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Abstract
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. 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. 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. Minimally invasive robotic
surgery, MILS, or total abdominal hysterectomy. Severe complications were dichotomized
and encompassed death within 30 days after surgery and intraoperative and postoperative
complications diagnosed within 90 days after surgery. 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). 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. This cohort study evaluates
the association between the nationwide introduction of minimally invasive robotic
surgery in Denmark and severe complications in patients with early-stage endometrial
cancer. Is the nationwide introduction of minimally invasive robotic surgery associated
with a decreased risk of severe complications in patients with early-stage endometrial
cancer? A Danish nationwide cohort of 5654 women with early-stage endometrial cancer
was divided into 2 groups based on the time of the introduction of minimally invasive
robotic surgery in their region. The risk of severe complications was significantly
reduced in the group undergoing surgery after the introduction of minimally invasive
robotic surgery. The national implementation of minimally invasive robotic surgery
was associated with an increased proportion of minimally invasive surgical procedures,
which translated into a reduced risk of severe complications in women with early-stage
endometrial cancer.
The objective was to compare laparoscopy versus laparotomy for comprehensive surgical staging of uterine cancer. Patients with clinical stage I to IIA uterine cancer were randomly assigned to laparoscopy (n = 1,696) or open laparotomy (n = 920), including hysterectomy, salpingo-oophorectomy, pelvic cytology, and pelvic and para-aortic lymphadenectomy. The main study end points were 6-week morbidity and mortality, hospital length of stay, conversion from laparoscopy to laparotomy, recurrence-free survival, site of recurrence, and patient-reported quality-of-life outcomes. Laparoscopy was initiated in 1,682 patients and completed without conversion in 1,248 patients (74.2%). Conversion from laparoscopy to laparotomy was secondary to poor visibility in 246 patients (14.6%), metastatic cancer in 69 patients (4.1%), bleeding in 49 patients (2.9%), and other cause in 70 patients (4.2%). Laparoscopy had fewer moderate to severe postoperative adverse events than laparotomy (14% v 21%, respectively; P < .0001) but similar rates of intraoperative complications, despite having a significantly longer operative time (median, 204 v 130 minutes, respectively; P < .001). Hospitalization of more than 2 days was significantly lower in laparoscopy versus laparotomy patients (52% v 94%, respectively; P < .0001). Pelvic and para-aortic nodes were not removed in 8% of laparoscopy patients and 4% of laparotomy patients (P < .0001). No difference in overall detection of advanced stage (stage IIIA, IIIC, or IVB) was seen (17% of laparoscopy patients v 17% of laparotomy patients; P = .841). Laparoscopic surgical staging for uterine cancer is feasible and safe in terms of short-term outcomes and results in fewer complications and shorter hospital stay. Follow-up of these patients will determine whether surgical technique impacts pattern of recurrence or disease-free survival.
Standard treatment for endometrial cancer involves removal of the uterus, tubes, ovaries, and lymph nodes. Few randomized trials have compared disease-free survival outcomes for surgical approaches.
Lymph-vascular space invasion (LVSI) is an important adverse prognostic factor in endometrial cancer (EC). However, its role in relation to type of recurrence and adjuvant treatment is not well defined, and there is significant interobserver variation. This study aimed to quantify LVSI and correlate this to risk and type of recurrence.
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