Total laparoscopic hysterectomy versus abdominal hysterectomy with lymphadenectomy for early-stage endometrial cancer: a prospective randomized study

Laparoscopic surgery for endometrial cancer is oncologically safe and improves hospital stay duration: a retrospective single-center study over a 16-year period

OBJECTIVE

To investigate changes in surgical procedures and patient outcomes of patients diagnosed with endometrial cancer (EC) at a German university hospital between 1998 and 2014.

METHODS

A monocentric, retrospective review was conducted to identify patients diagnosed and treated with EC during the aforementioned period at the Department of Gynecology and Obstetrics at the University Hospital Kiel, Germany.

RESULTS

303 patients were identified. Patient demographics, risk factors, histological subtypes and stages of EC remained consistent over time. The most common surgical procedure was total abdominal hysterectomy (TAH) (81.9%). In 2011, the institution carried out its first total laparoscopic hysterectomy (TLH) for EC, resulting in a significant increase in laparoscopic surgical procedures (2011-2014: N = 70; TAH 44.2%; TLH 51.4%). Although the total number of lymph node stagings remained consistent over time, there was a significant increase in the performance of simultaneous pelvic and para-aortic lymphonodectomy (LNE) compared to pelvic LNE alone (2.6 in 2001-2005 vs. 18.0% in 2011-2014, p ≤ 0.001). The duration of hospital stays significantly decreased over time, with a mean of 20.9 days in the first and 8.5 days in the last period. When comparing surgical procedures, TLHs resulted in significantly shorter postoperative stays with an average of 6.58 vs. 13.92 days for TAH. The surgical procedure performed did not affect 5-year overall survival rates in this study (84.9% for TAH and 85.3% for TLH, p = 0.85).

CONCLUSIONS

Our retrospective single-center study demonstrates that laparoscopic surgery for endometrial cancer is oncologically safe and shortens hospital stays.

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.

Robotic-assisted surgery in high-risk surgical patients with endometrial cancer

Many patients diagnosed with an endometrial cancer are at high-risk for surgery due to factors such as advanced age, raised body mass index or frailty. Minimally-invasive surgery, in particular robotic-assisted, is increasingly used in the surgical management of endometrial cancer however, there are a lack of clinical trials investigating outcomes in high-risk patient populations. This article will review the current evidence and identify areas of uncertainty where future research is needed.

Retrospective comparative study of robot-assisted surgery, laparoscopic surgery, and laparotomy for endometrial cancer in patients with a low risk of recurrence

AIM

Minimally invasive surgeries for endometrial cancer are increasing worldwide. In Japan, some articles have examined surgical outcomes, but only a few have addressed oncological outcomes. This study aims to compare robot surgery, laparoscopic surgery, and laparotomy in terms of surgical and oncological outcomes within a low-risk group for endometrial cancer recurrence.

METHODS

This study included patients with endometrial cancer deemed to be at low risk of recurrence and who underwent surgery between January 2011 and December 2020. We studied 99 patients who underwent robot surgery, 85 patients who underwent laparotomy, and 77 patients who underwent laparoscopic surgery. Surgical and oncological outcomes were compared retrospectively for these groups of patients.

RESULTS

The median follow-up period was 47, 61, and 60 months in the laparotomy, laparoscopy, and robotic groups, respectively. The three groups had similar perioperative and pathological data. No significant differences in overall survival and disease-free survival were observed among the groups. Univariate and multivariate analyses conducted on the overall study population for disease-free survival and overall survival showed that the surgical approach did not have any influence. Minimally invasive surgery groups had longer operating times compared to the laparotomy group, but they had significantly less blood loss. The number of resected pelvic lymph nodes was similar, and the complication rate was not significant.

CONCLUSIONS

Robot-assisted surgery and laparoscopic surgery were found to be less invasive and showed similar oncologic outcomes compared to laparotomy surgery for endometrial cancer in patients with a low risk of recurrence.

Long-term outcome of minimally invasive staging surgery for clinical stage I endometrial cancer: A single institute experience in Taiwan

BACKGROUND

Endometrial cancer is the most common gynecological cancer in developed countries. With recent advances in equipment and knowledge, minimally invasive surgery (MIS) is widely accepted for the treatment of endometrial cancer. This study had the largest number of cases to date in Taiwan, comparing outcomes between MIS and laparotomy staging surgery using real-world data with long-term follow-up.

METHODS

We retrospectively reviewed patients with clinical stage 1 endometrial cancer from 2009 to 2020 in our institute. All patients underwent comprehensive surgical staging procedures by MIS or laparotomy. The safety, morbidity, progression-free survival (PFS), and overall survival (OS) rates of the two groups were compared. Clinical and pathologic factors were compared with Chi-square and Fisher Exact test. PFS and OS were estimated by the Kaplan-Meier method. Differences between survival curves were analyzed using the log-rank test. A p value of <0.05 was considered statistically significant. Using Cox proportional hazards models, all factors found to be significantly associated with risk of recurrence on univariate analyses were then assessed together through multivariable models, resulting in a final oncologic outcome between MIS and laparotomy.

RESULTS

A total of 665 cases (412 cases in MIS group and 253 cases in laparotomy group) were enrolled for data analysis. Median operation time was shorter in MIS group (244 and 265 minutes, p < 0.001). Median blood loss was also less (75 and 430 mL, p < 0.001). Median postoperative hospitalization duration was longer in the laparotomy group (2 and 7 days, p = 0.001). After adjusting presurgery risk factors, the PFS and OS were no significant difference in MIS and laparotomy groups.

CONCLUSION

Using real-world data with long-term follow-up, we could confirm excellent PFS and OS in selective patients with clinical stage 1 endometrial carcinoma who received MIS, and the surgical time, hospital day, and blood loss were also less.

Questionnaire survey regarding current status of minimally invasive surgery for endometrial cancer in Japan: A cross-sectional survey for JSGOE members

AIM

Minimally invasive surgery (MIS) has been introduced as an alternative to more radical surgical procedures. The Japan Society of Gynecologic and Obstetric Endoscopy and Minimally Invasive Therapy conducted a cross-sectional questionnaire survey to ascertain the status of MIS for endometrial cancer.

METHODS

The survey was conducted between May 10 and June 30, 2022. The questionnaire included information on personal attributes, academic affiliations, qualifications, hysterectomies, and intraoperative procedures performed.

RESULTS

The total number of questionnaire respondents was 436 (9.2% of the membership). The hysterectomy methods and percentage performed were as follows: simple total hysterectomy (equivalent to benign surgery), 3%; simple total hysterectomy with care to avoid shaving the cervix, 31%; extended total hysterectomy, 48%; and modified radical hysterectomy, 15%. An analysis of hysterectomies performed using MIS for endometrial cancer by qualified gynecologists of endoscopy or board-certified gynecologic oncologists showed a tendency not to choose simple total hysterectomy compared to the gynecologists who did not hold certification (p = 0.019, p = 0.045, and p = 0.010, respectively). Additionally, 67% of respondents did not use uterine manipulators, and 59% of the respondents did not perform lymph node dissection following the guidelines for treating endometrial cancer in Japan.

CONCLUSION

This study provided the current status of MIS for endometrial cancer in Japan. The hysterectomy method, use of uterine manipulators, and criteria for omitting lymph node dissection were generally in agreement with the guidelines. Currently, an extra-fascial simple hysterectomy, including at least not shaving the cervix, was a major method for early invasive endometrial cancer using MIS.

Laparoscopy with or without robotic assistance does not negatively impact long-term oncologic outcomes in patients with uterine serous carcinoma

OBJECTIVES

We sought to compare outcomes between minimally invasive surgery (MIS) and laparotomy in patients with clinical stage I uterine serous carcinoma (USC).

