Laparoscopy versus laparotomy for the management of early stage endometrial cancer

Gynaecological Oncology, Princess Alexandra Wing, Royal Cornwall Hospital, Truro, UK. .
Cochrane database of systematic reviews (Online) (Impact Factor: 6.03). 09/2012; 9(9):CD006655. DOI: 10.1002/14651858.CD006655.pub2
Source: PubMed


Traditionally, surgery for endometrial cancer (hysterectomy with removal of both fallopian tubes and ovaries) is performed through laparotomy. It has been suggested that the laparoscopic approach is associated with a reduction in operative morbidity. Over the last 10 to 15 years there has been a steady increase of laparoscopy for endometrial cancer. This review investigates the evidence of benefits and harms of laparoscopic surgery compared with laparotomy for presumed early stage endometrial cancer.
To compare the overall survival (OS) and disease-free survival (DFS) for laparoscopic surgery versus laparotomy in women with presumed early stage endometrial cancer.
We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) Issue 3, 2012, MEDLINE, EMBASE and CINAHL up to April 2012. We also searched registers of clinical trials, abstracts of scientific meetings, and reference lists of included studies. Trial registers we searched included NHMRC Clinical Trials Register, UKCCCR Register of Cancer Trials, Meta-Register and Physician Data Query Protocol, as well as abstracts of scientific meetings.
Randomised controlled trials (RCTs) comparing laparoscopy and laparotomy for early stage endometrial cancer.
We independently abstracted data and assessed risk of bias. Hazard ratios (HRs) were used for OS and recurrence-free survival (RFS), risk ratios (RR) for severe adverse events and the mean difference (MD) method was used for continuous outcomes in women who received laparoscopy or laparotomy and these were then pooled in random-effects meta-analyses.
Eight RCTs comparing laparoscopy with laparotomy for the surgical management of early stage endometrial cancer were identified.All eight trials met the inclusion criteria, 3644 women were assessed at the end of the trials. Three trials assessing 359 participants with early stage endometrial cancer, found no statistically significant difference in the risk of death and disease or recurrence between women who underwent laparoscopy and those who underwent laparotomy (HR = 1.14, 95% confidence interval (CI): 0.62 to 2.10) and HR = 1.13, 95% CI: 0.90 to 1.42 for OS and RFS respectively). There was no statistically significant difference in the rate of peri-operative death, women requiring a blood transfusion, and bladder, ureteric, bowel and vascular injury. However, a meta-analysis of two trials found that women in the laparoscopy group lost significantly less blood than those in the laparotomy group (MD = -106.82 mL, 95% CI: -141.59 to -72.06). A further meta-analysis of two trials, which assessed 2923 women and included one very large trial of over 2500 participants, found that the rate of severe post-operative adverse events was significantly lower in the laparoscopy group compared with the laparotomy group (RR = 0.58, 95% CI: 0.37 to 0.91). The large trial did not give a breakdown of these severe post-operative adverse events into different adverse event categories. Most trials were at moderate risk of bias. Hospital stay was reported in all of the trials and results show that on average, laparoscopy was associated with a significantly shorter hospital stay.
This review has found evidence to support the role of laparoscopy for the management of early endometrial cancer.For presumed early stage primary endometrioid adenocarcinoma of the endometrium, laparoscopy is associated with similar overall and disease-free survival. Laparoscopy is associated with reduced operative morbidity and hospital stay. There is no significant difference in severe post-operative morbidity between the two modalities.

