I read with great interest the article by Zullo et al.

First, the authors reported a higher rate (7.5%) of vaginal cuff recurrence in patients who were treated with laparoscopic surgery for early-stage endometrial cancer and distant metastasis in this group occurred in 5%. The authors did not mention, in their article, what was their technique for vaginal resection (partial vaginectomy). What was the length of the vagina that was resected in the laparoscopic surgery and the open laparotomy groups? What were the technique and extent of bilateral pelvic and paraaortic lymphadenectomy that they used?

The issue of through pelvic and paraortic lymphadenectomy is important because the extent of lymphadenectomy is related to the number of metastatic lymph nodes identified. It has been shown that undergoing multiple-site lymphadenectomy had a significantly better survival than did those patients not undergoing lymphadenectomy ( P = .0002). Low-risk patients (disease confined to the uterus) with lymphadenectomy had better survival than did those without lymphadenectomy ( P = .026). High-risk patients (disease in the cervix, adnaxae, uterine serosa, or washings) who underwent lymphadenectomy also had a better survival than did those without lymphadenectomy ( P = .0006).

Second, it seems feasible that partial vaginectomy of the upper one third of the vagina would minimize the chances of vaginal vault recurrence.

Third, I disagree with the author that vaginal vault recurrence can be minimized by administering postoperative brachytherapy. Postoperative adjuvant vaginal vault brachytherapy was shown not to be associated with a measurable reduction in the risk of recurrence in surgical stage I endometrial cancer and intermediate-risk endometrial adenocarcinoma.

It is worth noting that robotic assisted laparoscopic surgery in patients with endometrial cancer has been shown to be associated with significantly minimal blood loss and intraoperative complication rate. This surgical procedure has significantly improved several perioperative outcomes when compared with laparotomy and laparoscopy surgery for early-stage endometrial cancer. The technique is safe, feasible, and cost effective with acceptable pathological and short- and long-term clinical outcomes. It retains the advantage of minimally invasive surgery.

To conclude, I agree with the authors that multicenter, randomized, controlled trials with adequate sample population are needed to demonstrate the efficacy, safety, and clinical outcomes in patients with early-stage endometrial cancer who are operated on with robotic assisted laparoscopic surgery and laparoscopic surgery.