Robotic-assisted surgery for endometrial cancer: a comparison of surgical and oncologic outcomes in patients with low and high BMI at an Indian tertiary care center

The robotic-assisted surgery for endometrial cancer (EC) is becoming increasingly important, owing to the superior surgical outcomes. However, efficacy data from India is limited, particularly for older women who are obese. We undertook this study to compare the surgical outcomes of robotic-assisted surgery among Indian EC patients with a BMI of < 30 and ≥ 30 kg/m2. A retrospective chart review was conducted for the period of May 2016 to October 2020. Data on patient demographics, medical history, clinical characteristics, and perioperative outcomes were collected by a single senior surgeon, followed by statistical analysis. A total of 99 patients; 39 in the BMI group < 30 and 60 in the BMI group ≥ 30 kg/m2 were included in the study. The mean age of the BMI groups < 30 and ≥ 30 kg/m2 was 60.92 ± 10.43 and 58.90 ± 8.52 years respectively (P = 0.2944). The mean total operating time was slightly higher in the BMI group < 30 kg/m2 (P = 0.8552) but the difference was not statistically significant. Similarly, the mean blood loss (P = 0.2041), length of hospital stays (P = 0.6564), early (P = 0.7758) and delayed complications (P = 0.1878) were less in the BMI group < 30 kg/m2 but the difference was not statistically significant either. At a median follow-up of 22.3 months, the number of recurrences (5.13% vs 3.33%) and deaths (2.56% vs 1.67%) were more in BMI < 30 kg/m2 group. Our study suggests that obese older women predisposed to multiple medical co-morbidities and surgical complications would especially benefit from robotic-assisted technology regardless of their BMI.

Outcomes of robotic surgery in morbidly obese patients with endometrial cancer: a retrospective study

With advances in minimal invasive surgery, robotic surgery has become the widespread approach for surgical staging of endometrial cancer in the obese population. This study aimed to evaluate safety and surgical outcomes of robotic surgery in the morbidly obese and extremely morbidly obese patients with endometrial cancer. Retrospective cohort study. A total of 391 obese women undergoing robotic-assisted surgical staging were identified and included in the study. Surgical outcomes for obese patients (BMI > 30 kg/m²) who underwent surgical staging between 2011 and 2019 were retrospectively collected. Preoperative characteristics, perioperative outcomes and postoperative complications were analyzed among the categories of obesity (BMI ≥ 30-34.9 kg/m²,  ≥ 35-39.9 kg/m²,  ≥ 40-49.9 kg/m²) including the extremely morbid obese (BMI  > 50 kg/m²). Comparative analysis revealed a higher percentage of postoperative complications with increasing BMI, although the results were not statistically significant. Postoperative complications are observed at higher rates among women with increasing BMI.

Value of robotic surgery in endometrial cancer by body mass index

OBJECTIVE

To compare perioperative outcomes and complications in robotically assisted laparoscopy (RAL) and standard laparoscopy (SLP) approaches in the treatment of endometrial cancer by body mass index (BMI, calculated as weight in kilograms divided by the square of height in meters).

METHODS

A comparative study was carried out of women treated for endometrial cancer at the Hospital Clinico San Carlos from January 2012 to December 2016: 133 patients were operated by RAL and 101 by SLP. Demographic characteristics of the patients, perioperative outcomes and complications were compared in both approaches.

RESULTS

Hospital stay was significantly lower in patients with BMI ≤30 operated with RAL (2 days RAL vs 4 days SLP; P=0.002). Estimated blood loss was significantly lower in the group with BMI<25 (60 mL RAL vs 100 mL SLP; P=0.004) and in the group with BMI ≥30 (87.5 mL RAL vs 180 SLP; P=0.003) operated with RAL. RAL significantly reduced the conversion rate in patients with BMI ≥30 (2 [3.4%] patients RAL vs 6 [27.3%] patients SLP; P=0.004).

CONCLUSIONS

RAL has demonstrated advantages in treating obese women with endometrial cancer by reducing blood loss and conversion to laparotomy.

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.

Laparoscopy versus laparotomy for the management of early stage endometrial cancer

BACKGROUND

Traditionally, 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 10 to 15 years there has been a steady increase of laparoscopy for endometrial cancer. This review investigates the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.