METHODS

Patients who underwent surgery for newly diagnosed USC between 11/1/1993 and 12/31/2017 were retrospectively identified and assigned to either the MIS cohort or the laparotomy cohort. Patients with conversion to laparotomy were analyzed with the MIS cohort. Chi-square and Mann-Whitney tests were used to compare categorical and continuous variables, respectively. Kaplan-Meier curves were used to estimate survival and compared using the log-rank test.

RESULTS

In total, 391 patients met inclusion criteria; 242 underwent MIS (35% non-robotic and 65% robotic-assisted laparoscopies) and 149 underwent laparotomy. Age, BMI, stage, and washings status did not differ between cohorts. Patients who underwent MIS were less likely to have lymphovascular space invasion (LVSI; 35.1% vs 48.3%), had fewer nodes removed (median, 9 vs 15), and lower rates of paraaortic nodal dissection (44.6% vs 65.1%). Rates of adjuvant therapy did not differ between cohorts. Median follow-up times were 63.0 months (MIS cohort) vs 71.0 months (laparotomy cohort; P = .04). Five-year PFS rates were 58.7% (MIS) vs 59.8% (laparotomy; P = .1). Five-year OS rates were 65.2% (MIS) compared to 63.5% (laparotomy; P = .2). On multivariable analysis, higher stage, deep myometrial invasion, and positive washings were associated with decreased PFS. Age ≥ 65 years, higher stage, LVSI, and positive washings were associated with shorter OS.

CONCLUSIONS

MIS does not compromise outcomes in patients with newly diagnosed USC and should be offered to these patients to minimize surgical morbidity.

Trend and characteristics of minimally invasive surgery for patients with endometrial cancer in Japan

OBJECTIVE

Owing to the potential benefits of minimally invasive hysterectomy for endometrial cancer, the practice pattern has recently shifted in Japan. This study examined the trends in minimally invasive surgery (MIS) in patients with endometrial cancer in Japan.

METHODS

This retrospective observational study examined the Japan Society of Obstetrics and Gynecology Tumor Registry database between 2015-2019. This study examined the time-specific proportion change and predictors of MIS use in initial endometrial cancer treatment in Japan, and compared it with the use of abdominal surgery. Additionally, the association between hospital surgical treatment volume and MIS use was examined.

RESULTS

A total of 14,059 patients (26.5%) underwent minimally invasive hysterectomy, and 39,070 patients (73.5%) underwent abdominal hysterectomy in the study period. Patients who underwent MIS were more likely to be treated at high-volume centers, younger, central, or western Japan residents, registered in recent years, and had a tumor with stage I disease, type 1 histology, and less myometrial invasion (all adjusted p<0.05). The proportion of MIS treatments increased from 19.1% in 2015 to 34.3% in 2019 (p<0.001). On multivariable analysis, treatment at high-volume centers was a contributing factor for MIS (adjusted odds ratio=3.85; 95% confidence interval=3.44-4.30). MIS at high-volume centers increased significantly from 24.8% to 41.0% (p<0.001) during the study period, whereas MIS at low-volume centers remained at median 8.8%.

CONCLUSION

MIS has increased significantly in recent years, accounting for nearly 34% of surgical management of endometrial cancer in Japan. High-volume treatment centers take the lead in performing MIS.

Robotic-assisted surgery for endometrial cancer is safe in morbidly and extremely morbidly obese patients

OBJECTIVE

Obesity has risen to affect >25% of the Canadian population. Perioperative challenges with increased morbidity are encountered. We evaluated the outcome of robotic-assisted surgery for endometrial cancer (EC) in obese patients.

METHODS

We retrospectively reviewed all robotic surgeries performed for EC in women with BMI ≥40 kg/m2, from 2012 to 2020 in our center. Patients were divided into 2 groups (class III: 40-49 kg/m2, class IV: ≥50 kg/m2). Complications and outcome were compared.

RESULTS

185 patients were included: 139 class III and 46 class IV. The main histology was endometrioid adenocarcinoma (70,5% of class III and 58,1% of class IV (p = 0,138)). The mean blood loss, overall sentinel node detection and median length of stay were similar in both groups. Six class III (4,3%) and 3 class IV (6,5%) patients required conversion to laparotomy due to poor surgical field exposure (p = 0,692). The rate of intraoperative complications was similar between the 2 groups (1.4% in class III vs none in class IV, p = 1). There were 10 class III (7,2%) and 10 class IV (21,7%) post-operative complications (p = 0.011), but most were grade 2 (3,6% in class III vs 13% in class IV, p = 0.029)). Grade 3 and 4 postoperative complications were low (2.7%) and not statistically different between the 2 groups. Readmission rate was low in both groups (4 in each group, p = 1.07). Recurrence occurred in 5,8% of class III and 4,3% of class IV patients (p = 1).

CONCLUSION

Robotic-assisted surgery for EC in class III and class IV obese patients is a safe and feasible procedure, with low complication rate, similar oncologic outcome, conversion rate, blood loss, readmission rate and length of hospital stay.

The incidence of postoperative symptomatic lymphocele after pelvic lymphadenectomy between abdominal and laparoscopic approach: a systemic review and meta-analysis

OBJECTIVE

To evaluate the risks of symptomatic lymphocele after pelvic lymphadenectomy between the laparoscopic and abdominal approach in uterine cervical and endometrial cancer.

METHODS

We searched Ovid Medline, Ovid EMBASE, and the Cochrane library through April 2020. We selected the comparative studies contained information on symptomatic lymphoceles in postoperative complications. All articles searched were independently reviewed and selected by two researchers. A meta-analysis was performed using the Stata MP version 16.0 software package.

RESULTS

A total of 33 eligible clinical trials were ultimately enrolled in this meta-analysis. When all studies were pooled, the odds ratios (OR) of the laparoscopic approach for the risk of symptomatic lymphoceles compared to the abdominal approach was 0.58 [95% confidence interval (CI): 0.42-0.81, p = 0.022, I-squared = 0.0%]. The risk of postoperative symptomatic lymphoceles in the laparoscopic group tended to decrease over time in the cumulative meta-analysis. In the subgroup analysis, there was no evidence for an association between cancer type, quality of the study methodology, hysterectomy type, and postoperative symptomatic lymphoceles. However, in a recently published article, being overweight (body mass index ≥ 25) and studies conducted in oriental area were associated with a lower incidence of postoperative symptomatic lymphoceles.

CONCLUSION

Laparoscopic lymphadenectomy was associated with a significantly lower risk of postoperative symptomatic lymphoceles than abdominal lymphadenectomy (PROSPERO registration number: CRD 42,020,187,165).

Clinical issues of surgery for uterine endometrial cancer in Japan

OBJECTIVE

The mainstay of treatment for uterine endometrial cancer is surgery, and recurrent-risk cases require multidisciplinary treatment, including surgery, chemotherapy and radiation therapy.

METHODS

The standard surgery for uterine endometrial cancer is hysterectomy and bilateral salpingooophorectomy, with additional retroperitoneal lymph node dissection and omentectomy, depending on the case. The appropriate treatment is determined based on the risk classification, such as the depth of invasion into the myometrium, diagnosis of histological type and grade, and risk assessment of lymph node metastasis.

