Laparoscopically assisted versus open surgery for endometrial cancer--a meta-analysis of randomized controlled trials

Laparoscopic vs. open procedure for intermediate‑ and high‑risk endometrial cancer: a minimum 4-year follow-up analysis

BACKGROUND

The long-term oncologic outcomes after laparoscopic and open procedures for patients with intermediate‑ and high‑risk endometrial cancer (EC) remain unclear. Accordingly, laparoscopy cannot still be recommended as the standard choice for intermediate‑ and high‑risk EC. This retrospective study aimed to assess the perioperative and long-term oncologic outcomes of laparoscopy and open surgery in patients with intermediate- and high‑risk ECs within a minimum 4-year follow-up.

METHODS

We included 201 patients who underwent laparoscopic or open procedures for intermediate‑ and high‑risk EC between 2010 and 2017. Between-procedure comparisons of perioperative and oncological outcomes were performed using the independent t-test or Pearson's chi-squared test and the Kaplan-Meier method, respectively.

RESULTS

Finally, there were 136 intermediate‑ and 65 high‑risk endometrial tumors in the laparoscopic and open groups, respectively. There were no between-group differences in all baseline characteristics. Compared with the open group, the laparoscopic group had a significantly longer mean operating time (p = 0.005) and a lower mean estimated blood loss (EBL) (p = 0.031). There was a higher possibility of postoperative complication in the open group than in the laparoscopic group (p = 0.048). There were no significant between-group differences in pathological outcomes as well as the recurrence-free survival and overall survival rates (p = 0.626 and p = 0.148, respectively).

CONCLUSIONS

Among patients with intermediate‑ and high‑risk EC, laparoscopic surgery has an advantage over the open surgery in reducing EBL and the rate of postoperative complications without weakening the oncological control. There were no between-procedure differences in the recurrence-free and overall survival rates.

Robotic Surgery in the Frail Elderly: Analysis of Perioperative Outcomes

PURPOSE

The frail are considered at higher risk for unfavorable surgical outcomes (major complications/mortality). We assessed the safety of and outcomes associated with robotic surgery in the frail elderly undergoing gynecologic procedures.

METHODS

We identified patients aged ≥ 65 years who underwent a robotic procedure between May 2007 and December 2016. Frailty was defined as the presence of at least three of five frailty factors-more than five comorbidities, low physical activity, weight loss, exhaustion, and fatigue. Perioperative outcomes were recorded. We compared variables among frail and non-frail patients and performed a multivariate logistic regression to detect variables associated with major complications (≥ grade 3) or 90-day mortality.

RESULTS

We identified 982 patients: 71 frail and 911 non-frail patients. Median age was 71 years. Median BMI was 29.8 kg/m². Thirty-four patients (3.5%) had a 30-day readmission. Seventy-seven (7.8%) had a postoperative complication, of which 23 (2.3%) were major. Ninety-day mortality was 0.5%. There were significant differences with regard to age (P < 0.001), body mass index (BMI) (P < 0.001) and performance status (P < 0.001); the frail were more likely to have had surgery for oncologic reasons (P = 0.047). There were differences in hospital stay (P < 0.001), postoperative (P = 0.042) and major complications (P = 0.007), and 90-day mortality (P = 0.05). At multivariable logistic regression, age ≥ 85 was associated with major complications. BMI, performance status, and major complications were associated with 90-day mortality.

CONCLUSIONS

The frail elderly have longer hospital stays and more complications after surgery than the general population, consistent with the reported literature. Careful selection of surgical candidates is required.

Laparoscopic versus Laparotomy: Staging Surgery for Endometrial Cancer - Malaysia's Early Experience

Objective:

The objective of the study is to assess the efficacy of laparoscopy compared with laparotomy in extrafascial hysterectomy and lymphadenectomy for endometrial cancer.

Design:

This was a retrospective study of small cases over a 5-year period.

Setting:

This study was conducted in Putrajaya Hospital, a district hospital with consultant care level in obstetrics and gynecology.

Sample:

Forty women presented with confirmed cases of endometrial cancer based on histopathology result and underwent extrafascial hysterectomy with or without lymphadenectomy between January 2010 and December 2014.

Materials and Methods:

Patient outcomes were compared between 26 women who underwent laparoscopic total hysterectomy with or without lymphadenectomy and 14 women who underwent open laparotomy extrafascial hysterectomy with or without lymphadenectomy. Data were collected using electronic medical records.

Main Outcome Measures:

Postoperative outcomes, operative time, total intraoperative blood loss, number of lymph nodes harvested, and total days of postoperative stay were obtained.

Results:

There was a significant reduction in operative blood loss in the laparoscopic group with mean 262.50 ± 47.87 and laparotomy group with mean 381.82 ± 138.33, 95% confidence interval, P < 0.05. Postoperative hospital stay was also significantly reduced in the laparoscopic group, where the mean postoperative stay in laparoscopic group was 2.5 ± 2.0 days and laparotomy 5.0 ± 3.6 days. There was no significant difference in mean operative time (the mean operative time: 256 ± 76.40 for laparotomy and 288.75 ± 43.66 for the laparoscopic approach). More number of lymph nodes were harvested laparoscopically (29.75 ± 16.59) than laparotomy (23.0 ± 12.62); however, this was not significant.

Conclusions:

Laparoscopic surgery had significant lesser blood loss and it is comparable to laparotomy in the surgical management of endometrial cancer. Experienced surgeon will be able to perform hysterectomy and lymphadenectomy as equally good to laparotomy with adequate tumor excision and complete staging.

Is Robotic-Assisted Surgery Safe in the Elderly Population? An Analysis of Gynecologic Procedures in Patients ≥ 65 Years Old

BACKGROUND

The elderly population is expanding worldwide but is underrepresented in clinical trials. We sought to assess the safety of robotic gynecologic surgery in an elderly cohort and to identify factors associated with unfavorable outcomes.