OBJECTIVES

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

SEARCH METHODS

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012, MEDLINE, EMBASE and CINAHL up to April 2012. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies. Trial registers we searched included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol, as well as abstracts of scientific meetings.

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. Hazard ratios (HRs) were used for OS and recurrence-free survival (RFS), risk ratios (RR) for severe adverse events and the mean difference (MD) method was used for continuous outcomes in women who received laparoscopy or laparotomy and these were then pooled in random-effects meta-analyses.

MAIN RESULTS

Eight RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer were identified.All eight trials met the inclusion criteria, 3644 women were assessed at the end of the trials. Three trials assessing 359 participants with early stage endometrial cancer, found no statistically significant difference in the risk of death and disease or recurrence between women who underwent laparoscopy and those who underwent laparotomy (HR = 1.14, 95% confidence interval (CI): 0.62 to 2.10) and HR = 1.13, 95% CI: 0.90 to 1.42 for OS and RFS respectively). There was no statistically significant difference in the rate of peri-operative death, women requiring a blood transfusion, and bladder, ureteric, bowel and vascular injury. However, a meta-analysis of two trials found that women in the laparoscopy group lost significantly less blood than those in the laparotomy group (MD = -106.82 mL, 95% CI: -141.59 to -72.06). A further meta-analysis of two trials, which assessed 2923 women and included one very large trial of over 2500 participants, found that the rate of severe post-operative adverse events was significantly lower in the laparoscopy group compared with the laparotomy group (RR = 0.58, 95% CI: 0.37 to 0.91). The large trial did not give a breakdown of these severe post-operative adverse events into different adverse event categories. Most trials were at moderate risk of bias. Hospital stay was reported in all of the trials and results show that on average, laparoscopy was associated with a significantly shorter hospital stay.

AUTHORS' CONCLUSIONS

This review has found 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 overall and disease-free survival. Laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe post-operative morbidity between the two modalities.

Laparoscopic, robotic and open method of radical hysterectomy for cervical cancer: A systematic review

BACKGROUND

Over the last two decades, numerous studies have indicated the feasibility of minimally invasive surgery for early cervical cancer without compromising the oncological outcome.

OBJECTIVE

Systematic literature review and meta analysis aimed at evaluating the outcome of laparoscopic and robotic radical hysterectomy (LRH and RRH) and comparing the results with abdominal radical hysterectomy (ARH).

SEARCH STRATEGY

Medline, PubMed, Embase, Cochrane library and Reference lists were searched for articles published until January 31(st) 2011, using the terms radical hysterectomy, laparoscopic radical hysterectomy, robotic radical hysterectomy, surgical treatment of cervical cancer and complications of radical hysterectomy.

SELECTION CRITERIA

Studies that reported outcome measures of radical hysterectomy by open method, laparoscopic and robotic methods were selected.

DATA COLLECTION AND ANALYSIS

Two independent reviewers selected studies, abstracted and tabulated the data and pooled estimates were obtained on the surgical and oncological outcomes.

RESULTS

Mean sample size, age and body mass index across the three types of RH studies were similar. Mean operation time across the three types of RH studies was comparable. Mean blood loss and transfusion rate are significantly higher in ARH compared to both LRH and RRH. Duration of stay in hospital for RRH was significantly less than the other two methods. The mean number of lymph nodes obtained, nodal metastasis and positive margins across the three types of RH studies were similar. Post operative infectious morbidity was significantly higher among patients who underwent ARH compared to the other two methods and a higher rate of cystotomy in LRH.

CONCLUSIONS

Minimally invasive surgery especially robotic radical hysterectomy may be a better and safe option for surgical treatment of cervical cancer. The laparoscopic method is not free from complications. However, experience of surgeon may reduce the complications rate.

The laparoscopic-assisted vaginal approach to early endometrial cancer

INTRODUCTION

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

RESULTS

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

CONCLUSION

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

The impact of robotics on practice management of endometrial cancer: transitioning from traditional surgery

BACKGROUND

Evaluation of the impact of a new robotic surgery programme on perioperative outcomes for endometrial cancer

METHODS

A prospective database of all patients undergoing staging for endometrial cancer during July 2007-July 2008 was collected and analysed. Demographic data and perioperative outcomes were compared between cases performed via laparotomy, laparoscopy and robotics.