RESULTS

Recently, minimally invasive surgery has been widely used not only in low-risk patients but also in intermediate- and high-risk patients. In low-risk patients, the possibility of ovarian preservation is discussed from a healthcare perspective for young women. Determining the need for retroperitoneal lymph node dissection based on sentinel lymph node evaluation may contribute in minimizing the incidence of post-operative lymphedema while ensuring accurate diagnosis of lymph node metastasis. Recently, many studies using sentinel lymph nodes have been reported for patients with uterine endometrial cancer, and the feasibility of sentinel lymph node mapping surgery has been proven. Unfortunately, sentinel lymph node biopsy and sentinel lymph node mapping surgery have not been widely adopted in surgery for uterine cancer in Japan. In addition, the search for biomarkers, such as RNA sequencing using The Cancer Genome Atlas, metabolic profile and lipidomic profile for early detection and prognostic evaluation, has been actively pursued.

CONCLUSIONS

Gynecologic oncologists expect to be able to provide uterine endometrial cancer patients with appropriate treatment that preserves their quality of life without compromising oncologic outcomes in the near future.

Characteristics and patterns of care of endometrial cancer before and during COVID-19 pandemic

Objective

Coronavirus disease 2019 (COVID-19) outbreak has correlated with the disruption of screening activities and diagnostic assessments. Endometrial cancer (EC) is one of the most common gynecological malignancies and it is often detected at an early stage, because it frequently produces symptoms. Here, we aim to investigate the impact of COVID-19 outbreak on patterns of presentation and treatment of EC patients.

Methods

This is a retrospective study involving 54 centers in Italy. We evaluated patterns of presentation and treatment of EC patients before (period 1: March 1, 2019 to February 29, 2020) and during (period 2: April 1, 2020 to March 31, 2021) the COVID-19 outbreak.

Results

Medical records of 5,164 EC patients have been retrieved: 2,718 and 2,446 women treated in period 1 and period 2, respectively. Surgery was the mainstay of treatment in both periods (p=0.356). Nodal assessment was omitted in 689 (27.3%) and 484 (21.2%) patients treated in period 1 and 2, respectively (p<0.001). While, the prevalence of patients undergoing sentinel node mapping (with or without backup lymphadenectomy) has increased during the COVID-19 pandemic (46.7% in period 1 vs. 52.8% in period 2; p<0.001). Overall, 1,280 (50.4%) and 1,021 (44.7%) patients had no adjuvant therapy in period 1 and 2, respectively (p<0.001). Adjuvant therapy use has increased during COVID-19 pandemic (p<0.001).

Conclusion

Our data suggest that the COVID-19 pandemic had a significant impact on the characteristics and patterns of care of EC patients. These findings highlight the need to implement healthcare services during the pandemic.

The prevalence of patients with early-stage endometrial cancer (EC) has been lower during coronavirus disease 2019 (COVID-19) pandemic than before its onset. Further evidence is needed to assess the impact of COVID-19 pandemic on survival outcomes of EC patients.

Association between hospital treatment volume and survival of women with gynecologic malignancy in Japan: a JSOG tumor registry-based data extraction study

Objective

Associations between hospital treatment volume and survival outcomes for women with 3 types of gynecologic malignancies, and the trends and contributing factors for high-volume centers were examined.

Methods

The Japan Society of Obstetrics and Gynecology tumor registry databased retrospective study examined 206,845 women with 80,741, 73,647, and 52,457 of endometrial, cervical, and ovarian tumor, respectively, who underwent primary treatment in Japan between 2004 and 2015. Associations between the annual treatment volume and overall survival (OS) for each tumor type were examined using a multivariable Cox proportional hazards model with restricted cubic splines. Institutions were categorized into 3 groups (low-, moderate-, and high-volume centers) based on hazard risks.

Results

Hazard ratio (HR) for OS each the 3 tumors decreased with hospital treatment volume. The cut-off points of treatment volume were defined for high- (≥50, ≥51, and ≥27), moderate- (20–49, 20–50, and 17–26), and low-volume centers (≤19, ≤19, and ≤16) by cases/year for endometrial, cervical, and ovarian tumors, respectively. Multivariate analysis revealed younger age, rare tumor histology, and initial surgical management as contributing factors for women at high-volume centers (all, p<0.001). The proportion of high-volume center treatments decreased, whereas low-volume center treatments increased (all p<0.001). Treatment at high-volume centers improved OS than that at other centers (adjusted HR [aHR]=0.83, 95% confidence interval [CI]=0.78–0.88; aHR=0.78, 95% CI=0.75–0.83; and aHR=0.90, 95% CI=0.86–0.95 for endometrial, cervical, and ovarian tumors).

Conclusion

Hospital treatment volume impacted survival outcomes. Treatments at high-volume centers conferred survival benefits for women with gynecologic malignancies. The proportion of treatments at high-volume centers have been decreasing recently.

For women with gynecologic malignancy, hospital treatment volume had an impact on survival outcome. The practice pattern shifted with scattering of patients and treatments at high-volume centers were decreasing. High-volume centers in Japan were associated with improved overall survival of gynecologic malignancies.

Could the Long-Term Oncological Safety of Laparoscopic Surgery in Low-Risk Endometrial Cancer also Be Valid for the High-Intermediate- and High-Risk Patients? A Multi-Center Turkish Gynecologic Oncology Group Study Conducted with 2745 Endometrial Cancer Cases. (TRSGO-End-001)

This study was conducted to compare the long-term oncological outcomes of laparotomy and laparoscopic surgeries in endometrial cancer under the light of the 2016 ESMO-ESGO-ESTRO risk classification system, with particular focus on the high–intermediate- and high-risk categories. Using multicentric databases between January 2005 and January 2016, disease-free and overall survivals of 2745 endometrial cancer cases were compared according to the surgery route (laparotomy vs. laparoscopy). The high–intermediate- and high-risk patients were defined with respect to the 2016 ESMO-ESGO-ESTRO risk classification system, and they were analyzed with respect to differences in survival rates. Of the 2745 patients, 1743 (63.5%) were operated by laparotomy, and the remaining were operated with laparoscopy. The total numbers of high–intermediate- and high-risk endometrial cancer cases were 734 (45%) patients in the laparotomy group and 307 (30.7%) patients in the laparoscopy group. Disease-free and overall survivals were not statistically different when compared between laparoscopy and laparotomy groups in terms of low-, intermediate-, high–intermediate- and high-risk endometrial cancer. In conclusion, regardless of the endometrial cancer risk category, long-term oncological outcomes of the laparoscopic approach were found to be comparable to those treated with laparotomy. Our results are encouraging to consider laparoscopic surgery for high–intermediate- and high-risk endometrial cancer cases.

Oncologic safety of minimally invasive surgery in non-endometrioid endometrial cancer

OBJECTIVE

This study was aimed to compare the oncologic outcomes of patients with non-endometrioid endometrial cancer who underwent minimally invasive surgery with the outcomes of patients who underwent open surgery.

METHOD

This is a retrospective, multi-institutional study of patients with non-endometrioid endometrial cancer who were surgically staged by either minimally invasive surgery or open surgery. Oncologic outcomes of the patients were compared according to surgical approach.

RESULTS

113 patients met the inclusion and exclusion criteria. 57 underwent minimally invasive surgery and 56 underwent open surgery. Patients who underwent minimally invasive surgery had smaller tumors (median size, 3.3 vs. 5.2%, p = 0.0001) and a lower lymphovascular space invasion rate (29.8% vs. 48.2%, p = 0.045). In the overall population, the numbers and rate of recurrence were significantly higher in the open surgery group (p = 0.016). In multivariate analysis, disease stage and tumor size were associated with DFS in contrast to surgical procedure.

CONCLUSION

Minimally invasive surgery showed similar survival outcomes when compared to open surgery in non-endometrioid endometrial cancer patients, irrespective of disease stage. When minimally invasive surgery is managed by expert surgeons, non-endometrioid histological subtypes should not be considered a contraindication for minimally invasive surgery.

