Objective
The objective of the study was to compare adverse event rates between laparoscopic vs open surgery for endometrial cancer.
Study Design
This was a retrospective cohort study comparing 107 women who underwent laparoscopy with 269 age- and body mass index–matched women who underwent laparotomy for treatment of endometrial cancer.
Results
Adverse event rates were similar between cohorts (37% laparoscopy vs 43% laparotomy, P = .248). Laparotomies had higher rates of cellulitis (16% vs 7%, P = .018) and open wound infection (9% vs 2%, P = .02), whereas laparoscopy had higher rates of sensory peripheral nerve deficit (5% vs 0%, P = .008) and lymphedema (7% vs 1%, P = .003). Laparoscopy was associated with longer mean operating room times but with shorter hospital stays and lower mean blood loss.
Conclusion
Laparoscopy was associated with decreased rates of surgical site infections but had an increased risk of peripheral sensory nerve deficits and lymphedema when compared with laparotomy.
Surgery is both the primary treatment for early-stage endometrial cancer and the means for comprehensive staging as recommended by the International Federation of Gynecology and Obstetrics. Because most patients present at an early stage during which surgery is often curative, a thorough understanding of the potential morbidity associated with different surgical approaches is important to determine the optimal surgical technique for the treatment of this disease.
Several studies have examined surgical approaches to the treatment of endometrial cancer and have demonstrated comparable surgical outcomes between laparoscopic and open (laparotomy) techniques. The Gynecologic Oncology Group (GOG) recently released results detailing operative outcome and adverse events from the LAP2 trial, a randomized controlled trial that compared laparoscopy with laparotomy for hysterectomy and surgical staging of endometrial cancer. This large trial reported that adverse event rates were lower in patients who underwent laparoscopy. Although this study definitively highlighted many of the adverse events and surgical outcomes associated with each approach, only moderate to major complications were reported, and several specific adverse events such as lymphedema and neuropathy were not included in the analysis.
The purpose of the present study was to compare the perioperative surgical outcomes and specific adverse events associated with the laparoscopic and open approaches to the treatment of endometrial cancer.
Materials and Methods
Following institutional review board approval, the Duke University Tumor Registry was reviewed to retrospectively identify all patients with endometrial cancer who underwent primary surgical treatment via a laparoscopic approach at Duke University Medical Center during the years 2006 and 2007, a time frame during which this was the most common surgical approach. For comparison, a cohort was identified, matched with respect to age and body mass index (BMI), who underwent initial laparotomy (open cohort) for treatment of endometrial cancer between 2002 and 2005, years during which this was the primary surgical approach at the authors’ institution.
Matching was performed before statistical analysis in a 2.5:1 ratio (2.5 laparotomies to every 1 laparoscopy). Inclusion criteria were an initial procedure that included hysterectomy and a final pathology report consistent with surgical stage I disease, although lymph node dissection was not required. Exclusion criteria were preoperative radiation, coexisting second primary gynecologic cancer, and primary surgery not performed at our institution. All cases that began laparoscopically but were converted to laparotomy were included in the laparoscopic cohort to approximate an intent-to-treat analysis.
Clinical data were abstracted from patient electronic medical records, paper charts, and Cancer Center Tumor Registry information and included all in-patient and outpatient encounters at our institution with follow-up through March 2008. The Common Terminology Criteria for Adverse Events was used to designate major vs minor complications; applicable grade 2 and higher events were listed as major complications.
The Fisher’s exact test and χ 2 analysis were used to analyze categorical variables and Student t tests were used to compare continuous variables. Two-tailed P values were used and statistical significance was set at a P = .05. All statistical analyses were performed using SAS software version 8.2 (Statistical Analysis Software, Cary, NC).
Results
One hundred seven patients who underwent an attempted laparoscopic surgical approach for the treatment of endometrial cancer between January 2006 and December 2007 were identified. Of these, 84% (90) were completed laparoscopically. For comparison, 269 patients, matched by age and BMI, who underwent initial laparotomy for the treatment of endometrial cancer between 2002 and 2005 were identified. Patient demographic and clinical data are detailed in Table 1 .
| Characteristic | Laparoscopy (n = 107), n (%) | Laparotomy (n = 269), n (%) | P value |
|---|---|---|---|
| Age, y | |||
| 30-39 | 3 (3) | 7 (3) | .940 |
| 40-49 | 10 (9) | 25 (9) | |
| 50-59 | 29 (27) | 79 (29) | |
| 60-69 | 33 (31) | 82 (30) | |
| ≥70 | 32 (30) | 76 (28) | |
| BMI, kg/m 2 | .921 | ||
| <25 | 17 (16) | 43 (16) | |
| 25 to <30 | 23 (22) | 57 (21) | |
| 30 to <35 | 24 (23) | 63 (23) | |
| 35 to <40 | 20 (19) | 52 (19) | |
| 40-85 | 21 (20) | 54 (20) | |
| Missing | 4 | 0 | |
| Race | .869 | ||
| White | 82 (77) | 214 (80) | |
| Black | 20 (19) | 47 (17) | |
| Other | 4 (4) | 8 (35) | |
| Parity | .863 | ||
| 0 | 21 (20) | 62 (23) | |
| 1 | 18 (17) | 34 (13) | |
| 2 | 29 (27) | 76 (28) | |
| 3 | 17 (16) | 46 (17) | |
| ≥4 | 21 (20) | 51 (19) | |
| Histology | .732 | ||
| Adenocarcinoma | 87 (85) | 217 (84) | |
| Serous | 6 (6) | 16 (6) | |
| Clear cell | 0 (0) | 4 (2) | |
| Other | 10 (10) | 21 (8) | |
| Grade | |||
| 1 | 56 (52) | 105 (39) | .04 |
| 2 | 23 (21) | 89 (33) | |
| 3 | 28 (26) | 75 (28) | |
| Adjuvant radiation | |||
| Yes | 15 (14) | 38 (14) | > .99 |
| No | 92 (86) | 231 (86) |
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