Which Surgical Techniques Yield the Best Outcomes for Early Endometrial Cancer?

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Researchers compared surgical outcomes among patients with early endometrial cancer who underwent laparoscopic, robotic-assisted, or open surgery.

Minimally invasive surgery employing robotic-assisted or laparoscopic techniques appears to be safer and more effective than open surgery for the early treatment of endometrial cancer (EC), according to the authors of a review published in Cancers.

EC is currently the sixth most common cancer among women and the fifteenth most common cancer overall, with more than 417,000 new cases diagnosed in 2020.

Early symptoms most commonly include postmenopausal bleeding but can also include persistent intermenstrual and heavy vaginal bleeding associated with features of anovulation. Diagnosis involves a histological evaluation of an endometrial sample.

Based on evidence from randomized controlled trials (RCTs) demonstrating low post-operative morbidity with comparable oncological outcomes, current guidelines recommend minimally invasive surgery as the preferred route for early-stage EC. Purushothaman Natarajan and colleagues noted existing RCTs may report limited risks and outcomes and may not include a complete picture of different surgical approaches.

To better understand the benefits, complications, and outcomes associated with minimally invasive surgical options, the researchers conducted a systematic review and network meta-analysis, incorporating evidence from randomized and nonrandomized studies. The final sample included 99 studies, comprising 181,716 women and 14 different outcomes.

Primary outcomes included the duration of the operation, the length of stay in the hospital, blood loss, blood transfusions, postoperative complications, complications of uncertain timing, total complications, total intraoperative and postoperative complications, and oncologic outcomes, including disease-free survival and recurrence.

“The network meta-analysis, a random-effect model, was expanded with a Bayesian method that allowed the inclusion of direct and indirect comparisons of the surgical techniques used, allowing for a better understanding of the data,” the authors wrote.

Comparing Surgical Methods

“Compared with open surgery, laparoscopic and robotic-assisted surgery demonstrated reduced blood loss and length of hospital stay but increased operating time,” Natarajan and colleagues wrote.

Laparoscopic and robot-assisted methods demonstrated significant differences in blood loss, −226.9 mL (95% CI, −298.4 to −155.9) and −257.2 mL (95% CI, −351.2 to −163.8), respectively, compared with open surgery. The difference between the two techniques was not statistically significant.

Both laparoscopic and robot-assisted options also demonstrated significant reductions in length of hospital stay, with mean differences of −3.54 days (95% CI, −4.22 to −2.87) and −3.79 days (95% CI, −4.79 to −2.79), respectively. Reduced hospital stays also correlated with reduced healthcare costs.

When compared with open surgery, robotic-assisted surgery was associated with a significant reduction in ileus (OR, 0.40; 95% CI, 0.17-0.87) and total intra-operative complications (OR, 0.38; 95% CI, 0.17-0.75), as well as a higher disease-free survival (OR, 2.45; 95% CI, 1.04-6.34).

The duration of operating time is one area where open surgery surpassed minimally invasive options, with an increase of 18.95 minutes (95% CI, 7.68–30.20) in laparoscopic and an added 29 minutes (95% CI, 13.66–44.23) in robot-assisted surgeries.

“Although the duration of surgery was slightly longer,” the authors noted, “minimally invasive surgery was associated with significantly lower rates of complications during and after surgery, in conjunction with a possible superiority in oncological outcomes, compared with those who underwent open surgery.”

Techniques Depend on Multiple Factors

The study authors conducted a ranking analysis and determined that open surgery is often the best technique, considering the duration of the operation or total lymph nodes. Laparoscopic techniques may be preferred in cases of infections, venous thromboembolism, and recurrence.

Meanwhile, robot-assisted surgeries stood out as the best choice regarding blood loss, length of stay, disease-free survival, incidences of blood transfusion, fever, ileus, total complications, total intra-operative complications, and total postoperative complications.

“The main strength of this study is the inclusion of all relevant published data from both RCTs and cohort studies,” Natarajan and colleagues concluded. “By including data from cohort studies that were excluded by previous systematic reviews, our study represents, to our knowledge, the most comprehensive summary to date of peri- and post-operative and oncological outcomes associated with surgical treatment for early EC.”