Category
Laparotomy
Laparoscopy
Operating room time (min)
113
168
Number of para-aortic LN obtained
6.75
7.58
Number of pelvic LN obtained
19.5
19.6
Estimated blood loss (ml)
305
131
Blood transfusion rate
10.1 %
104/1,022
7 %
128/1,801
Intraoperative complications
6.6 %
93/1,363
8.8 % 201/2,284
Bladder, ureter, bowel, vascular injury
1.2 %
14/1,149
1 %
20/2,020
Postoperative complications
23 %
320/1,389
15.2 %
353/2,310
Early postoperative complicationsa
4.2 %
47/1,097
2.6 %
53/1,965
Postoperative hospital stay (days)
6.2
3.1
Quality of life 6 weeks after surgery
↓
↑
Recurrence-free survival
88 %
154/175
87 %
161/184
Overall survival
88 %
154/175
91.8 %
169/184
A striking difference is the significantly shorter postoperative hospital stay after laparoscopy despite longer operative times.
The higher rate of intraoperative complications sometimes described in patients who had laparoscopy has been associated with the lack of technical skill and the longer learning curve for laparoscopy compared to laparotomy. Furthermore, more than half of patients included in most of the systematic reviews were derived from the GOG LAP2 trial [15]. This landmark study compared 1,696 patients randomly assigned to laparoscopy to 920 patients assigned to laparotomy for the surgical treatment of endometrial cancer in the United States. Some of these patients were enrolled as early as 1996, when the expertise for laparoscopy was still developing. Despite this, the rate of significant intraoperative complications such as bladder, ureter, bowel, and vascular injuries was similar in both arms. Total and pelvic lymph node yields and the detection rate of advanced-stage disease, both surrogate markers for surgical completion, were similar in both arms. Para-aortic lymph node counts were equally similar when reported [10–15].
A few concerns remained regarding oncologic outcomes after laparoscopic surgery:
1.
The loss of tactile sense during laparoscopy may result in failure to detect metastatic tumor otherwise palpable at laparotomy.
2.
Failure to identify and remove high left para-aortic lymph nodes below the renal vein.
3.
Potential change in patterns of recurrence associated with the high intra-abdominal pressures resulting from carbon dioxide insufflation.
4.
Potential for tumor spill secondary to the use of an intrauterine manipulator and uterine extraction through the vagina.
Most of the concerns faded away following the publication of recurrence and survival in the follow-up publication of the GOG LAP2 study that demonstrated the absence of adverse effects on overall survival, recurrence-free survival, recurrence rate (estimated difference at 3 years, 1.14 %), or the patterns of recurrent disease following laparoscopy [18]. This in combination with the shorter hospital stay, the decreased rate of early and late postoperative complications, the faster recovery, and superior quality of life observed in the laparoscopy cohorts has made minimal invasive surgery the treatment of choice for patients with endometrial cancer.
Special Considerations
Conversion to Laparotomy
Conversions from laparoscopy to laparotomy have been reported from 17 % to 28 % in various series [15, 19]. Higher conversion rates are associated with widespread metastatic disease, increasing BMI and increasing patient age. Conversions may be due to either anatomical difficulties such as dense adhesions, difficult exposure, advanced disease, and a uterus too large to be removed intact through the vagina, or intraoperative complications such as management of intraoperative complications, control of intraoperative bleeding, and intolerance of increased abdominal pressure. The most common reported reason for conversion is insufficient visualization caused by inability to maintain adequate Trendelenburg position. In the LAP2 study, the rate of conversion to laparotomy for women with BMI >40 kg/m2 was 57 %, and for each 10-year increase in age, the chance of conversion increased by 30 % [15].
Vaginal Cuff Recurrence and Port-Site Metastasis
During laparoscopic staging, the cancer-affected uterus and adnexa are removed through the vagina which may raise a concern for increased vaginal cuff recurrence. Fortunately, no statistically significant difference in the rate of vaginal vault recurrence was noticed between the laparoscopic and abdominal approach [18, 20].
