Objective
We sought to examine the evolution of surgical care for early-stage endometrial cancers and factors affecting use of laparoscopy.
Study Design
Women with surgically managed early-stage endometrial cancer were divided into 2 groups corresponding to before and after addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform.
Results
In all, 502 women were identified. Laparoscopic management increased from 24-69% between time periods ( P < .0001). Performance of comprehensive surgical staging, and lymph node counts, increased ( P < .0001) despite an increase in median body mass index ( P = .001). A traditional “straight stick” technique was performed in 72% of laparoscopic cases during the later period. Laparoscopy patients had lower estimated blood losses and shorter hospital stays (each P < .0001) compared to laparotomy patients.
Conclusion
Addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform shifted management of early-stage endometrial cancer toward laparoscopy.
Endometrial cancer is the most common gynecologic malignancy in the United States, affecting an estimated 43,470 women in 2010. Fortunately, a large percentage present with symptoms prompting relatively early diagnosis. Most women with presumed uterine-confined disease are initially managed surgically, both as treatment and to establish surgical stage. Traditionally, hysterectomy, bilateral salpingo-oophorectomy, and staging lymphadenectomy were performed via laparotomy incision. From May 1996 through September 2005, the Gynecologic Oncology Group Lap-2 trial enrolled 2616 women on a randomized controlled trial comparing surgical staging of endometrial cancer via laparotomy vs laparoscopy. Although survival results continue to mature, initial publication has established fewer complications and shorter hospital stay as benefits of the laparoscopic approach compared to laparotomy. Unfortunately, 25.8% of women randomized to laparoscopic staging required conversion to laparotomy to complete the comprehensive staging procedure required by the protocol. The main indication for conversion (56.7%) was difficulty with exposure limiting the ability to perform lymphadenectomy. Conversion correlated with increasing age, body mass index (BMI), and the presence of metastatic disease.
Laparoscopic surgery requires a skill set unique from laparotomy and is a relatively new technology. In part due to the results of GOG Lap-2, a much stronger emphasis has been placed on developing laparoscopic skills during gynecologic oncology fellowship training. Recently graduated fellows often bring these expert skills to institutions where laparotomy had primarily been utilized. More recently, robotic-assisted laparoscopic surgery (RA LS) has been championed as allowing procedures such as laparoscopic endometrial cancer staging to be performed with greater ease. Furthermore, it has been proposed as a tool to increase the ability to perform staging procedures in increasingly morbidly obese women.
We sought to examine the evolution of surgical care for clinical early-stage endometrial cancers within our institution and factors affecting utilization of a laparoscopic surgical approach, specifically the impact of the addition of faculty with formal fellowship training in laparoscopic staging and access to a robotic surgery platform.
Materials and Methods
Retrospective data collection under an institutional review board–approved protocol was undertaken. All women undergoing surgical management of clinical early-stage endometrial cancer at a single academic teaching hospital with an American Board of Obstetrics and Gynecology-approved fellowship in gynecologic oncology were identified. Clinical data were abstracted from a computerized medical record system. Women were divided into 2 groups: time period 1 (T1 = April 2006 through November 2008) and time period 2 (T2 = December 2008 through December 2010), corresponding to before and after the addition of a faculty member with formal fellowship training in laparoscopic staging and access to a robotic surgery platform.
All women underwent hysterectomy and bilateral salpingo-oophorectomy, along with collection of washings for cytology. For purposes of this study, comprehensive surgical staging was defined as performance of pelvic and paraaortic lymph node removal. The surgical approach and extent of nodal staging was performed at the discretion of the attending surgeon. The minimally invasive technique used incorporated either traditional “straight-stick” (n = 182) or robotic-assisted (n = 48) instrumentation.
Statistical analysis was performed using GraphPad InStat, version 3.10 for Windows (GraphPad Software, San Diego, CA). All statistical tests performed were 2-sided and a P value < .05 was considered to be statistically significant.
Results
In all, 502 women underwent surgical management of early-stage endometrial cancer during the study period; 257 of them were managed during T1 and 245 during T2. Median BMI was greater during T2 (33 vs 30 kg/m 2 , P = .001), but was similar between surgical approaches (31 kg/m 2 , laparotomy and laparoscopy, P = .16) ( Table 1 ). Of women undergoing laparoscopy, median BMI during T1 was lower than during T2 (28 vs 32 kg/m 2 , P = .01), but did not differ during T2 between women undergoing traditional “straight stick” laparoscopic surgery (SS LS) compared to RA LS ( P = .14). Although a higher proportion of women with preoperative grade ≥2 histology were managed by laparotomy over the combined time periods and during T2 ( P < .0001 and P = .0002), the proportion of these women managed laparoscopically was significantly higher during T2 as compared to during T1 ( P = .03).
| Group | n | Age, y | BMI, kg/m 2 | Preoperative histologic grade, n (%) | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Median | Range | P value | Median | Range | P value | 1 | 2 | 3 | Other | P value | ||
| T1 | 257 | 62 | 27–88 | Reference | 30 | 17–73 | Reference | 129 (50) | 72 (28) | 48 (19) | 8 (3) | Reference |
| T2 | 245 | 61 | 27–90 | .41 | 33 | 18–88 | .001 | 147 (60) | 47 (19) | 39 (16) | 12 (5) | .01 a |
| Laparoscopy | 230 | 61 | 26–88 | Reference | 31 | 17–73 | Reference | 148 (64) | 49 (21) | 24 (11) | 9 (4) | Reference |
| Laparotomy | 272 | 62 | 27–90 | .02 | 31 | 18–88 | .16 | 128 (47) | 70 (26) | 63 (23) | 11 (4) | < .0001 a |
| SS LS T1 | 61 | 62 | 26–84 | Reference | 28 | 17–73 | Reference | 33 (54) | 20 (33) | 7 (11) | 1 (2) | Reference |
| SS LS T2 | 121 | 60 | 39–88 | .25 b | 32 | 18–57 | .01 b | 82 (67) | 23 (19) | 8 (7) | 8 (7) | .03 a b |
| RA LS | 48 | 62 | 32–78 | .55 c | 34 | 20–64 | .14 c | 33 (69) | 6 (12) | 9 (19) | 0 (0) | .70 a c |
a P value for grade 1 vs grade ≥2;
b P value for SS LS, T1 vs T2;
The proportion of patients undergoing a minimally invasive procedure increased from 24-69% between time periods ( P < .0001) ( Table 2 ). Of those in whom comprehensive staging was completed, the proportion in whom a laparoscopic approach was utilized increased from 11-67% ( P < .0001). During T2, RA LS became available and was performed in 48 women compared to 121 SS LS procedures. Comprehensive surgical staging was more often performed with RA LS compared to SS LS (63% vs 33%, P = .0006). The 2 faculty members who performed procedures throughout the entire study time period increased their utilization of laparoscopy from 17-43% between T1-T2 ( P < .0001). More than 93% of their procedures during T2 were performed using SS LS. Conversion from laparoscopy to laparotomy occurred in 6.3% and 2.3% of cases overall in T1 and T2, respectively, and in 16.7% and 1.4% of comprehensive staging cases ( P = .22 and P = .15, respectively).
