgical procedure also influences this association. Minimally invasive surgeries are more useful and are accompanied with fewer complications than conventional laparotomy and can be performed safely in obese patients. Conclusions: Obesity is a significant risk in the etiology, treatment, and surgical outcomes of patients with endometrial cancer. Future research will need more randomized controlled trials and prospective studies to identify the best procedures for maximal outcomes. (J GYNECOL SURG 32:149).

Predictive Factor of Conversion to Laparotomy in Minimally Invasive Surgical Staging for Endometrial Cancer

OBJECTIVE

The aim of the study was to identify risk factors associated with laparotomy conversion during total laparoscopic hysterectomy for endometrial cancer.

METHODS

This is a retrospective study examining endometrial cancer cases that underwent hysterectomy-based surgical staging initiated via conventional laparoscopic approach. Factors related to patient, tumor, and surgeon were examined to establish risk of laparotomy conversion using a multivariate logistic regression model.

RESULTS

There were 251 cases identified including 30 cases (12.0%) of laparotomy conversion. The most common indication for laparotomy conversion was a large uterus (27.0%), followed by extensive adhesions (24.3%) and surgical complications (18.9%). Outcomes of cases resulting in laparotomy conversion include longer surgical time (333 vs 224 minutes, P < 0.001), larger blood loss (350 vs 100 mL, P < 0.001), longer hospital stay (4 vs 2 days, P < 0.001), and increased risk of hospital readmission (10% vs 1.4%, P = 0.024). In multivariate analysis, morbid obesity (odds ratio [OR], 4.51; P = 0.011), suboptimal pelvic examination or enlarged uterus during preoperative evaluation (OR, 3.55; P = 0.034), para-aortic lymphadenectomy (OR, 10.5; P = 0.001), uterine size 250 g or greater (OR, 3.49; P = 0.026), and extrauterine disease (OR, 4.68; P = 0.012) remained the independent predictors for laparotomy conversion. The following numbers of risk factors were significantly correlated with laparotomy-conversion rate: none, 1.1%; single risk factor, 5.3% (OR, 5.00; P = 0.15); double risk factors, 21.7% (OR, 24.9; P = 0.002); and triple or more risk factors, 50% (OR, 90.0; P < 0.001). Ultrasonographic 3-dimensional volumes of 496 cm in preoperative uterine size correlate with actual uterine weight of 250 g (Y = 61.5 + 0.38X, P < 0.001).

CONCLUSIONS

Laparotomy conversion significantly impacts outcomes of patients with endometrial cancer. In this setting, our predictive model for laparotomy conversion will be useful to guide the surgical management of endometrial cancer.

Body mass index and mortality in endometrial cancer: A systematic review and meta-analysis

OBJECTIVE

To evaluate the association between body mass index (BMI) and mortality in women with endometrial cancer.

METHODS

A systematic review was performed utilizing a Medline search with Mesh keywords 'endometrial neoplasms' and ('body mass index' or 'obesity') and ('survival analysis' or 'mortality' or 'survivor' or 'survival') for studies published prior to June 2013. Inclusion criteria included studies that assessed associations between BMI and survival in endometrial cancer patients. Two investigators independently reviewed the title and abstract and full-text of articles for inclusion or exclusion decision; discordant decisions were adjudicated by a third reviewer. A random-effects model was constructed that was comparable to the standard random-effects models used in the meta-analysis of odds ratios. The model was fitted using SAS PROC NLMIXED.

RESULTS

1451 studies were identified and reviewed in duplicate, 18 met inclusion criteria. A random-effects meta-analysis demonstrated significantly higher odds of mortality with increasing BMI in endometrial cancer patients. Specifically the odds ratios were 1.01, 1.17, 1.26, and 1.66 for BMI categories of 25-29.9, 30-34.9, 35-39.9, and 40+, respectively. The odds ratio for all-cause mortality in endometrial cancer patients with a BMI≥40 compared to those with a BMI<25 was 1.66 (CI: 1.10-2.51, p=0.02). A single dose-response model indicated that a 10% increase in BMI resulted in a 9.2% increase in the odds of all-cause mortality (p=0.007).

CONCLUSION

Increased BMI is significantly associated with increased all-cause mortality in women with endometrial cancer, with the highest risk for those with a BMI≥40.