Some have stipulated that the use of uterine manipulator during laparoscopic staging may contribute to dissemination of malignant cell from the uterine cavity thorough the fallopian tubes into the pelvic cavity. A study by Eltabbakh and Mount evaluated peritoneal washings before and after insertion of a uterine manipulator. None of the 42 patients had a change from negative to positive washing results after insertion of the manipulator [21]. Although there is no definitive data to support peritoneal cavity seeding by the uterine manipulator, several authors do advocate sealing the tubes at the start of the case and minimize uterine manipulation [22].
There have been a number of case reports of port-site metastasis after laparoscopic treatment of endometrial cancer. In fact, port-site metastasis has been reported in a small percent of all gynecologic malignancies undergoing laparoscopy [23]. The fact that wound recurrences are not uncommon after conventional surgery clearly attenuates the responsibility of laparoscopic surgery in the occurrence of abdominal wall recurrences [24]. A study from Memorial Sloan Kettering Cancer Center reported 18 abdominal wall metastases in 1,634 gynecologic cancer patients treated by laparoscopy. Fifteen occurred in 767 patients with adnexal/peritoneal malignancy (2 %), two in 160 cervical cancer patients, and one in 457 endometrial cancer patients. Seventeen out of the eighteen patients had concomitant intraperitoneal disease at the time of diagnosis of the port-site metastasis. Overall, port-site tumor implantation is low and almost always occurs in the setting of synchronous, advanced intra-abdominal, or distant metastatic disease [25].
The presence of port-site implantation is often a surrogate for advanced disease and is not anymore an argument against laparoscopic surgery in gynecologic malignancies including endometrial cancer.
Obesity
Obesity and the concomitant excess of unopposed estrogen are associated with endometrial cancer [26], particularly type 1. These patients frequently suffer from other comorbidities, i.e., diabetes mellitus, hypertension, and/or coronary heart disease. Morbid obesity is considered by some to be a relative contraindication to laparoscopic surgery. Of particular concern are cardiopulmonary compromise and difficulties with ventilation resulting from increased intra-abdominal pressure. These complications may prevent the steep Trendelenburg position sometimes necessary to complete the operation and increase the rate of conversion to laparotomy [27].
In open abdominal surgery, obesity and diabetes mellitus are associated with significantly higher perioperative complication rates such as longer surgery durations, more blood loss, and higher transfusion rates. Postoperative complications, like wound infection and dehiscence or symptomatic ileus, are also increased. Finally, due to prolonged hospital stay, the risks of thrombosis and/or pulmonary embolism rates are higher.
On the other hand, others recommend laparoscopy over laparotomy in obese patients to minimize these peri- and postoperative complications [28]. Vaginal procedures already provide the advantages of reducing total surgery duration and perioperative surgical and anesthetic morbidity. However, during vaginal surgery, neither nodal nor abdominal staging can take place, and safe removal of the adnexa is often compromised. Vaginal approach may be limited by anatomical circumstances as well as patients’ parity. Therefore, laparoscopy, even with its limitations, constitutes a valid surgical procedure in obese women. Peritoneal access restrictions, difficulty accessing the pelvic organs and performing adequate lymphadenectomy, as well as the aforementioned anesthetic complications are all associated with the proportional increase in conversion rate to laparotomy with increasing BMI. A recent multicentered study explored the advantages of laparoscopy versus laparotomy in extremely obese women (BMI > 35) with early-stage endometrial cancer. In all cases, systematic pelvic lymphadenectomy was performed. In two women of the laparoscopy group (4.4 %), a port-site hematoma was observed and was resolved without a second surgery. In three women (10 %) of the laparotomy group, dehiscence of the abdominal suture with surgical site infection was observed and was re-sutured [29]. There is no consensus for an upper limit above which laparoscopy should not be considered. The decision is almost entirely surgeon dependent and relies on the experience acquired over the years.