Download full-text


Available from: Khadra Galaal,
  • Source
    • "Lastly, the SEER registry does not record surgical techniques, so it was not possible to differentiate between patients who received open surgery and those who received minimally invasive techniques. However, a recent meta-analysis found no apparent clinical differences between the two techniques aside from reduced operative morbidity [25]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective To determine the incidence of regional lymph node involvement for early-stage endometrial cancer by using the Surveillance, Epidemiology, and End Results (SEER) registry. Methods In a retrospective study, data were analyzed from patients who were diagnosed with stage IA–IIB endometrioid adenocarcinoma and were treated between 1998 and 2003. The incidence of pelvic and para-aortic lymph node involvement was determined. Results Data were analyzed from 4052 patients. Incidences of pelvic and para-aortic lymph node metastases were: 1% and 0% in stage IA, grade 1 disease; 2% and 0% in IA, grade 2; 2% and 1% in IA, grade 3; 2% and 0% in IB, grade 1; 3% and 1% in IB, grade 2; 3% and 2% in IB, grade 3; 7% and 3% in IC, grade 1; 8% and 5% in IC, grade 2; 12% and 8% in IC, grade 3; 7% and 3% in IIA, grade 1; 10% and 4% in IIA, grade 2; 10% and 5% in IIA, grade 3; 8% and 4% in IIB, grade 1; 13% and 8% in IIB, grade 2; and 19% and 12% in IIB, grade 3. Conclusion Incidences of pelvic and para-aortic metastases were lower than previously reported. Patients at higher stages and grades had a 10% or higher risk of lymph node involvement and might benefit from aggressive therapy.
    International Journal of Gynecology & Obstetrics 12/2014; 127(3). DOI:10.1016/j.ijgo.2014.06.022 · 1.54 Impact Factor
  • Source
    • "Staging of EC is performed surgically, according to the International Federation of Gynecology and Obstetrics (FIGO) guidelines, by means of laparotomy , and includes hysterectomy, bilateral oophorectomy, pelvic and para-aortic lymphadenectomy, omentectomy and peritoneal sampling [3]. However, the results of recent studies demonstrating the questionable utility of lymphadenectomy in patients affected by low recurrence risk (low grade and early stage) EC [4] [5] [6], associated to the wider knowledge of less invasive surgical approaches than laparotomy [7] [8] [9], are leading to a progressive increase in the demand of preoperative staging of EC in order to tailor the best surgical strategy for each patient. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Purpose: To compare the diagnostic performance of T2-weighted images (T2-WI)+contrast-enhanced T1-weighted images (CE T1-WI) with the one of T2-WI+diffusion-weighted images (DWI) in the assessment of myometrial and cervical stromal infiltration by endometrial carcinoma (EC). Materials and methods: Institutional review board approved our retrospective study; requirement for informed consent was waived. 56 patients with histologically proven EC who underwent preoperative MRI and surgery at our Institution over a 34 months period were included. Two radiologists independently evaluated T2-WI+CE T1-WI and T2-WI+DWI of each patient. Confidence in imaging evaluation (0-3), depth of myometrial invasion (</≥50%) and presence of cervical stromal infiltration (Yes/No) were assessed. MRI findings were compared with pathological ones. Results: Confidence in imaging evaluation was higher for T2-WI+CE T1-WI (2.83/3) than for T2-WI+DWI (2.62/3). T2-WI+DWI showed a better diagnostic performance than T2-WI+CE T1-WI in recognizing deep myometrial infiltration by EC (accuracy, sensitivity and specificity of 0.89, 0.89 and 0.89 vs. 0.86, 0.84, 0.86; p>0.05) whereas both imaging sequences combinations showed the same diagnostic performance in recognizing cervical stromal infiltration (accuracy, sensitivity and specificity of 0.95, 0.98 and 0.80, p>0.05). Conclusion: T2-WI+DWI can reliably replace the "classical" combination T2-WI+CE T1-WI for local staging of endometrial carcinoma.
    European Journal of Radiology 11/2014; 84(2). DOI:10.1016/j.ejrad.2014.11.010 · 2.37 Impact Factor
  • Source
    • "The role of laparoscopy for major abdominal surgery has been well established, especially in the field of gynecology.1,2 Multiple studies have shown that laparoscopic surgery results in lower morbidity, better visualization, decreased blood loss, decreased postoperative pain, and faster recovery.3–5 As endoscopic surgeons continue to advocate for minimally invasive surgery, a logical next step is to improve efficiency by using ambulatory care settings. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background/Objectives: It has been shown that major gynecologic laparoscopy is safe in hospital ambulatory settings, but there is little data to suggest the same in freestanding ambulatory surgery centers. This study evaluates the safety and efficacy of advanced gynecologic laparoscopic surgery using a fast-track model in freestanding ambulatory surgery centers and discusses our institution protocols. Methods: Retrospective, multicenter review was conducted of major gynecologic surgeries from August 1st 2010 to September 30th 2011 in 3 surgical centers with one primary surgeon. All patients were treated for symptomatic uterine leiomyomas and/or endometriosis. Primary outcome measures were unplanned admissions and discharge within 23 hours. Results: One hundred and thirty-four patients underwent major laparoscopic gynecologic surgery with a total of 160 procedures: 77 stage IV endometriosis treatment including 7 disk excisions of endometriosis from the large bowel, 3 ureteroneocystostomies and 1 partial bladder resection, 38 myomectomies, and 34 hysterectomies including 12 modified radical hysterectomies. The overall unplanned admission rate was 4.5%. One hundred and thirty-one patients (97.7%) were discharged within 24 hours after surgery. Three patients (2.2%) were transferred to the hospital postoperatively: 1 patient for observation of postoperative anemia and 2 patients for postoperative fever. Three patients (2.2%) were admitted to the hospital after discharge: 1 patient for postoperative ileus, 1 patient for postoperative fever, and 1 patient with septic pelvic thrombophlebitis. These postoperative issues all resolved without complication, and all patients had an uneventful follow-up. Conclusions: With appropriate resources and an experienced surgeon, advanced laparoscopic surgery can be safely performed in a fast-track ambulatory surgery center with a high rate of discharge within 23 hours and low unplanned readmission rate.
    JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 07/2014; 18(3). DOI:10.4293/JSLS.2014.00291 · 0.91 Impact Factor
Show more

Similar Publications