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Shift to minimally invasive surgery for endometrial cancer linked to fewer complications
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A shift from open surgery to minimally invasive surgical approaches for early-stage endometrial cancer appeared associated with a significantly decreased risk for severe complications, according to results of a population-based Danish study published in JAMA Surgery.
“The implementation of [minimally invasive robotic surgery (MIRS)] led to an increase in the proportion of women who underwent [minimally invasive surgery], and it reduced the number of severe complications,” Siv Lykke Jørgensen, MD, of the department of gynecology and obstetrics at Odense University Hospital in Denmark, and colleagues wrote. “The reduction in the number of severe complications was observed despite a higher proportion of women with an older age, a high [American Society of Anesthesiologists] score, high-risk histopathologic characteristics, and intra-abdominal adhesions being offered [minimally invasive surgery] and a higher proportion of women undergoing staging lymphadenectomy.”
In the nationwide prospective cohort study, Jørgensen and colleagues analyzed the association between the introduction of MIRS across Denmark and severe complications among 5,654 women with early-stage endometrial cancer who underwent surgery between January 2005 and June 2015.
Researchers divided the women into two groups, depending on whether they underwent surgery before the introduction of MIRS (n = 3,091; mean age, 67 years) or after implementation of MIRS (n = 2,563; mean age, 68 years). They excluded women whose disease stage, association with MIRS implementation and histologic findings were unknown, as well as women with sarcoma or synchronous cancer and those who underwent vaginal or an unknown surgical type of hysterectomy.
Among the women who underwent surgery before the implementation of MIRS, 436 (14.1%) had minimally invasive laparoscopic surgery (MILS).Among women who underwent surgery after MIRS implementation, 569 (22.2%) had MILS and 1,282 (50%) had MIRS.
Severe complications — dichotomized for each woman and encompassing death within 30 days after surgery and intraoperative and postoperative complications diagnosed within 90 days after surgery — served as the primary outcome. Intraoperative complications included unintended vascular, urinary tract, bowel or nerve damage. Postoperative complications included acute renal failure, paralytic ileus, deep venous thrombosis, pulmonary embolism, acute myocardial infarction, sepsis, fistula, deep or intra-abdominal hematoma, surgical evacuation of cavities, and the need for gynecologic reoperation.
Multivariate logistic regression analyses showed that women who underwent surgery before implementation of MIRS had significantly higher odds of severe complications than women who underwent surgery after MIRS implementation (OR = 1.39; 95% CI, 1.11-1.74).
Among women who had surgery after MIRS implementation, total abdominal hysterectomy appeared associated with higher odds of severe complications than MILS (OR = 2.58; 95% CI, 1.8-3.7) and MIRS (OR = 3.87; 95% CI, 2.52-5.93).
Researchers observed no difference in odds of complications between MILS and MIRS (OR = 1.5; 95% CI, 0.99-2.77).
Researchers cited several study limitations, including an inability to adjust for the surgeon-specific learning curve.
The analysis has several caveats, including the lack of a true control group and the centralization of endometrial cancer treatment in Denmark — from 28 centers to six hospitals — that coincided with the introduction of MIRS, Jason D. Wright, MD, of the division of gynecologic oncology and department of obstetrics and gynecology at Columbia University, and colleagues wrote in a related editorial.
“Disentangling the association of regionalization, secular trends in the performance of [minimally invasive surgery], and the introduction of a robotic platform is not possible with the present study,” they wrote. “Regardless, Jørgensen and colleagues have demonstrated that increasing the rate of minimally invasive hysterectomy can improve outcomes for women undergoing hysterectomy for early-stage endometrial cancer. Going forward, the use of [minimally invasive surgery] for early-stage endometrial cancer should be an important quality metric.” – by John DeRosier
Disclosures: The study authors report no relevant financial disclosures. Wright reports consultant roles with Clovis Oncology and Tesaro. The other editorial authors report no relevant financial disclosures.
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