METHODS

All patients ≥ 65 years who underwent a robotically assisted procedure at a single institution between May 2007 to December 2016 were divided into three age groups: 65-74 (Group 1); 75-84 (Group 2); ≥ 85 (Group 3). Perioperative outcomes were recorded in patients who did not require conversion to laparotomy. We compared clinical variables among groups and performed multivariate logistic regression to detect variables associated with major complications (≥ Grade 3) or 90-day mortality.

RESULTS

We retrospectively identified 982 cases: 685 in Group 1; 249 in Group 2; 48 in Group 3. Median age = 71 years. Median BMI = 28.9. Malignancy was documented in 72.8% of cases; the majority were endometrial cancer (61.8%). Thirty-four patients (3.5%) were readmitted within 30 days. Seventy-seven (7.8%) had a postoperative complication, and 23 (2.3%) had a major complication. Ninety-day mortality was 0.5%. There was significant difference between groups with respect to body mass index (P = 0.026), ECOG PS (P ≤ 0.001), > 5 comorbidities (P = 0.005), hospital stay (P < 0.001), major complications (P = 0.001), and 90-day mortality (P < 0.001). On multivariable logistic regression, age ≥ 85 years was associated with major complications. Body mass index, age ≥ 85 years, and major complications were significantly associated with 90-day mortality.

CONCLUSIONS

Robotic-assisted surgery appears to be safe in an elderly cohort. The incidence of overall and major complications is consistent with those reported in the literature. Patients ≥ 85 years old appear to be at higher risk of unfavorable outcomes.

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.

Comparative outcomes in older and younger women undergoing laparotomy or robotic surgical staging for endometrial cancer

BACKGROUND

Older patients are at increased risk of perioperative morbidity and mortality. There are limited data on the safety of a robotic approach in the staging for endometrial cancer.

OBJECTIVE

We compared outcomes in women undergoing laparotomy or robotic surgical staging for endometrial cancer.

STUDY DESIGN

Using the Healthcare Cost and Utilization Project National Inpatient Sample database from 2008 through 2010, we abstracted records for patients who had surgery for endometrial cancer with either a robotic approach or laparotomy. Patients were categorized by age (<65 vs ≥65 years and 5-year increments). Medical comorbidity scores were calculated using the Charlson Comorbidity Index. Outcomes included intraoperative/perioperative/medical complications, death, length of stay (LOS), and discharge disposition. Student t and χ(2) tests were used to compare groups and approach. Multiple analysis of variance models were used to compare differences between robotics and laparotomy and age groups.

RESULTS

We identified 16,980 patients who had surgery for endometrial cancer with either a robotic approach (age ≥65 years, n = 1228; age <65 years, n = 1574) or laparotomy (age ≥65 years, n = 5914; age <65 years, n = 8264). Older patients had a higher Charlson Comorbidity Index score at the time of surgery (2.6 vs 2.5, P < .001). In laparotomy cases, intraoperative complication rates were similar (4.1% vs 3.7%, P = .17). Older patients had higher rates of perioperative surgical (20.5% vs 15.4%, P < .001) and medical (23.3% vs 15.5%, P < .001) complications, longer LOS (5.1 vs 4.2 days, P < .001), and lower rates of discharge to home (71.2% vs 90.1%, P < .001). In robotic cases, rates of intraoperative complications were similar (5.9% vs 6.8%, P = .32). Older patients had higher rates of perioperative surgical (8.3% vs 5.2%, P = .001) and medical (12.3% vs 6.7%, P = .001) complications, longer LOS (2.00 vs 1.67 days, P < .001), and lower rates of discharge to home (88.8% vs 96.8%, P < .001). With both approaches, as age increased, perioperative surgical and medical complications also increased in a linear fashion. In a subanalysis of older patients (n = 7142), there were lower rates of perioperative surgical (8.3% vs 20.5%, P < .001) and medical (12.3% vs 23.3%, P < .001) complications, death (0.0% vs 0.8%, P < .001), shorter LOS (2.00 vs 5.13 days, P < .001) and higher rate of discharge to home (88.8% vs 71.2%, P < .001) in robotic compared to laparotomy cases.

CONCLUSION

Although the risks of surgery increase with age, in patients age ≥65 years, a robotic approach for endometrial cancer appears to be safe given current selection criteria utilized in the United States.

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.

Symptomatic and anatomic 1-year outcomes after robotic and abdominal sacrocolpopexy

OBJECTIVE

The purpose of this study was to compare symptomatic and anatomic outcomes 1 year after robotic vs abdominal sacrocolpopexy.

STUDY DESIGN

Our retrospective cohort study compared women who underwent robotic sacrocolpopexy (RSC) with 1 surgeon to those who underwent abdominal sacrocolpopexy (ASC) as part of the Colpopexy and Urinary Reduction Efforts trial. Our primary outcome was a composite measure of vaginal bulge symptoms or repeat surgery for prolapse.

RESULTS

We studied 447 women (125 with RSC and 322 with ASC). Baseline characteristics were similar. There were no significant differences in surgical failures 1 year after surgery based on our primary composite outcome (7/86 [8%] vs 12/304 [4%]; P = .16). When we considered anatomic failure, there were also no significant differences between RSC and ASC (4/70 [6%] vs 16/289 [6%]; P = .57).

CONCLUSION

One year after sacrocolpopexy, women who underwent RSC have similar symptomatic and anatomic success compared with those women who underwent ASC.

Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation

BACKGROUND

Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions.

METHODS

A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests.

RESULTS

More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01--120th and p < 0.001--168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group.

CONCLUSIONS

MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.

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.