RESULTS

Sixty-five patients underwent staging during the time of data collection (LAP-26, LSC-7, ROB-32). No difference in surgical volume in the year before vs. after robotics was identified. Median operative time for robotics and laparotomy was significantly less than for laparoscopy (p = 0.023). There was no significant difference in lymph node yields between the three groups (p = 0.92). Robotics was associated with significantly less blood loss (p < 0.0001). Complication rates were significantly lower in the robotic group compared to the laparotomy group (p = 0.05). Median hospital stay was 1 day for the minimally invasive groups. Total number of perioperative inpatient days decreased from 331 to 150 in one year. Practice management of endometrial cancer transitioned from a predominantly open approach (5.6% LSC) to robotics (11% LSC, 49% ROB) within 12 months.

CONCLUSIONS

Robotic surgery dramatically altered our management of endometrial cancer and was associated with a significant improvement in several perioperative outcomes when compared to laparotomy and laparoscopy.

Surgical outcomes of robotic-assisted surgical staging for endometrial cancer are equivalent to traditional laparoscopic staging at a minimally invasive surgical center

OBJECTIVE

To compare peri- and post-operative complications and outcomes of robotic-assisted surgical staging with traditional laparoscopic surgical staging for women with endometrial cancer.

METHODS

A retrospective chart review of cases of women undergoing minimally invasive total hysterectomy and pelvic and para-aortic lymphadenectomy by a robotic-assisted approach or traditional laparoscopic approach was conducted. Major intraoperative complications, including vascular injury, enterotomy, cystotomy, or conversion to laparotomy, were measured. Secondary outcomes including operative time, blood loss, transfusion rate, number of lymph nodes retrieved, and the length of hospitalization were also measured.

RESULTS

275 cases were identified-102 patients with robotic-assisted staging and 173 patients with traditional laparoscopic staging. There was no significant difference in the rate of major complications between groups (p=0.13). The mean operative time was longer in cases of robotic-assisted staging (237 min vs. 178 min, p<0.0001); however, blood loss was significantly lower (109 ml vs. 187 ml, p<0.0001). The mean number of lymph nodes retrieved were similar between groups (p=0.32). There were no significant differences in the time to discharge, re-admission, or re-operation rates between the two groups.

CONCLUSION

Robotic-assisted surgery is an acceptable alternative to laparoscopy for minimally invasive staging of endometrial cancer. In addition to the improved ease of operation, visualization, and range of motion of the robotic instruments, robotic surgery results in a lower mean blood loss, although longer operative time. More data are needed to determine if the rates of urinary tract injuries and other surgical complications can be reduced with the use of robotic surgery.

Laparoscopic versus open surgery for endometrial cancer: a minimum 3-year follow-up study

BACKGROUND

The paucity of long-term oncologic results published in the literature still prevents the scientific community from cementing the place of laparoscopy as the procedure of choice for managing endometrial cancer. We present the outcomes of consecutive patients with endometrial cancer managed laparoscopically with >3-year follow-up.

METHODS

Data from 117 consecutive women undergoing surgery for treatment of a clinical stage I endometrial cancer and who achieved at least 3-year follow-up were prospectively analyzed. These cases were compared with a historical cohort of 122 consecutive patients with endometrial cancer who had undergone surgery through laparotomy.

RESULTS

The laparoscopy and laparotomy groups were similar with regard to baseline patient characteristics, surgical stage, proportion of tumors with unfavorable histology and high grade, as well as patterns of adjuvant therapy. The median (range) follow-up of surviving patients was 52 (36-84) months in the laparoscopic cohort and 80 (36-151) months in the laparotomy cohort. Women who underwent laparoscopy and those who underwent laparotomy had similar 3-year recurrence-free survival rates (91.4% vs. 88.5%, P = 0.52), as well as similar 3-year overall survival rates (94.0% vs. 93.4%, P = 1.0). Multivariate analysis showed that advanced surgical stage, unfavorable histology, and patient age >65 years significantly affect survival, regardless of the surgical approach used.