Minimally invasive surgery for patients with advanced stage endometrial cancer

Objective: Compare the oncologic outcomes of patients with advanced stage endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 138 patients with advanced stage endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 138 patients included in this study, 72 underwent open surgery (52.2%) and 66 underwent MIS (47.8%). In patients with advanced-stage endometrial cancer, the recurrence rate was significantly higher among those who underwent open surgery (43.1% vs. 25.8%, p = 0.033). Patients with advanced-stage endometrial cancer who underwent open surgery had a significantly lower disease-free survival (p = 0.029) than those who underwent minimally invasive surgery, however, the overall survival (p = 0.051) was similar between the two groups. Conclusion: Minimally invasive surgery showed better survival outcomes when compared to open surgery in advanced-stage EC patients irrespective of the histologic type.

Survival rates of patients who undergo minimally invasive surgery for endometrial cancer with cervical involvement

Objective: Compare the oncologic outcomes of patients with intermediate-risk endometrial cancer who were staged by minimally invasive surgery with the outcomes of patients who underwent open surgery. Methods: Data from 206 patients with intermediate-risk endometrial cancer who were treated between January 2009 and January 2019 were reviewed. The patients' data were retrieved from five institutions. The patients were divided into two groups: those who underwent open surgery and those who underwent minimally invasive surgery. Tumor characteristics, recurrence rate, disease-free survival, and overall survival were compared according to surgical approach. Results: Among the 206 patients included in this study, 76 underwent open surgery (36.9%) and 130 underwent MIS (63.1%). In patients with stage IB endometrial cancer, the recurrence rate, disease-free survival, and overall survival were not significantly different between those who underwent minimally invasive surgery and those who underwent open surgery. However, in patients with stage II endometrial cancer, the recurrence rate was significantly higher among those who underwent minimally invasive surgery (37.5% vs. 5.3%, p = 0.013). Patients with stage II endometrial cancer who underwent minimally invasive surgery had a significantly lower disease-free survival (p = 0.012) than those who underwent open surgery, however, the overall survival (p = 0.252) was similar between the two groups. Conclusion: Minimally invasive surgery results in less favorable survival outcomes than open surgery in patients with stage II endometrial cancer.

Robotic-Assisted Laparoscopic Hysterectomy for Endometrial Hyperplasia or Grade 1 Endometrial Adenocarcinoma: A 10-year, Single-Centre Experience

OBJECTIVE

To describe the outcomes of patients undergoing robotic-assisted laparoscopic hysterectomy for grade-1 endometroid endometrial cancer or endometrial hyperplasia at our centre.

METHODS

Retrospective chart review was completed for 160 patients who underwent robotic-assisted laparoscopic hysterectomy by 5 general gynaecologists in a tertiary care setting between September 2008 and September 2018. Outcomes collected included operative time, estimated blood loss, length of stay, perioperative complications, readmissions, and recurrences. Subgroup analysis was completed after stratifying by body mass index (BMI; 3 groups: A, <40 kg/m²; B, 40-50 kg/m²; and C, >50 kg/m²). Subgroups were compared with ANOVA or Fisher exact test.

RESULTS

The intraoperative complication rate was 3%. The rate of conversion to laparotomy was 2%, and the rate of bowel injury, 1%. The postoperative complication rate was 8%. The rate of major postoperative complications was 4%, and 3% of patients required readmission postoperatively. The mean BMI was 43 (range 21-71) kg/m². There were no differences in perioperative complication, readmission, or recurrence rates between subgroups. Groups B and C were more likely to have had an ASA of 3-4, suggesting a higher burden of comorbidity. Operating room time, procedure time, and estimated blood loss were higher in group C.

CONCLUSION

Despite this cohort's mean BMI falling within the category of class III obesity, complication and conversion rates were similar to those reported in the literature and did not increase with BMI, despite an increased comorbidity burden. These results suggest that robotic surgery is a safe and effective method for providing minimally invasive surgery to a technically challenging population.

Comparison of survival outcomes between laparoscopic and open surgery in patients with low-risk endometrial cancer

OBJECTIVE

To evaluate the feasibility, safety and surgical outcomes of laparoscopic surgery for the treatment of low-risk endometrial cancer.

METHODS

Of 155 patients with low-risk endometrial cancer, who were included in this retrospective study between May 2008 and March 2017, 82 and 73 underwent laparoscopic and open surgery, respectively. Clinicopathological and surgical data, recurrence-free survival and overall survival were analyzed.

RESULTS

No statistically significant differences in median age, final pathological type, International Federation of Gynecology and Obstetrics stage and lymphovascular space involvement were observed between the laparoscopic and open surgery groups. No procedure in the laparoscopic surgery group was converted to open surgery. The median follow-up period was 60 months, with oncologic recurrence identified in three cases (one lung carcinoma and two pelvic cavity carcinomas) in the laparoscopic surgery group. There was no significant between-group difference in 5-year recurrence-free survival (laparoscopic surgery group: 96.3%, open surgery group: 92.6%) and overall survival (laparoscopic surgery group: 100%, open surgery group: 95.4%).

CONCLUSIONS

Laparoscopic surgery is a feasible and safe treatment for endometrial cancer and should be considered as a standard treatment option for low-risk endometrial cancer.

Updates and Controversies of Robotic-Assisted Surgery in Gynecologic Surgery

minimally invasive surgery (MIS) is the standard approach to performance of several gynecologic procedures, including hysterectomy, gynecologic cancer staging procedures, myomectomy, pelvic organ prolapse repair, and select adnexal procedures. Robotic-assisted surgery, a computer-based MIS approach, has been adopted widely in the United States and several other countries. Robotics may offer technological and ergonomic benefits that overcome limitations associated with conventional laparoscopy; however, it is not clear that reported claims of superiority translate into improved gynecologic patient outcomes compared with other MIS approaches. This review critically appraises the evolving role, benefits, limitations, and controversies of robotic-assisted surgery utilization in benign and oncologic gynecology settings.

Surgicopathological Outcomes and Survival in Carcinoma Body Uterus: A Retrospective Analysis of Cases Managed by Laparoscopic Staging Surgery in Indian Women

Objectives:

The context of this article is based on two main titles those being Gynecologic Oncology and Minimal invasive surgery. The aim of this study was to report the laparoscopic management of a series of cases of endometrial carcinoma managed by laparoscopic surgical staging in Indian women.

Materials and Methods:

This study was conducted in a private hospital (referral minimally invasive gynecological center).

This was a retrospective study (Canadian Task Force Classification II-3). Eighty-eight cases of clinically early-stage endometrial carcinoma staged by laparoscopic surgery and treated as per final surgicopathological staging. All patients underwent laparoscopic surgical staging of endometrial carcinoma, followed by adjuvant therapy when needed. Data were retrieved regarding surgical and pathological outcomes. Recurrence-free and overall survival durations were measured at follow-up. Survival analysis was calculated using Kaplan–Meier survival analysis.

Results:

The median age of presentation was 56 years, whereas the median body mass index was 28.3 kg/m². Endometroid variety was the most commonly diagnosed histopathology. There were no intraoperative complications reported. The median blood loss was 100 cc, and the median intraoperative time was 174 min. There were a total of 5 recurrences (5.6%). The outcome of this study was comparable to studies conducted in Caucasian population. The predicted 5-year survival rate according to Kaplan–Meier survival analysis is 95.45%, which is comparable to Caucasian studies.