Elderly Patients
Older women constitute another challenge group of patients for laparoscopy.
A number of studies dealt with this issue; in one, 59 women aged 75 years or older who underwent laparoscopy were compared with a cohort of 66 women aged 75 years or older who underwent open staging. Women who underwent laparoscopy had similar operative time (P = 0.14), lower blood loss (P = 0.005), and shorter length of stay (P < 0.001) in comparison with women who underwent open surgical procedure. Overall, women who underwent laparoscopy experienced less postoperative complications than women in the control group (P < 0.001). No differences in survival outcomes (including time of recurrence, site of recurrence, disease-free survival, and overall survival) were recorded (P > 0.05) [30].
In conclusion, in this population, a minimally invasive procedure will lead to fewer perioperative complications such as myocardial infarction, deep vein thrombosis, and pneumonia without a significant increase in operative time, blood loss, or length of hospital stay. Therefore, laparoscopic staging for endometrial cancer is safe and feasible in the elderly population [30–32].
Quality of Life
The excellent cure rates that are attained for well-differentiated EC have allowed shifting focus from the already high survival toward quality of life issues after treatment. In a recent prospective, randomized study comparing laparoscopy to laparotomy in the management of endometrial cancer, Zullo et al. prospectively demonstrated that patients treated with laparoscopy did indeed have improved quality of life for the first 6 months after surgery [11].
Quality of life up to 6 months after surgery was also assessed in a randomized controlled trial comparing total laparoscopic hysterectomy with total abdominal hysterectomy (TAH) for stage I endometrial cancer [17]. Three hundred and sixty-one participants were enrolled. Three hundred and thirty-two completed the quality of life analysis. Patients who had laparoscopic surgery reported significantly greater improvement in quality of life (QoL) from baseline, in all subscales, apart from emotional and social well-being that are related to dealing with cancer.
GOG LAP2 also required patients to complete quality of life assessment at baseline and then at 1, 3, and 6 weeks and 6 months postoperatively [33]. The first 802 eligible patients randomized in LAP2 participated in the QoL study. Within 6 weeks of surgery, patients assigned to laparoscopy reported significantly better QoL on all scales other than fear of recurrence. In summary, during this 6-week postoperative period, patients assigned to laparoscopy were found to have superior QoL, fewer physical symptoms, less pain and pain-related interference with functioning, better physical functioning and emotional state, earlier resumption of normal activities, earlier return to work, and better body image as compared to those assigned to laparotomy.
The LAP2 QoL study arm completed a self-report QoL survey, which contained sexual function items. Of 752 patients who completed the QoL survey, 225 completed the sexual function items within the QoL survey. No significant differences of sexual function were found between the patients randomized to laparoscopy and to laparotomy. Sexual function scores declined after surgery and recovered to presurgery levels at 6 months. Sexual function was positively associated with better quality of relationship (P < 0.001), body image (P < 0.001), and QoL (P < 0.001) and negatively associated with fear of sex (P < 0.001). Younger patients, those who were married, and those who had quality relationships were more likely to answer the sexual function items and have better quality of sexual function. Factors such as age, relationship quality, body image, and pain may place women with endometrial cancer at risk for sexual difficulties in the immediate recovery period; however, sexual function improved by 6 months postoperatively in the cohort of patients with early-stage endometrial cancer [34]. As the concern of recurrence has been addressed by randomized studies, the benefits of minimal invasive surgery in terms of QoL make it the preferred approach.