CONCLUSIONS

Cancer control in women with endometrial cancer does not appear to be worsened by laparoscopic surgery. In the absence of level I evidence to establish long-term recurrence and survival equivalence, analysis of series as they mature is crucial to fully evaluate disease control afforded by laparoscopy.

Endometrial cancer and obesity: epidemiology, biomarkers, prevention and survivorship

Endometrial cancer is the most common gynecologic malignancy in the Western world and is strongly associated with obesity. Despite the fact that most cases are diagnosed in early, more favorable stages, endometrial cancer incidence and mortality rates are on the rise. Morbidly obese women with endometrial cancer are more likely to die of their co-morbidities and also of their cancers when compared to their leaner cohorts. Given the increasing rates of morbid obesity in the United States, it is essential to develop appropriate screening tools and guidelines to reduce cancer morbidity and death amongst this group. Through an analysis of the existing literature, we present a review of the epidemiologic trends in obesity and endometrial cancer, discuss the promising role of screening biomarker studies, review prevention efforts and modifiable risk factors, and ways in which health outcomes and quality of life for endometrial cancer survivors may be optimized.

Gynecologic oncology group trials in uterine corpus malignancies: recent progress

The Gynecologic Oncology Group (GOG) has conducted multiple trials related to malignancies of the uterine corpus. Recently, several of these trials have been presented and/or published. Areas of focus included the feasibility of laparoscopic staging for endometrial cancer, the adjuvant management of locally advanced endometrial cancer, whole abdominal irradiation in maximally resected advanced endometrial carcinoma, and combination chemotherapy regimens for stage I and II carcinosarcoma after primary surgery and for advanced or recurrent carcinosarcoma. This article will discuss the background and details of each of these important advances.

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

OBJECTIVE

The aim of this study was to compare, in a series of 159 women the feasibility, safety and morbidity of total laparoscopic hysterectomy (LPS) and abdominal hysterectomy with lymphadenectomy (LPT) for early-stage endometrial cancer and to assess disease-free survival and recurrence rate.

METHODS

159 patients with clinical stage I endometrial cancer were enrolled in a prospective randomized trial and treated with LPS or LPT approach. The para-aortic lymphadenectomy was performed in all cases with positive pelvic lymph nodes discovered at frozen section evaluation, in patients with poorly differentiated tumors with myometrial invasion greater than 50% (ICG3), and non-endometrioid carcinomas.

RESULTS

The mean operative time was 136 min+/-31 (95% CI 118-181) in the LPS group and 123 min+/-29 (95% CI 111-198) in the LPT group (P<0.01). The mean blood loss was 50 ml+/-12 in the LPS group (95% CI 20-90) and 145 ml+/-35 in the LPT group (95% CI 60-255) (P<0.01). The mean length of hospital stay was 5.1+/-1.2 in the LPT group (95% CI 1-7) and 2.1+/-0.5 in the LPS group (95% CI 1-5) (P<0.01).

CONCLUSIONS

Laparoscopy is a suitable procedure for the treatment of patients with early endometrial cancer and may offer the potential benefits of decreased discomfort with decreased convalescence time without compromising the degree of oncological radicality required; however, it does not seem to modify the disease-free survival and the overall survival, although multicenter randomized trials and long-term follow-up are required to evaluate the overall oncologic outcomes of this procedure.

Quality of Life Considerations in Gynecologic Cancer

Quality of life (QOL) is a fundamental consideration for patients with life threatening diseases. Major evolving paradigms are discussed: improved QOL with laparoscopic surgery, the impact on QOL of intraperitoneal chemotherapy for optimally cytoreduced ovarian cancer, combination therapy, sexuality, and survivorship. The goals of treatment for many patients with gynecologic tumors remain largely palliative, and patient reported QOL is the primary outcome determining the utility of treatment. Particularly in this area, QOL endpoints are increasingly important in clinical trials. The QOL issues facing gynecologic cancer patients, the use of validated QOL instruments, recent advances in the evaluation of interventions, and changes in concepts related to QOL are reviewed.