Robotic versus laparoscopic hysterectomy in morbidly obese women for endometrial cancer

Diabetes mellitus complications associated with recurrence of stage I endometrioid endometrial cancer: A single-center retrospective study

OBJECTIVE

Identifying clinical features that are associated with recurrence of endometrioid endometrial carcinoma (EEC) in patients with diabetes mellitus (DM).

METHODS

A single-center retrospective cohort study was performed on patients with a diagnosis of both DM and Stage I EEC. Clinical and pathologic features were analyzed in relation to 5-year progression free survival (PFS). Kaplan-Meier Curves and Cox proportional hazard ratios were utilized to assess effect on 5-year PFS.

RESULTS

A total of 539 patients were included, with biopsy proven recurrence in 86 (18 %), and 456 (82 %) with no evidence of recurrence. Age, BMI, HgbA1c, metformin use, number of antihyperglycemic medications, use of adjuvant radiation, and surgical approach were not associated with differences in PFS. Presence of end-organ complications associated with diabetes was correlated with worse PFS (HR 1.78, 95 % CI 1.1-2.9, P = 0.02), and specifically diabetic neuropathy was associated with higher rates of recurrence (HR 3.6, 95 % CI 2.1-6.2, P < 0.01). In this cohort, PFS was independently associated with extent of myoinvasion (HR 2.33, 95 % CI 1.4-3.7, P < 0.01) as well as both microsatellite instability (HR 3.43, 95 % CI 1.8-6.6, P < 0.01), and no specific molecular profile (HR 0.3, 95 % CI 0.2-0.6, P < 0.01) molecular subtypes.

CONCLUSIONS

In patients with DM and EEC, extent of myoinvasion and TCGA molecular subtype correlated with worse PFS. Control of DM as evidenced by HgbA1c, BMI, and use of antihyperglycemic medications did not correlate with PFS in our cohort of patients with Stage I EEC, while the presence of diabetic neuropathy was associated with a higher risk of recurrence. These results highlight importance of evaluating diabetes severity and molecular subtype in endometrial cancer patients.

Robotic surgery for deep-infiltrating endometriosis: is it time to take a step forward?

Endometriosis is a chronic debilitating disease that affects nearly 10% of women of the reproductive age. Although the treatment modalities of endometriosis are numerous, surgical excision of the endometriotic implants and nodules remains the sole cytoreductive approach. Laparoscopic excision of endometriosis was proven to be beneficial in improving the postoperative pain and fertility. Moreover, it was also proved to be safe and efficient in treating the visceral localization of deep endometriosis, such as urinary and colorectal endometriosis. More recently, robotic-assisted surgery gained attention in the field of endometriosis surgery. Although the robotic technology provides a 3D vision of the surgical field and 7-degree of freedom motion, the safety, efficacy, and cost-effectiveness of this approach are yet to be determined. With this paper, we aim to review the available evidence regarding the role of robotic surgery in the management of endometriosis along with the current practices in the field.

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.

Robot-assisted versus laparoscopic minimally invasive surgery for the treatment of stage I endometrial cancer

OBJECTIVE

Recent reports in both cervical and endometrial cancer suggest that minimally invasive surgery (MIS) had an unanticipated negative impact on long-term clinical outcomes, including recurrence and death. Given increasing use of robotic surgery since the LAP2 trial, we sought to compare the intermediate and long-term outcomes between those who underwent robotic surgery or laparoscopy for Stage I endometrial cancer.

METHODS

We performed a retrospective review of patients from a single, large, academic, urban practice who underwent either laparoscopic or robot-assisted MIS (RA-MIS) for the treatment of endometrial carcinoma between 2006 and 2016, ensuring at least 5 years of potential follow-up. To adjust for differences in confounding variables between groups, propensity score-based inverse probability of treatment weighting (IPTW) was performed. Overall and recurrence-free survival were compared using Cox proportional hazards regression models adjusting for confounding weights.

RESULTS

1027 patients were included; 461 received laparoscopy and 566 received RA-MIS. RA-MIS use increased steadily during the study window, which resulted in longer mean surveillance in laparoscopy group (median 8.7 years versus 6.3 years, p < 0.001). RA-MIS was associated poorer recurrence-free (HR: 1.41, 95% CI: 1.12, 1.77) and overall survival (HR: 1.39, 95% CI: 1.06, 1.83). Disease-specific survival was also poorer in the RA-MIS group (HR: 3.51, 95% CI: 2.19, 5.63). Among those who recurred, median time to first recurrence was shorter in the RA-MIS group than the laparoscopy group (16.3 vs. 28.7 months, p = 0.07).

CONCLUSION

RA-MIS was associated with poorer long-term patient outcomes. Our data in this lower-risk population indicate relevant clinical endpoints may be occurring during intermediate and long-term follow-up windows. These findings support a prospective evaluation of the long-term outcomes of RA-MIS.

Robotic-assisted versus conventional laparoscopic hysterectomy for endometrial cancer

Objective

The safety and efficacy of robotic-assisted laparoscopic hysterectomy (RALH) compared with conventional total laparoscopic hysterectomy (TLH) for surgical staging of endometrial cancer has not been clearly established. With the commencement of a robotic program at our institution, our objective was to evaluate and compare the surgical outcomes of RALH with TLH for endometrial cancer.

Methods

A retrospective cohort study was performed on 39 patients who underwent RALH and 41 patients who underwent TLH for endometrial cancer at a tertiary care academic institution.

Results

In the setting of endometrial cancer RALH is significantly longer to perform than TLH (mean operating time 133 min vs 107 min, p = 0.0001). There is higher estimated blood loss in TLH cases than RALH cases (78 mL vs 22 mL, p = 0.015). Women who underwent RALH had a shorter length of stay (1.3 days vs 1.8 days, p = 0.006) than TLH patients, and six cases (15 %) of the RALH group were discharged on the same day of surgery. There were no differences between the RALH and TLH groups in intraoperative or postoperative complications and there were no conversions to laparotomy.

Conclusion

RALH is safe and feasible for the treatment of endometrial cancer, with low morbidity, less blood loss and shorter length of stay than TLH. RALH is associated with longer mean operating times than TLH and this may improve with enlisting a consistent experienced team. Prospective randomised studies which include analysis of quality of life measures and long-term outcomes are required to further establish the role of RALH in the surgical staging of endometrial cancer.