Conclusion:

Laparoscopic management of early-stage endometrial carcinoma is a standard practice worldwide. However, there is still a paucity of data from the Indian subcontinent regarding the outcomes of laparoscopic surgery in endometrial carcinoma. The Asian perspective has been highlighted by a number of studies from China and Japan. To our knowledge, this study is the first from India to analyze the surgicopathological outcomes following laparoscopic surgery in endometrial carcinoma. The outcome of this study was comparable to studies conducted in Caucasian population.

Nationwide Introduction of Minimally Invasive Robotic Surgery for Early-Stage Endometrial Cancer and Its Association With Severe Complications

Importance

Minimally invasive laparoscopic surgery (MILS) for endometrial cancer reduces surgical morbidity compared with a total abdominal hysterectomy. However, only a minority of women with early-stage endometrial cancer undergo MILS.

Objective

To evaluate the association between the Danish nationwide introduction of minimally invasive robotic surgery (MIRS) and severe complications in patients with early-stage endometrial cancer.

Design, Setting, and Participants

In this nationwide prospective cohort study of 5654 women with early-stage endometrial cancer who had undergone surgery during the period from January 1, 2005, to June 30, 2015, data from the Danish Gynecological Cancer Database were linked with national registers on socioeconomic status, deaths, hospital diagnoses, and hospital treatments. The women were divided into 2 groups; group 1 underwent surgery before the introduction of MIRS in their region, and group 2 underwent surgery after the introduction of MIRS. Women with an unknown disease stage, an unknown association with MIRS implementation, unknown histologic findings, sarcoma, or synchronous cancer were excluded, as were women who underwent vaginal or an unknown surgical type of hysterectomy. Statistical analysis was conducted from February 2, 2017, to May 4, 2018.

Exposure

Minimally invasive robotic surgery, MILS, or total abdominal hysterectomy.

Main Outcomes and Measures

Severe complications were dichotomized and encompassed death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery.

Results

A total of 3091 women (mean [SD] age, 67 [10] years) were allocated to group 1, and a total of 2563 women (mean [SD] age, 68 [10] years) were allocated to group 2. In multivariate logistic regression analyses, the odds of severe complications were significantly higher in group 1 than in group 2 (odds ratio [OR], 1.39; 95% CI, 1.11-1.74). The proportion of women undergoing MILS was 14.1% (n = 436) in group 1 and 22.2% in group 2 (n = 569). The proportion of women undergoing MIRS in group 2 was 50.0% (n = 1282). In group 2, multivariate logistic regression analyses demonstrated that a total abdominal hysterectomy was associated with increased odds of severe complications compared with MILS (OR, 2.58; 95% CI, 1.80-3.70) and MIRS (OR, 3.87; 95% CI, 2.52-5.93). No difference was found for MILS compared with MIRS (OR, 1.50; 95% CI, 0.99-2.27).

Conclusions and Relevance

The national introduction of MIRS changed the surgical approach for early-stage endometrial cancer from open surgery to minimally invasive surgery. This change in surgical approach was associated with a significantly reduced risk of severe complications.

Comparative Study of Laparoscopic versus Conventional Open Surgical Staging Procedure for Endometrial Cancer: Our Institutional Experience

Objective:

The aim of this study was to compare laparoscopic surgical staging of endometrial cancer with conventional open methods.

Materials and Methods:

The retrospective data were collected from 90 endometrial cancer patients who were operated between 2013 and 2018 in our government institution. The safety and morbidity of the two groups were compared based on mean operative time, blood loss, intraoperative complications, postoperative complication, etc., and the results were analyzed. Statistical analysis was performed using IBM SPSS statistics version 20. Clinical and pathologic factors were compared between two groups with Fisher's exact test and Student's t-test for data analysis. The survival data were analyzed using Kaplan–Meier survival curves. P < 0.05 was considered statistically significant.

Results:

Thirty-two patients underwent laparoscopic staging, 45 underwent laparotomy, and 13 cases lap converted to open surgery. The mean operative time for the laparoscopic procedure was lower than the open procedure (P = 0.001). The mean hospital stay of patients who underwent laparoscopic staging was around 7.1 days significantly less compared to the laparotomy group. Intraoperative blood loss of patients undergoing laparoscopic surgery was significantly less than that of the laparotomy group (P = 0.015). There was no statistically significant difference in nodal retrieval between laparotomy and laparoscopy group (P = 0.172). The mean duration of hospitalization was statistically significantly greater in the laparotomy group than the laparoscopic group (13 and 7 days, P < 0.001). Based on the Kaplan–Meier survival curve, there was no difference in survival rates between the groups. Median follow-up duration was 32 months.

Conclusion:

Laparoscopic surgical staging is oncologically safe for the management of endometrial cancer with acceptable morbidity compared to the open approach with far less blood loss and shorter postoperative stay.

A comparison of disease recurrence between robotic versus laparotomy approach in patients with intermediate-risk endometrial cancer

OBJECTIVE

Advances in minimally invasive surgery, particularly with robotic surgery, have resulted in improved peri-operative outcomes in patients with endometrial cancer. In addition, randomized trials have shown that addition of adjuvant radiotherapy following surgery improves loco-regional disease control among stage I intermediate-risk endometrial cancer patients. We aimed to investigate the efficacy and safety of combined treatment of robotic surgery and adjuvant radiotherapy in this patient population.

METHODS

A single-center retrospective study was conducted on stage I endometrioid-type endometrial cancer patients with intermediate-risk features (<50% myometrial involvement and grade 2-3 histopathology, or >50% myometrial involvement and grade 1-2 histopathology) treated with hysterectomy and adjuvant radiotherapy between January 2010 and December 2015. Data on surgery and radiotherapy were collected and correlated with clinical and surgical outcomes using log-rank. Oncologic outcomes were then compared between robotic surgery and laparotomy.

RESULTS

A total of 179 intermediate-risk endometrial cancer patients were identified, of whom 135 (75.4%) received adjuvant radiotherapy and were included in the final analysis. Median age at diagnosis was 63 years (range 40-89) and median follow-up was 4.7 years (range 1.1-8.8). Seventy-seven patients (57%) underwent robotic surgery and 58 patients (43%) underwent laparotomy. Surgical staging with lymph node dissection was performed on 79.3% of the patients. The majority of patients (79.3%) received vaginal brachytherapy as part of adjuvant radiotherapy, while 20.7% received external-beam radiotherapy. Among the entire cohort, eight (5.9%) patients recurred and all eight recurrences occurred in the robotic surgery group; no recurrence was found in the laparotomy group. This translated into 5 year disease-free survival of 100% in the laparotomy group, compared with 91.8% in the robotic surgery group (p=0.005). No difference in overall survival was found between the two groups (p=0.51).

CONCLUSION

Oncologic outcomes for stage I intermediate-risk endometrial cancer treated with hysterectomy and adjuvant radiotherapy at our institution are comparable to the previously published literature. The higher recurrence rate observed with robotic surgery at our institution has not been observed previously and requires further investigation.

Evaluating unplanned readmission and prolonged length of stay following minimally invasive surgery for endometrial cancer

OBJECTIVE

To evaluate risk factors for 30-day unplanned readmission and increased length of stay (LOS) following minimally invasive surgery (MIS) for endometrial cancer.

METHODS

This was a retrospective, case-control study using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP). Multivariable logistic regression was used to assess perioperative variables associated with readmission and increased LOS after MIS for endometrial cancer.

