Role of laparoscopic hysterectomy in the management of endometrial cancer

Laparoscopic treatment of endometrial cancer: systematic review

The objective of this review was to assess the efficacy and safety of laparoscopy compared with laparotomy for treatment of endometrial cancer. Trials were identified by searching the Cochrane Gynecological Cancer Collaborative Review Group Trial Register, MEDLINE, EMBASE, PubMed, BIOSIS Previews, the China Biological Medicine Database, China National Knowledge Infrastructure Whole Article Database, Wan Fang Data, and VIP Information, from January 1991 to May 2012, as well as the Cochrane Central Register of Controlled Trials (Cochrane Library, issue 5, 2012). We also hand searched unpublished and gray literature, reference lists of identified studies, gynecologic cancer handbooks, and conference abstracts. All randomized controlled trials (RCTs) comparing laparoscopic surgery with laparotomy for treatment of all stages of endometrial cancer were selected. Data extraction was performed independently by 2 review authors who assessed study quality and extracted data. The whole articles were assessed for method quality by using the Cochrane Collaboration Back Review Group method quality criteria. Heterogeneity between studies was assessed using the I2 statistic, which estimates the percentage of heterogeneity between trials. The outcomes were pooled statistically when no clinical heterogeneity was apparent. For time to event data, hazard ratios were pooled using the generic inverse variance facility of RevMan 5. Random effects models were used for all meta-analyses. The search yielded 9 eligible RCTs (1361 laparotomy and 2255 laparoscopy). There was no significant difference between laparoscopic and laparotomic approaches to endometrial cancer in 3-year overall survival (odds ratio [OR], 0.91; 95% confidence interval [CI], 0.49 to 1.71; p = .77), 3-year disease-free survival (OR, 0.95; 95% CI, 0.29 to 1.80; p = .89), recurrence at 3-year follow-up (OR, 1.11; 95% CI, 0.60 to 2.06; p = .74), and pelvic node yield (mean difference [MD, 0.45; 95% CI, -0.41 to 1.32; p = .30). The benefits of laparoscopic surgery vs laparotomy were shorter length of hospital stay (MD, -3.42; 95% CI, -3.81 to -3.03; p < .01), and lower rates of postoperative complications (OR, 0.62; 95% CI, 0.52 to 0.73; p < .01). Disadvantages were higher rates of intraoperative complications (OR, 1.35; 95% CI, 1.05 to1.74; p = .02) and longer duration of surgical procedures (MD, 32.73; 95% CI, 16.34 to 49.13; p < .01). We conclude that, compared with laparotomy, laparoscopic surgery seems to be beneficial in women with endometrial cancer, in particular insofar as postoperative complications and length of hospital stay. However, more well-designed RCTs are needed to assess the long-term clinical outcomes, in particular the quality of life.

[Novel laparoscopic techniques in gynecologic surgery]

The practice of gynecologic surgery has been revolutionized by laparoscopic techniques in the past decades. Nowadays minimal invasive procedures are feasible and safe standard options in the management of most benign and malignant gynecologic diseases. Natural orifices transluminal endoscopic surgery (NOTES) and laparoendoscopic single-site surgery (LESS) have been developed in an attempt to further reduce the morbidity and scarring with minimal invasive procedures. These techniques share a common conception that a reduction in the number of transcutaneous points of access may benefit patients in terms of port-related complications, risk of hernia formation, recovery time, pain and cosmetics by potentially performing scarless surgery. The development of LESS has been facilitated by the concept of scarless surgical procedures. Increasing experience revealed by recent publications have allowed for the expansion of NOTES and LESS techniques in the gynecologic surgery. Almost all laparoscopic procedures can be performed by acquiring these concepts. Although these surgical methods are feasible and safe, certain technical problems (e.g. loss of triangulation, problems of visualization, ergonomic considerations) has yet to be solved and several questions must be answered before LESS and NOTES could gain widespread acceptance as single procedures. Despite successful technical developments these methods remain investigational approaches and refinement of indications as well as further development of instrumentation are expected to define its area of future application.