Robotics for Endometrial Cancer
Although the proportion of endometrial carcinoma patients treated by laparoscopy is slowly increasing [19, 35], many surgeons find the laparoscopic approach difficult to master because of the counterintuitive movements and the fulcrum effect and do not offer it to most of their patients, mainly those who could most benefit from it such as obese and elderly patients with multiple morbidities [36]. A computer-controlled system that assists the surgeon in utilization and manipulation of surgical instruments in minimally invasive surgery was developed. This computer-assisted minimally invasive surgery has been termed “robotic surgery” although it does not fulfill the definitions of a “robot,” because it does not perform the surgical procedure on its own nor does it involve any artificial intelligence for the moment [37]. In April 2005, the FDA approved the only currently available surgical robotic system (Da Vinci Surgical System, Intuitive Surgical, Inc., Sunnyvale, CA, USA) for gynecologic minimally invasive procedures. Over the following years, robotics rapidly gained acceptance by surgeons as an effective tool for performing hysterectomy with staging lymphadenectomy in the management of endometrial cancer. It is estimated that in 2010, more than 50 % of endometrial carcinoma staging procedures in the USA were managed with robotic-assisted surgery, representing a paradigm shift toward minimally invasive surgery not previously achieved with traditional laparoscopic technique. It is expected for this trend to continue as more systems are installed worldwide and more surgeons are trained to use this platform [38].
Robotic surgery has significant technical advantages and some disadvantages compared to conventional laparoscopy [39–42]:
1.
Binocular three-dimensional high-definition immersion view of the operative field: the surgeon has full control of the camera. Robotic approach eliminates surgeons’ dependence on an assistant that holds a 2D vision camera projected on a screen a few feet away.
2.
Seven degrees of freedom permitted with the wristed instruments:
a.
Improved dexterity mimics the freedom of human hand and wrist motion.
b.
Provides a better precision of movement without tremor, which allows superior operative technique, precise dissection, and better exposure.
c.
Intuitive instrument movement enables surgical procedures to be carried out similar to the way they are accomplished during laparotomy.
3.
Less torque of the abdominal wall through the operative ports, which results in less postoperative pain.
4.
Easier to complete radical and complex gynecologic surgeries thus reducing the need for more morbid laparotomies.
5.
Improved ergonomics for the surgeon. Reduces surgeon fatigue and muscle pain thus allowing longer and more complex operations.
6.
Easier suturing and knot tying.
7.
A shorter learning process.
Disadvantage of the robotic surgical system:
a.
Lack of tactile perception
b.
Increased cost
c.
Need for large operating room (to accommodate the size of the robotic system)
d.
Risk of intraoperative mechanical failure
e.
Need for additional trained staff
Despite the potential benefits of robotic approach, there have been no prospective RCTs comparing laparotomy, laparoscopy, and robotic-assisted laparoscopic staging procedures for treatment of uterine malignancies. The available studies have been relatively small in size, nonrandomized, and limited to highly experienced surgeons and centers. Still, these studies are informative and demonstrate the feasibility of this technique, its safety, and efficacy [37].
The bulk of retrospective case series and two meta-analyses (eight and nine comparative studies, 1,591 and 1,640 total patients, respectively) [36, 37] indicate similarities with laparoscopy in most categories, except for reduced blood loss and fewer conversions to laparotomy in robotic surgeries (Table 20.2). Robotic and traditional laparoscopic surgeries have better outcomes than laparotomy in terms of blood loss, blood transfusions, peri- and postoperative complications, wound infection, postoperative pain, shorter recovery time, and decreased length of hospital stay. Pelvic and para-aortic lymph node counts, which are a measure of surgical quality, were similar for the three modalities.
Category | Laparotomy | Laparoscopy | Robotic |
|---|---|---|---|
Number | 2,555 | 746 | 949 |
Age | 61 | 62 | 63 |
BMI | 31 | 29 | 31 |
Number of para-aortic LN obtained | 10.3 | 7.8 | 5.7 |
Number of pelvic LN obtained | 18.5 | 17.8 | 14.5 |
Operating room time (min) | 186 | 211 | 142 |
Estimated blood loss (ml) | 86 | 131 | 227 |
Transfusion rate (%) | 1 | 4 | 7 |
Postoperative hospital stay (days) | 1.6 | 1.9 | 5.1 |
Overall complications | 13 | 13 | 40 |
The advantages of robotic surgery for the patient compared with traditional laparoscopy are not always evident [39]. Robotic surgery is probably neither safer nor better than laparoscopy in the hands of expert surgeons, but it allows more patients needing complex or radical surgery to benefit from the minimally invasive approach [40, 42].