RESULTS

The study population included 10,840 patients who met the criteria of having undergone MIS with a resultant endometrial malignancy confirmed on postoperative pathology. Common reasons for readmission included organ/space surgical site infection (65 cases), sepsis/septic shock (19 cases), and venous thromboembolism (20 cases). Notable risk factors for readmission included (Odds Ratio, Confidence Interval, p-value): dialysis dependence (6.77, 2.51-17.80, <0.01), increased length of stay (3.00, 2.10-4.10, <0.01), and preoperative weight loss (2.80, 1.06-7.17, 0.03); notable risk factors for increased LOS: ascites (8.51, 2.00-36.33, <0.01), operation duration >5 h (6.93, 5.29-9.25, <0.01), and preoperative blood transfusion (5.37, 2.05-14.04, <0.01).

CONCLUSIONS

Identification of risk factors for adverse postoperative outcomes is necessary to inform and improve standards of care in MIS for endometrial cancer. Using nationally reported data from the ACS NSQIP, this study identifies independent risk factors for unplanned readmission and prolonged LOS, and in doing so, highlights potential avenues for quality improvement.

Laparoscopic surgical access in morbidly obese women undergoing endometrial cancer surgery: Repurposing the left upper quadrant approach

OBJECTIVE

The study purpose was to report the outcomes of patients undergoing endometrial cancer surgical staging with laparoscopic abdominal access entry using a left upper quadrant (LUQ) access technique.

METHODS

This was a retrospective cohort study conducted from 1 January 2013 to 1 January 2018. The setting was an academic, single institution gynecologic oncology service with a high volume of minimally invasive surgery (MIS). The patient cohort included obese (defined as BMI > 30 kg/m²) or morbidly obese (BMI > 40 kg/m²) women undergoing MIS for endometrial cancer staging. All patients underwent laparoscopic abdominal access via a 5-mm or 10-mm optical trocar system using a LUQ technique.

RESULTS

In total, 317 patients were included with a median age of 54 years (range, 24-79) and median BMI 42.5 kg/m² (range, 32-70); 60 % morbidly obese. Successful LUQ access was achieved in 98.1 %. Of those with a failed LUQ approach, two had undergone previous LUQ surgery and 4 had ≥1 previous midline vertical incisions. There was one LUQ trocar-related visceral injury (0.3 %) and no vascular injuries during the study period.

CONCLUSION

A LUQ abdominal technique is a safe and reliable method of laparoscopic access in morbidly obese women undergoing MIS for endometrial cancer staging. This may be the preferred method of laparoscopic access for women with a panniculus or central adiposity, given the caudal displacement of the umbilicus and poor correlation with intraperitoneal anatomic landmarks in this setting.

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.

Disease-Free and Survival Outcomes for Total Laparoscopic Hysterectomy Compared With Total Abdominal Hysterectomy in Early-Stage Endometrial Carcinoma: A Meta-analysis

OBJECTIVES

Laparoscopic hysterectomy is currently offered to a large number of patients, and assessing the noninferiority to abdominal hysterectomy with respect to clinical outcomes is key. We examine rates of recurrence, disease-free survival (DFS), and overall survival, and surgical complications of laparoscopic compared with abdominal hysterectomy for the treatment of early-stage endometrial cancer.

METHODS

Electronic databases were systematically searched to identify relevant studies, and patient characteristics and clinical outcomes extracted. The primary outcome was 3-year DFS, and estimates were pooled using an inverse-variance weighted meta-analysis.

RESULTS

Nine studies (4405 patients) were identified in which DFS was reported in 5 studies. The difference in 3-year DFS was 1.44% (95% confidence interval [CI], -0.65% to 3.53%) in favor of total abdominal hysterectomy, consistent with a noninferiority margin of 5%. Differences in DFS (hazard ratio, 1.10; 95% CI, 0.92-1.32), overall survival (hazard ratio, 1.16; 95% CI, 0.81-1.66), and local recurrence (difference, 0.42%; 95% CI, -0.41% to 1.25%) were not significant. Rates of intraoperative complications showed no difference (0.5%; 95% CI, -1.1% to 2.0%) based on 7 studies. There was a significant reduction in postoperative complications with the laparoscopic procedure (-6.83%; 95% CI, -9.19% to -4.47%).

CONCLUSIONS

Noninferiority of laparoscopy was demonstrated on clinical outcomes and was associated with a reduction in postoperative complications. These results support continued treatment by laparoscopic hysterectomy for early-stage endometrial cancer.

Comparison of outcomes following laparoscopic and open hysterectomy with pelvic lymphadenectomy for early stage endometrial carcinoma

INTRODUCTION

Endometrial carcinoma is the most common gynaecological malignancy. Studies have shown that laparoscopic total hysterectomy, bilateral salpingo-oophorectomy and pelvic lymph node dissection was advantageous compared to laparotomy in reducing length of stay and intraoperative blood loss. However, these studies had a predominantly Caucasian population. A comparison study was conducted among the Singapore population to investigate the differences in oncological and surgical outcomes between these two methods.

METHODS

A retrospective, single-centre cohort study was conducted. Records of hospitalised patients with Stage 1 endometrioid carcinoma from 2008 to 2014 were extracted for review. Demographic data and study-specific parameters, including operative time, length of hospitalisation, intraoperative and postoperative complications, pain scores, final staging and recurrence rates, were compared between the two groups.

RESULTS

475 endometrioid carcinoma patients were admitted for surgical staging, among whom 374 fulfilled our inclusion criteria. Out of these patients, 229 underwent laparotomy and 145 underwent laparoscopy. The race, parity and body mass index of both groups were comparable. Patients who underwent laparoscopic surgery reported reduced pain score within two hours postoperatively (p = 0.007) and at Postoperative Days 1, 2 and 3 (p < 0.001). Laparoscopic surgery also illustrated better outcomes such as reduced length of stay (p < 0.001) and reduced intraoperative blood loss (p < 0.001). The operative time, recurrence rate and disease-free intervals were comparable between both groups.

CONCLUSION

Laparoscopy offered similar oncological outcomes with superior surgical outcomes compared to laparotomy. It provides a suitable alternative in the surgical staging of endometrioid carcinoma.

Laparoscopy versus laparotomy for the management of early stage endometrial cancer

BACKGROUND

This is an update of a previous Cochrane Review published in 2012, Issue 9.Surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last two decades there has been a steady increase of the use of laparoscopy for endometrial cancer. This review investigated the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.

OBJECTIVES

To compare overall survival (OS) and disease free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer.

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2018, Issue 5) in the Cochrane Library, MEDLINE via Ovid (April 2012 to June 2018) and Embase via Ovid (April 2012 to June 2018). We also searched registers of clinical trials, abstracts of scientific meetings and reference lists of included studies. The trial registers included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol.

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer.

DATA COLLECTION AND ANALYSIS

We independently abstracted data and assessed risk of bias. We used hazard ratios (HRs) for OS and recurrence free survival (RFS), risk ratios (RR) for severe adverse events and mean differences (MD) for continuous outcomes in women who received laparoscopy or laparotomy with 9% confidence intervals (CI). These were pooled in random-effects meta-analyses.

MAIN RESULTS

We identified one new study in this update of the review. The review contains nine RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer.All nine studies met the inclusion criteria and assessed 4389 women at the end of the studies. Six studies assessing 3993 participants with early stage endometrial cancer found no significant difference in the risk of death between women who underwent laparoscopy and women who underwent laparotomy (HR 1.04, 95% 0.86 to 1.25; moderate-certainty evidence) and five studies assessing 3710 participants found no significant difference in the risk of recurrence between the laparoscopy and laparotomy groups (HR 1.14, 95% CI 0.90 to 1.43; moderate-certainty evidence). There was no significant difference in the rate of perioperative death; women requiring a blood transfusion; and bladder, ureteric, bowel and vascular injury. However, one meta-analysis of three studies found that women in the laparoscopy group lost significantly less blood than women in the laparotomy group (MD -106.82 mL, 95% CI -141.59 to -72.06; low-certainty evidence). A further meta-analysis of two studies, which assessed 3344 women and included one very large trial of over 2500 participants, found that there was no clinical difference in the risk of severe postoperative complications in women in the laparoscopy and laparotomy groups (RR 0.78, 95% CI 0.44 to 1.38). Most studies were at moderate risk of bias. All nine studies reported hospital stay and results showed that on average, laparoscopy was associated with a significantly shorter hospital stay.