The impact of BMI on surgical complications and outcomes in endometrial cancer surgery--an institutional study and systematic review of the literature

OBJECTIVES

We aimed to evaluate the association between body mass index (BMI), perioperative complications and outcomes in endometrial cancer (EC) patients at our institution. In addition, we performed a systematic review to compare our results to the literature.

METHODS

This was a retrospective study of surgically managed EC patients between January 2006 and January 2015. Patient characteristics, surgical complications and intra- and postoperative outcomes were evaluated across BMI groups; BMI <30kg/m(2), BMI ≥30kg/m(2) and BMI ≥40kg/m(2). The systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

In total, we identified 627 women of which 514 were included; 249 women had a BMI of <30kg/m(2), 195 women had a BMI of 30-39.9kg/m(2), and 70 women were morbidly obese (BMI ≥40kg/m(2)). Obese women (BMI ≥30kg/m(2)) had significantly more postoperative surgical complications, including wound complications and antibiotics use, which was confirmed by the systematic review. The increase in complications mainly occurred in open surgery and morbidly obese patients were at highest risk. Obesity did not impact other outcomes including 30-day mortality.

CONCLUSION

Obesity is associated with an increased risk of surgical morbidity in EC patients, and is most profound in open surgery and among the morbidly obese. Laparoscopic surgery may well prevent the majority of postoperative complications in this group of patients, and should therefore be the favoured approach.

[Morbidity of pelvic lymphadenectomy and para-aortic lymphadenectomy in endometrial cancer]

The aim of this study was to evaluate the complication rate of pelvic and para-aortic lymphadenectomy in the management of endometrial cancer following the changes to the recommendations of INCa 2010. This is a retrospective study of 208 patients operated for endometrial cancer between July 2010 and March 2014 in two referral centers. Eighty lymphadenectomy were performed, 65 with hysterectomy and bilateral annexectomy and 18 lymphadenectomy were performed for restaging. Complications assessment is based on the Dindo Clavien classification. We report 17 severe complications (grade 3a and over) (P<0.001), including 14 among patients receiving lymphadenectomy. Morbidity increases with the number of lymphnodes removed and their positivity (P<0.001). The para-aortic lymphadenectomy is primarily responsible for complications (P <0.001). We describe 7 lower limbs lymphedema, 12 nerve injuries, 8 ileus, 5 venous or arterial thromboembolism, 17 blood transfusions, 13 lymphoceles including 9 infected. The rate of intraoperative complications on a first lymphadenectomy is 8% while it reached 22% for restaging. Restaging is significantly more at risk of serious complications (P=0.03) with two deaths. Twenty-four chronic disorders with impaired quality of life (2 without lymphadenectomy) are reported. They are present in 50% of restaging (P=0.033 compared to first lymphadenectomy). Lymphadenectomy is a source of severe morbidity (17.5%) with 2.5% mortality. The benefit of this surgery should probably be discussed again.

Laparoscopic staging in women older than 75 years with early-stage endometrial cancer: comparison with open surgical operation

OBJECTIVE

Older age is a relevant risk factor for developing endometrial cancer (EC) and has been traditionally regarded as a relative contraindication to laparoscopy. Our aim was to analyze the safety and effectiveness of laparoscopic staging in older women with EC.

METHODS

Consecutive women aged 75 years or older who underwent laparoscopic staging for EC between May 2002 and October 2012 were compared with consecutive women aged 75 years or older who underwent abdominal staging before the adoption of the laparoscopic approach in our institution. Postoperative complications were graded according to the Accordion Severity Grading System.

RESULTS

Fifty-nine women aged 75 years or older who underwent laparoscopy were compared with a cohort of 66 women aged 75 years or older who underwent open staging before the incorporation of laparoscopy. Demographic and disease characteristics, as well as the Charlson comorbidity index, were balanced between groups. Women who underwent laparoscopy had similar operative time (P = 0.14), lower blood loss (P = 0.005), and shorter length of stay (P < 0.001) in comparison with women who underwent open surgical operation. Overall, women who underwent laparoscopy experienced less postoperative complications than women in the control group (P < 0.001). In addition, focusing only on complications grade 3 or higher, we observed a trend toward decreased complication rates in the laparoscopic group (P = 0.06). No differences in survival outcomes (including time of recurrence, site of recurrence, disease-free survival, and overall survival) were recorded (P > 0.05).

CONCLUSIONS

Our findings suggest that EC patients older than 75 years may benefit from minimally invasive surgical operation and should not be denied laparoscopy based on mere chronological age.