Disadvantages include present cost associated with purchasing the robotic system and disposable equipment and possibly loss of haptic sensation. Operative times for robotic and laparoscopy cases were similar, but longer than that for laparotomy cases [43].
Recent cost analysis studies indicate that the shorter operating times and the efficiencies gained with robotic surgical experience may translate into significant reductions in operating room costs, such that the widely held belief that robotic surgery is “too expensive” is not true for many institutions [44, 45].
Finally, three recently published retrospective survival analyses of combined 1,054 [46–48] patients provide evidence that robotic-assisted laparoscopy for endometrial carcinoma has similar overall and recurrence-free survival rates to traditional laparoscopy and laparotomy.
Special Considerations
Conversion to Laparotomy
Robotics has become widely used for the hysterectomy and surgical staging of endometrial cancer. Numerous series have reported the success of robotics for endometrial cancer staging and have shown decreased morbidity compared to laparotomy, with low rates of conversion which range from 0 % to 12 % [49, 50], even among subgroups of patients known to be technically challenging for MIS approaches (Table 20.3). Turunen et al. compared surgical outcomes of laparoscopic and robotic hysterectomy for the treatment of endometrial carcinoma in a center with extensive laparoscopic expertise. The robotic cohort (n = 67) had a longer operative time than the laparoscopic cohort (n = 150), and the rate of overall complications was similar in both groups, but still the rate conversion to laparotomy was higher in the laparoscopic group (3.3 %) compared to the robotic group (0 %) [51].
Table 20.3
Comparison of laparoscopy and robotics in conversion rates to laparotomy
Year | Study | Technique | N | Age | BMI | Conversion rate |
|---|---|---|---|---|---|---|
2008 | Boggess et al. [65] | Laparoscopy | 81 | 62 | 29 | 4.9 % |
Robotics | 103 | 62 | 33 | 2.9 % | ||
2008 | DeNardis et al. [66] | Laparoscopy | – | – | – | – |
Robotics | 56 | 59 | 29 | 5.4 % | ||
2009 | Seamon et al. [50] | Laparoscopy | 76 | 57 | 29 | 26 % |
Robotics | 105 | 59 | 34 | 12 % | ||
2009 | Holloway et al. [67] | Laparoscopy | – | – | – | – |
Robotics | 100 | 60 | 29 | 4 % | ||
2009 | Peiretti et al. [68] | Laparoscopy | – | – | – | – |
Robotics | 80 | 58 | 25 | 3.8 % | ||
2009 | Lowe et al. [69] | Laparoscopy | – | – | – | – |
Robotics | 405 | 62 | 32 | 6.7 % | ||
2010 | Cardenas-Goicoechea et al. [70] | Laparoscopy | 173 | 60 | 33 | 5.2 % |
Robotics | 102 | 62 | 32 | 1 % | ||
2011 | Paley et al. [71] | Laparoscopy | – | – | – | – |
Robotics | 377 | 62 | 31 | 2.9 % | ||
2012 | Coronado et al. [72] | Laparoscopy | 84 | 66 | 27 | 8.3 % |
Robotics | 71 | 67 | 29 | 2.4 % | ||
2012 | Backes et al. [73] | Laparoscopy | – | – | – | – |
Robotics | 471 | 60 | 32 | 6.4 % | ||
2012 | ElSahwi et al. [49] | Laparoscopy | – | – | – | – |
Robotics | 155 | 62 | 35 | 0 % | ||
2012 | Lau et al. [74] | Laparoscopy | – | – | – | – |
Robotics | 143 | 65 | 32 | 4.2 % | ||
2012 | Leitao et al. [75] | Laparoscopy | – | –
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