AUTHORS' CONCLUSIONS

This review found low to moderate-certainty evidence to support the role of laparoscopy for the management of early endometrial cancer. For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar OS and DFS. Furthermore, laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe postoperative morbidity between the two modalities.The certainty of evidence for OS and RFS was moderate and was downgraded for unclear risk of bias profiles and imprecision in effect estimates. However, most studies used adequate methods of sequence generation and concealment of allocation so studies were not prone to selection bias. Adverse event outcomes were downgraded for the same reasons and additionally for low event rates and low power thus these outcomes provided low-certainty evidence.

Minimally invasive hysterectomy surgery rates for endometrial cancer performed at National Comprehensive Cancer Network (NCCN) Centers

OBJECTIVES

Minimally invasive surgery (MIS) is a quality measure for endometrial cancer (EC) established by the Society of Gynecologic Oncology and the American College of Surgeons. Our study objective was to assess the proportion of EC cases performed by MIS at National Comprehensive Cancer Network (NCCN) centers and evaluate perioperative outcomes.

METHODS

A retrospective cohort study of women who underwent surgical treatment for EC from 2013 to 2014 was conducted at four NCCN centers. Multivariable mixed logistic regression models analyzed factors associated with failure to perform MIS and perioperative complications.

RESULTS

In total 1621 patients were evaluated; 86.5% underwent MIS (robotic-assisted 72.5%, laparoscopic 20.9%, vaginal 6.6%). On multivariable analysis, factors associated with failure to undergo MIS were uterine size >12cm (Odds Ratio [OR]: 0.17, 95% CI 0.03-0.9), stage III (OR: 0.16, 95% CI 0.05-0.49) and IV disease (OR: 0.07, 95% CI 0.02-0.22). For stage I/II disease, complications occurred in 5.1% of MIS and 21.7% of laparotomy cases (p<0.01). Laparotomy was associated with increases in any complication (OR: 6.0, 95% CI 3.3-10.8), gastrointestinal (OR: 7.2, 95% CI 2.6-19.5), wound (OR: 3.7, 95% CI 1.5-9.2), respiratory (OR 37.5, 95% CI 3.9-358.0), VTE (OR 10.5, 95% CI 1.3-82.8) and 30-day readmission (OR: 2.6, 95% CI 1.4-4.9) compared to MIS.

CONCLUSIONS

At NCCN-designated centers, the MIS hysterectomy rate in EC is higher than the published national average, with low perioperative complications. Previously identified disparities of age, race, and BMI were not observed. A proposed MIS hysterectomy benchmark of >80% in EC care is feasible when performed at high volume centers.

Total Laparoscopic Hysterectomy with Pelvic/Aortic Lymph Node Dissection for Endometrial Cancer Using Passive Instrument Positioners: A Retrospective Case-Control Series

STUDY OBJECTIVE

To investigate the influence of the use of passive instrument positioners (PIPs) on laparoscopic operative outcomes for endometrial cancer relative to other independent variables.

DESIGN

Retrospective case-controlled study (Canadian Task Force classification II-2).

SETTING

Laparoscopies performed by the author in multiple community hospitals.

PATIENTS

A total of 297 consecutive patients between December 2009 and October 2016 with clinically isolated endometrial cancer or retroperitoneal lymphadenopathy on imaging studies.

INTERVENTIONS

Total laparoscopic hysterectomy with bilateral salpingo-oophorectomy and pelvic/aortic lymph node dissection using passive instrument positioners to secure the laparoscope (PIP group) and using instruments providing exposure and historical control by hand control of all instruments (HC group).

MEASUREMENTS AND MAIN RESULTS

The overall group mean age was 63.2 years (range, 32.4-90.9 years), and patient characteristics were equivalent in the 2 groups. In the PIP group, 1 procedure was converted to a laparotomy (0.5%), and in the HC group, 6 procedures were converted (5.4%; p = .008). The mean operative time was 140.1 minutes for the PIP group and 153.8 minutes for the HC group (p < .001). The mean length of hospital stay was 44.8 hours for the PIP group and 58.6 hours for the HC group (p < .001). Multivariate analysis confirmed that study group (PIP vs HC; p = .014) and the presence vs absence of metastatic disease (p = .001) influenced conversion; study group (PIP vs HC; p < .001), body mass index (p < .001), past surgical history (p = .010), and assistant training (p = .011) influenced operative time; and study group (PIP vs HC; p < .001), Eastern Cooperative Oncology Group performance status (p < .001), and operative time (p = .051) influenced hospital stay.

CONCLUSION

For clinically localized endometrial cancer managed laparoscopically, the use of PIPs reduces conversions, operative time, and hospital stay.

Minimally Invasive Staging Surgery in Women with Early-Stage Endometrial Cancer: Analysis of the National Cancer Data Base

PURPOSE

The aim of this study was to determine factors associated with the adoption of minimally invasive surgery (MIS) compared with laparotomy in the treatment of endometrial cancer and to compare surgical outcomes and survival between these two surgical modalities.

METHODS

We utilized the National Cancer Data Base (NCDB) to identify women diagnosed with presumed early-stage endometrial cancer between 2010 and 2012. We also identified factors associated with the performance of MIS and utilized propensity score matching to create a matched cohort of women who underwent minimally invasive staging surgery or laparotomy for surgical staging.

RESULTS

Overall, 20,346 women were eligible for inclusion in the study; 12,604 (61.9%) had MIS, while 7742 (38.1%) had a laparotomy. African American race (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.49-0.60], Hispanic ethnicity (OR 0.70, 95% CI 0.61-0.80), Charlson score >2 (OR 0.79, 95% CI 0.69-0.91), high-grade histology (OR 0.63, 95% CI 0.59-0.68), presumed clinical stage II disease (OR 0.53, 95% CI 0.46-0.60), and surgery at a community cancer program (OR 0.46, 95% CI 0.39-0.55) or in the Midwest region (OR 0.70, 95% CI 0.64-0.76) were associated with a decreased likelihood of having MIS, while private insurance (OR 1.69, 95% CI 1.45-1.97) and highest quartile median household income (OR 1.13, 95% CI 1.03-1.24) were associated with an increased likelihood of having MIS. After propensity score matching, there was no association between minimally invasive staging surgery and 3-year overall survival (hazard ratio 1.03, 95% CI 0.92-1.16).

CONCLUSION

There are notable racial, ethnic, socioeconomic, and geographic variations in the utilization of MIS for endometrial cancer staging in the US. After controlling for the aforementioned factors, MIS had a similar 3-year survival compared with laparotomy in women undergoing staging surgery for endometrial cancer.

Does the Type of Surgical Approach and the Use of Uterine Manipulators Influence the Disease-Free Survival and Recurrence Rates in Early-Stage Endometrial Cancer?

OBJECTIVE

The purpose of this study was to compare the long-term safety, disease-free survival, and recurrence rate of total laparoscopic hysterectomy using uterine manipulator and abdominal hysterectomy in the surgical treatment in early-stage endometrial cancer.

STUDY DESIGN

This was a cohort study of 147 patients with clinical endometrial cancer (laparoscopic surgery group, 77 women; laparotomy group, 70 women). Data were evaluated and analyzed by intention-to-treat principle, and survival data of stage I endometrial cancer (129 patients; 66 from laparoscopic surgery group and 60 from laparotomy group) were estimated by using the Kaplan-Meier curves.

RESULTS

After a follow-up period of 60 months for both laparoscopic surgery and laparotomy groups, no significant difference in the cumulative recurrence rates (7.4% and 13.1%, P = 0.091) and overall survival (97.1% and 95.1%, P = 0.592) was detected between both groups of stage I endometrial cancer. Conversion to laparotomy occurred in 10.4% (8/77) of the laparoscopic procedures. Laparoscopic hysterectomy was associated with less use of pain medication (P = 0.001) and a shorter hospital stay (P < 0.001), but the procedure took longer than laparotomic hysterectomy (P < 0.001). The proportion of patients with intraoperative and long-term complications was not significantly different between both groups. The use of uterine manipulators did not have increased recurrence rate in patients treated with laparoscopic approach.

CONCLUSIONS

The laparoscopic surgery approach to early-stage endometrial cancer using uterine manipulators is as safe and effective as the laparotomic approach.

Practice guidelines for management of uterine corpus cancer in Korea: a Korean Society of Gynecologic Oncology Consensus Statement

Clinical practice guidelines for gynecologic cancers have been developed by many organizations. Although these guidelines have much in common in terms of the practice of standard of care for uterine corpus cancer, practice guidelines that reflect the characteristics of patients and healthcare and insurance systems are needed for each country. The Korean Society of Gynecologic Oncology (KSGO) published the first edition of practice guidelines for gynecologic cancer treatment in late 2006; the second edition was released in July 2010 as an evidence-based recommendation. The Guidelines Revision Committee was established in 2015 and decided to produce the third edition of the guidelines as an advanced form based on evidence-based medicine, considering up-to-date clinical trials and abundant qualified Korean data. These guidelines cover screening, surgery, adjuvant treatment, and advanced and recurrent disease with respect to endometrial carcinoma and uterine sarcoma. The committee members and many gynecologic oncologists derived key questions from the discussion, and a number of relevant scientific literatures were reviewed in advance. Recommendations for each specific question were developed by the consensus conference, and they are summarized here, together with other details. The objective of these practice guidelines is to establish standard policies on issues in clinical areas related to the management of uterine corpus cancer based on the findings in published papers to date and the consensus of experts as a KSGO Consensus Statement.

Laparoscopic treatment of early-stage endometrial cancer with and without uterine manipulator: Our experience and review of literature

OBJECTIVE

The aim of this study was to retrospectively compare in a series of 110 patients with early-stage endometrial cancer recurrence rate and surgical outcomes after total laparoscopic (LPS) hysterectomy with lymphadenectomy performed with or without uterine manipulator.

STUDY DESIGN

110 patients with clinical stage I endometrial cancer were enrolled in a retrospective study and underwent surgical staging comprised of LPS hysterectomy, bilateral salpingo-oophorectomy, and in all cases we performed systematic bilateral pelvic lymphadenectomy with uterine manipulator (Group 1, 55 patients) or without (Group 2, 55 patients).

RESULTS

The rate of positive cytology and LVSI did not significantly differ between Group 1 and Group 2. 1 patient of the Group 1 had a bladder injury and another patient of Group 2 had an ureteral stricture temporarily treated with a stent. 1 patient of the Group 1 had a bowel occlusion due to a port site hernia under the left 10 mm port, resolved with a bowel resection and an end-to-end anastomosis. In 1 patient of the Group 1 and 2 patients of Group 2 we observed a vaginal cuff dehiscence and in 1 case of Group 2 a pelvic lymphocyst was reported. Postoperative fever was reported in 3 patients of the Group 1 and in 5 patients of group 2 (p = 0.07).

CONCLUSIONS

Our study confirms that use of uterine manipulator for laparoscopic treatment of endometrial cancer does not increase positive peritoneal citology, LVSI and recurrence rate.

Comparative Effectiveness of Minimally Invasive Hysterectomy for Endometrial Cancer

PURPOSE

Despite the potential benefits of minimally invasive hysterectomy for uterine cancer, population-level data describing the procedure's safety in unselected patients are lacking. We examined the use of minimally invasive surgery and the association between the route of the procedure and long-term survival.

METHODS

We used the SEER-Medicare database to identify women with stage I-III uterine cancer who underwent hysterectomy from 2006 to 2011. Patients who underwent abdominal hysterectomy were compared with those who had minimally invasive hysterectomy (laparoscopic and robot-assisted). Perioperative morbidity, use of adjuvant therapy, and long-term survival were examined after propensity score balancing.

RESULTS

We identified 6,304 patients, including 4,139 (65.7%) who underwent abdominal hysterectomy and 2,165 (34.3%) who underwent minimally invasive hysterectomy; performance of minimally invasive hysterectomy increased from 9.3% in 2006 to 61.7% in 2011. Robot-assisted procedures accounted for 62.3% of the minimally invasive operations. Compared with women who underwent abdominal hysterectomy, minimally invasive hysterectomy was associated with a lower overall complication rate (22.7% v 39.7%; P < .001), and lower perioperative mortality (0.6% v 1.1%), but these women were more likely to receive adjuvant pelvic radiotherapy (34.3% v 31.3%) and brachytherapy (33.6% v 31.0%; P < .05). The complication rate was higher after robot-assisted hysterectomy compared with laparoscopic hysterectomy (23.7% v 19.5%; P = .03). There was no association between the use of minimally invasive hysterectomy and either overall (HR, 0.89; 95% CI, 0.75 to 1.04) or cancer-specific (HR, 0.83; 95% CI, 0.59 to 1.16) mortality.

CONCLUSION

Minimally invasive hysterectomy does not appear to compromise long-term survival for women with endometrial cancer.

Timing of Intrauterine Manipulator Insertion During Minimally Invasive Surgical Staging and Results of Pelvic Cytology in Endometrial Cancer

STUDY OBJECTIVE

Considering the hypothetical concern of retrograde tumor spread to the peritoneal cavity by insertion of an intrauterine manipulator, we examined the correlation between the timing of manipulator insertion and the results of pelvic cytology during total laparoscopic hysterectomy (TLH) in endometrial cancer.

DESIGN

Case-control study (Canadian Task Force classification II-2).

SETTING

University-based hospitals.

PATIENTS

Stage I to IV endometrial cancer patients who underwent TLH in which an intrauterine manipulator was used. Medical records were reviewed for patient demographics, surgical details, and tumor characteristics.

INTERVENTIONS

Archived medical record review.

MEASUREMENTS AND MAIN RESULTS

A total of 333 patients was identified. Cases were divided into those with intrauterine manipulator insertion after pelvic cytology sampling (Group 1, n = 103) and those with intrauterine manipulator insertion before pelvic cytology sampling (Group 2, n = 230). Types of intrauterine manipulator were similar across the 2 groups (p = .77). There was no statistical difference in the results of pelvic cytology between the 2 groups: Group 1 versus 2, atypical cells 2.9% versus 4.8% and malignant cells 5.8% versus 9.6% (p = .36). Uterine perforation related to intrauterine manipulator insertion was seen in 1.0% and .4% of each group (p = .52). In a multivariate analysis controlling for demographics and tumor characteristics, advanced-stage disease remained an independent risk factor associated with increased risk of atypical and malignant cells (adjusted odds ratio, 10.3; 95% confidence interval, 4.44-23.8; p < .001).

CONCLUSION

Our study suggested that the timing of intrauterine manipulator insertion during TLH for endometrial cancer is not associated with the results of pelvic cytology.